EARLY STAGES OF BREAST CANCER
The term “early breast cancer” refers to stages of breast cancer labeled 0, I, and II.
Cancer cells are present in either the lining of a breast lobule or a duct, but they have not spread to the surrounding fatty tissue. This stage is also called ductal carcinoma in situ, or DCIS.
Cancer has spread from the lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered to be invasive. The tumor is 2 cm or less in diameter (approximately 1 inch or less); the lymph nodes are not involved.
Cancer has spread from the lobules or ducts to nearby tissue in the breast. In this stage, the tumor can range from about 2 cm to greater than 5 cm in diameter (approximately 1 to 2 inches); sometimes the lymph nodes may be involved.
A recurrence is a return of breast cancer. After surgery for early breast cancer, adjuvant, or additional, therapy may be given to reduce the chance of a recurrence.
ADVANCED STAGES OF BREAST CANCER
The term “advanced breast cancer” refers to stages of breast cancer labeled III and IV.
Known as locally advanced cancer; tumor may be larger than 5 cm (2 inches) in diameter, and cancer may or may not have spread to lymph nodes or other tissues near the breast.
Known as metastatic; cancer has spread from the breast and lymph nodes under the arm to other parts of the body, such as bone, liver, lung, or brain.
The presence of hormone receptors in the tumor cells is also important. When these receptors are present, the tumor cells depend on hormones, such as estrogen, for growth. Hormone (either estrogen or progesterone) receptor-positive tumors appear to grow less aggressively than those that are estrogen receptor-negative or progesterone hormone receptor-negative.
Women whose tumors are hormone receptor positive have a lower risk of recurrence than than those who are hormone receptor negative. And, in women with hormone receptor positive tumors, adjuvant hormonal treatment reduces that risk.
BREAST HEALTH FOR PREVENTATIVE CARE
The three-step plan for preventive care. Although breast cancer cannot be prevented at the present time, early detection of problems provides the greatest possibility of successful treatment.
WHAT IS THE THREE-STEP PLAN?
Routine care is the best way to keep you and your breasts healthy. Although detecting breast cancer at its earliest stages is the main goal of routine breast care, other benign conditions, such as fibrocystic breasts, are often discovered through routine care.
STEP 1. BREAST SELF-EXAMINATION (BSE)
A woman should begin practicing breast self-examination by the age of 20 and continue the practice throughout her life — even during pregnancy and after menopause. BSE should be done regularly at the same time every month. Regular BSE teaches you to know how your breasts normally feel so that you can more readily detect any change.
Changes may include:
• Development of a lump
• A discharge other than breast milk
• Swelling of the breast
• Skin irritation or dimpling
• Nipple abnormalities (i.e., pain, redness, scaliness, turning inward)
If you notice any of these changes, see your health care provider as soon as possible for evaluation.
STEP 2. CLINICAL EXAMINATION
A breast examination by a physician or nurse trained to evaluate breast problems should be part of a woman’s physical examination.
The American Cancer Society recommends:
•Between the ages of 20 and 39, women should have a clinical breast examination by a health professional every 3 years.
• After age 40, women should have a breast exam by a health professional every year.
• A physical breast examination by a physician or nurse is very similar to the procedures used for breast self examination. Women who routinely practice BSE will be prepared to ask questions and have their concerns addressed during this time.
STEP 3. MAMMOGRAPHY
Mammography is a low-dose x-ray of the breasts to find changes that may occur. It is the most common imaging technique. Mammography can detect cancer or other problems before a lump becomes large enough to be felt, as well as assist in the diagnosis of other breast problems. However, a biopsy is required to confirm the presence of cancer.
Because when to begin and how often to have mammograms is controversial, talk with your physician about a mammography schedule that is appropriate for you based on your overall health and medical history, risk factors, and personal opinion or preference.
According to the National Cancer Institute, women in their 40s and older should begin having a screening mammogram on a regular basis, every 1 to 2 years. But, the American Cancer Society recommends that by age 40, women should have a screening mammogram every year. (A diagnostic mammogram may be required when a questionable area is found during a screening mammogram.)
MYTHS ABOUT BREAST CANCER
This section outlines some of the common myths and misconceptions about breast cancer. False rumors about breast cancer are becoming more frequent with the increased use of email and the Internet. For example, a recent inaccurate e-mail message was widely circulated stating that the use of antiperspirants is a leading cause of breast cancer. The purpose of this section is to dispel false rumors about what causes breast cancer, how the disease develops, and how different treatment options affect patients.
Myth: Only Women Get Breast Cancer.
Fact: It is estimated that 1,450 men will be diagnosed with breast cancer in 2004 and 470 will die from the disease.
Myth: Only Women with a Family History of Breast Cancer are at Risk.
Fact: While a family history of breast cancer can mean that a woman is at higher than average risk of developing breast cancer, more than 80% of women diagnosed with breast cancer have no identifiable risk factors for the disease.
Myth: Breast Cancer is Mainly a Genetic Disease.
Fact: Only a very small percentage (5%-10%) of breast cancer cases are thought to be due to abnormal genes. Researchers have identified two genes on chromosome 17, BRCA1 (breast cancer gene 1) and BRCA2 (breast cancer gene 2), that may increase breast cancer risk (although more genes that affect breast cancer risk may also exist).
However, only 5% of breast cancer cases are related to mutated BRCA1 or BRCA2 genes. Furthermore, a mutated BRCA gene is only one of the risk factors for developing breast cancer. Other high risk factors include: age, family history, high fat diets, obesity, previous breast biopsy showing benign (non-cancerous) conditions, menstruation beginning at an early age, menstruation continuing past age 50, not having children, having a first child after age 30, etc. Also, up to 80% of women who get breast cancer have no identifiable risk factors.
Myth: Older Women are Less Likely to Get Breast Cancer Than Younger Women.
Fact: As a woman’s age increases, her risk of getting breast cancer also increases. In fact, age is one of the strongest risk factors for developing breast cancer. To help detect breast cancer early, women forty years of age and older should get regular mammograms in addition to a yearly clinical breast examinations (CBE) and monthly breast self-examinations (BSE). Women between the ages of 20 and 40 should also practice monthly breast self-exams and receive physician-performed clinical breast exams at least every three years.
Myth: Breast Cancer is Contagious.
Fact: Cancer is not a communicable disease. Breast cancer is defined as an abnormal increase in breast cells, resulting in a malignant (cancerous) tumor of the breast tissue. Changes in one woman’s cells cannot affect the cells of another woman. Generally accepted risk factors of breast cancer include:
• Family history
• Previous breast biopsy showing benign conditions
• Menstruation beginning at an early age
• Menstruation continuing past age 50
• Not having children
• Having a first child after age 30
• High fat diets
• Mutations of the genes, BRCA1 and BRCA2
Myth: All Breast Lumps are Cancerous.
Fact: In general, 80% of lumps are caused by benign (non-cancerous) changes in the breast. This percentage tends to fluctuate with age. For young women, more than 80% of breast lumps are benign. As a woman ages, her risk for breast cancer increases. The percentage of benign breast lumps in older women may be much lower than in younger women. It is still important for women to report any breast abnormality to their physician, especially if it persists after two or more menstrual cycles.
Myth: A Woman with Lumpy Breasts is at High Risk of Developing Breast Cancer.
Fact: In the past, health care professionals believed women with lumpy breasts were at higher risk for breast cancer. However, this myth has recently been dispelled. Women with lumpy breasts often suffer from a benign (non-cancerous) condition called fibrocystic change.
Symptoms of fibrocystic change in the breast include cysts (accumulated packets of fluid), fibrosis (formation of scar-like connective tissue), lumpiness, areas of thickening, tenderness, or breast pain. One type of rare benign growth, atypical hyperplasia (abnormal increase in the number of breast cells), may increase a woman’s risk of invasive breast cancer. However, only about 3% of breast biopsies reveal atypical hyperplasia.
Myth: Small-Breasted Women Cannot Get Breast Cancer.
Fact: The amount of breast tissue a woman has does not affect her risk of developing breast cancer. Breast size is certainly not a significant risk factor for breast cancer.
Myth: Fibrocystic Change Increases a Woman’s Risk of Developing Breast Cancer.
Fact: Fibrocystic change is a benign (non-cancerous) breast condition and does not increase a woman’s risk of developing breast cancer. However, in some instances, fibrocystic change can make breast cancer more difficult to detect with mammography. This is because the breast density associated with fibrocystic breasts may eclipse breast cancer on a mammogram film. Therefore, it is important that breast self-exams and clinical breast exams also be preformed. In some cases, women with fibrocystic breasts may need additional breast imaging, such as ultrasound, if cancer is suspected but not detectable with mammography.
Myth: Drinking Coffee Increases a woman’s Risk of Developing Breast Cancer.
Fact: Coffee does not cause breast cancer, and in several studies with rats, coffee has been shown to actually prevent cancer. Health care professionals once believed that caffeine caused fibrocystic change (a common non-cancerous breast condition characterized by cysts, lumpiness, tenderness, pain, etc.). Some women find that reducing their caffeine intake by avoiding coffee, tea, chocolate, and soft drinks decreases water retention and breast discomfort. This is a controversial topic among health care professionals, though, since studies linking breast pain and caffeine have been inconsistent.
Myth: Antiperspirants or Antiperspirants/deodorant Combinations are a Leading Cause of Breast Cancer.
Fact: Antiperspirants (or antiperspirant/deodorant combinations) do not cause breast cancer. A false rumor has been broadly circulated claiming that antiperspirants prevent the body from purging dangerous toxins. The message reports that because antiperspirants actually work to stop underarm perspiration (as opposed to regular deodorants that merely provide fragrance), certain toxins become trapped inside the body. These toxins, according to the rumor, are deposited in the lymph nodes below the arms, leading to cell mutations and the development of breast cancer. This link between antiperspirants and breast cancer is completely inaccurate. The body does not, in fact, need to purge toxins from the armpits in the form of perspiration. There are no toxins to purge; sweat is made up of a combination of 99.9% water, sodium, potassium and magnesium. The National Cancer Institute and the U.S. Food and Drug Administration are unaware of any substantial evidence that antiperspirants cause breast cancer.
Myth: Pesticides, Lawn Chemicals, and/or Dry Cleaning Services Cause Breast Cancer.
Fact: A number of small studies over the past few years have shown a possible increased incidence of breast cancer in women who use dry cleaning services or professional lawn services. However, several health care professionals doubt the scientific validity of these studies whose data is often contradicted in larger studies. Similar data linking pesticides to increased incidences of breast cancer have also been inconclusive.
Myth: If a Woman is Diagnosed with Lobular Carcinoma in situ (LCIS), She Will Definitely Develop Breast Cancer.
Fact: Though technically a Stage 0 cancer, most physicians do not consider lobular carcinoma in situ (LCIS; also called lobular neoplasm) to be cancer. However, LCIS is a marker for increased breast cancer risk. Women with LCIS are more likely to develop cancer in either breast later in their lives. LCIS begins in the lobules (the milk-producing glands of the breast) but does not penetrate the lobular walls.
Myth: Breast-Feeding Causes Breast Cancer.
Fact: Breast-feeding does not cause breast cancer. In fact, some preliminary studies reveal that breast-feeding may decrease a woman’s risk of developing breast cancer. However, this data has not been confirmed. Women who breast-feed can still get breast cancer, but they are not at any increased risk compared to women who do not breast-feed.
Myth: Nipple Discharge Indicates Breast Cancer.
Fact: Most nipple discharges do not indicate a cancerous condition. Up to 20% of women may experience spontaneous milky, opalescent, or clear fluid nipple discharge. Up to 60% of women experience nipple discharge during breast self-examination. Usually, if the discharge is clear, milky, yellow, or green, it does not indicate cancer. Bloody or watery nipple discharge is considered abnormal; however, only 10% of abnormal discharges are cancerous. Most bloody discharges are due to non-cancerous papillomas. Women should report any worrisome nipple discharges to their physician for clinical examination. Nipple discharge may be a concern if it is:
• Bloody or watery (serous) with a red, pink, or brown color
• Sticky and clear in color or brown to black in color (opalescent)
• Appears spontaneously without squeezing the nipple
• Persistent on one side only (unilateral)
• A fluid other than breast milk
Myth: Underwire Bras Cause Breast Cancer.
Fact: A book published a few years ago called Dressed to Kill suggested that underwire bras can constrict the body’s lymph node system, causing breast cancer. The authors of the book attributed the high rate of breast cancer in North America (compared to less industrialized countries in the world) to the fact that most North American women wear bras. This link between underwire bras and breast cancer is completely inaccurate. The authors of Dressed to Kill did not take into account any other genetic, environmental, or social factors that could contribute to breast cancer risk (such as age, family history, high fat diet, obesity, not having children, etc.).
Myth: An Injury to the Breast Causes Cancer.
Fact: Injury or trauma to the breast does not cause breast cancer. However, the breast may become bruised or develop a benign (non-cancerous) lump as the result of an injury. Fat necrosis is a rare benign breast condition that occurs when fatty breast tissue swells or becomes tender. When the body attempts to repair the damaged breast tissue, the affected area may sometimes be replaced with firm scar tissue. Fat necrosis may be mistaken as cancer on mammogram; however symptoms of fat necrosis usually subside within a month.
Myth: Oral Contraceptive Pills (Birth Control Pills) Cause Breast Cancer.
Fact: Birth control pills do not cause breast cancer, even after prolonged use (10+ years). Though oral contraceptives do contain small amounts of estrogen and progesterone (hormones often linked with increased risk over time), the amount of these hormones is too small to pose a noteworthy risk. Today, most women are prescribed “low-dose” formulas which contain less than 50 micrograms of estrogen (50% to 100% less estrogen than most birth control pills contained before 1975). Low-dose formulas were developed to ease bothersome side effects of the regular-dose pill such as bloating. In one recent study of 3,383 cases of breast cancer from 1976 to 1992, no overall relationship was noted between the duration of oral contraceptive use and breast cancer risk, even among women who used oral contraceptives for more than 10 years. For women who began taking oral contraceptives after 1975 no significant risk of breast cancer has been noted even among those with a family history of breast cancer. Still, women at high risk for breast cancer should discuss any concerns about oral contraceptives with their physicians.
Myth: The Statistic “One in Eight Women Will Develop Breast Cancer” Means that if Eight Women are Randomly Selected, then One of those Eight Women is Guaranteed to Get Breast Cancer.
Fact: The one-in-eight-women statistic is not a per year estimate. Rather, it is calculated over a lifetime to age ninety-five. If researchers were to follow a large group of girls born today and track them until they became ninety-five years old, then one out of every eight of those girls (approximately 12.5%) would develop breast cancer sometime in her lifetime.
Myth: A Mammogram Prevents Breast Cancer.
Fact: A mammogram cannot prevent breast cancer; however mammography is an excellent tool to screen for and detect the disease at an early stage. Currently, mammography is the only FDA approved exam to screen for breast cancer in asymptomatic women (women who have no symptoms of breast cancer such as a lump). To help detect breast cancer early, women forty years of age and older should have a regular mammogram in addition to a yearly clinical breast examinations (CBE) and monthly breast self-examinations (BSE). Women between the ages of 20 and 40 do not typically need annual screening mammograms unless they have special circumstances (i.e., a strong family history of breast cancer). However women 20-40 years of age should practice monthly breast self-exams and receive clinical breast exams at least every three years.
Myth: A Mammogram Causes Breast Cancer.
Fact: A mammogram is a safe procedure that uses extremely low levels of radiation to create detailed images of the breast. Modern mammography systems typically use only about 0.1 to 0.2 rad dose per x-ray (rad is the scientific unit that measures radiation energy dosage). The MQSA (Mammography Quality Standards Act) was created by the American College of Radiology (ACR) and passed by Congress to mandate rigorous guidelines for x-ray safety during mammography. The MQSA guidelines assure that mammography systems are safe and use the lowest dose of radiation possible. Patients should make sure they are being imaged at an ACR accredited facility using modern mammography systems.
Myth: Mammography is 100% Accurate in Early Breast Cancer Detection.
Fact: Mammography is considered the gold standard for breast cancer detection. However, it is not 100% at detecting breast cancer. Overall, mammography is about 80% effective at detecting breast cancer, when all age groups are considered. However, individual characteristics, such as age, breast density, menopausal status, etc. may affect the accuracy of mammography. For example, sometimes an irregularity goes undetected because surrounding breast tissue is the same density as the irregular tissue. If a patient has a lump or other change and the mammogram is “negative” (interpreted as not suspicious or cancerous), the patient should still pursue that finding with her physician.
Myth: Mammography Always Finds Cancer When it is Curable.
Fact: Mammography is the most accurate screening tool for breast cancer. While annual screening mammograms will detect the vast majority of breast cancers, some cancers are extremely aggressive and can metastasize (spread) to other areas of the body before they are detected by mammogram. In general, breast cancer has a slow rate of growth. It may take six to eight years for a breast cancer developing from one cell to grow to the size of one centimeter. This long growth period allows ample time for aggressive cancers to spread into blood vessels, lymphatic vessels, and beyond the breast. Again, to help detect breast cancer early, when the chances for survival are the greatest, women 20 years of age and older should perform breast self-examination (BSE) every month. Women 20-39 should have a clinical breast examination (CBE) at least every three years in addition to performing monthly BSE. Women 40 and older should practice monthly BSE, have CBE performed by a health care professional every year, and have mammograms every year to two years.
Myth: Breast Cancer Always Presents Itself in the Form of a Lump
Fact: While a breast lump can certainly be a sign of breast cancer (as well as a number of non-cancerous conditions), not all women who are diagnosed with breast cancer will have a noticeable lump. Therefore, women should check for the following warning signs while performing monthly breast self-exams:
• Any new lump or hard knot found in the breast or armpit
• Any lump or thickening that does not shrink or lessen after your next period
• Any change in the size, shape or symmetry of your breast
• A thickening or swelling of the breast
• Any dimpling, puckering or indention in the breast
• Dimpling, skin irritation or other change in the breast skin or nipple
• Redness or scaliness of the nipple or breast skin
• Nipple discharge (fluid coming from your nipples other than breast milk), particularly if the discharge is bloody, clear and sticky, dark or occurs without squeezing your nipple
• Nipple tenderness or pain
• Nipple retraction: turning or drawing inward or pointing in a new direction
• Any breast change that may be cause for concern
While one or more of these changes warrants clinical examination, these changes do not mean that a woman has breast cancer. In addition, breast cancer can be present without any symptoms. For example, screening mammography often detects breast cancer before a lump can be felt. In general, the early breast cancer is diagnosed, the better the chances for successful treatment and survival.
Myth: If a Breast Lump is Painful, Then it is Not Cancerous.
Fact: Up to 10% of breast cancers are associated with pain. However, pain is very rarely the only evidence of a breast tumor. Pain may accompany a breast lump, etc. If a patient has breast pain but physical exams and mammography do not reveal an abnormality, most physicians will not pursue further breast imaging because the likelihood of breast cancer is very small. Breast pain is the third most common non-cancerous breast complaint, and may be caused by a variety of conditions. Bilateral breast pain is less likely to be associated with breast cancer than unilateral breast pain.
Myth: The Best Place to Practice Breast Self-Examination (BSE) is in the Shower.
Fact: BSE can be performed while in the shower. However, wet, soapy hands may make it difficult for a woman to feel the intricacies of her breast. Cold air or water also causes the breasts and nipples to contract. Women over twenty years of age should practice monthly BSE in three positions: lying down, standing up, and standing in front of the mirror (to check for visual breast changes).
Myth: If a Woman is Diagnosed With Breast Cancer, She Will Lose Her Breast.
Fact: Many women who are diagnosed with breast cancer will undergo some type of surgery as part of their treatment. However, breast-conserving therapy (lumpectomy, usually followed by radiation therapy) is becoming common treatment for early stage breast cancers (such as ductal carcinoma in situ (DCIS)). Lumpectomy is the surgical removal of a breast lump and a surrounding margin of normal breast tissue. To date, women with DCIS have chosen equally among lumpectomy and mastectomy (removal of the affected breast), though specific cases may sometimes favor lumpectomy over mastectomy or vice versa. Chemotherapy (the use of anti-cancer drugs) is also being used in some cancer patients to shrink the size of a breast tumor so that a woman may have lumpectomy instead of mastectomy. Recent studies of the drug tamoxifen and other alternative treatments show a growing trend toward less invasive breast cancer treatment.
Myth: Mastectomy Ensures Breast Cancer Will Be Eliminated Forever.
Fact: Mastectomy (removal of the affected breast) does not guarantee that breast cancer will not recur. Some women experience breast cancer recurrence at the site of the mastectomy scar. There is also that possibility that the cancer has spread to the lymph nodes or other areas of the body. Many women who have modified radical mastectomy also undergo axillary lymph node dissection (removal of the underarm lymph nodes) to ensure that the cancer has not spread beyond the breast.
Myth: Women Who Have Prophylactic (Preventive) Mastectomy Will Not Develop Breast Cancer.
Fact: Prophylactic mastectomy is a preventive procedure in which one or both of the breasts are removed in women who are at very high risk for developing breast cancer. The decision to have prophylactic mastectomy should be made carefully after consultation with physicians and family members. Recent research has shown that prophylactic mastectomy can reduce the risk of breast cancer by 90%.
However, some women who are identified to be at high breast cancer never develop disease and thus would not benefit from prophylactic mastectomy. Breast tissue also extends up towards the neck, under the arms, and to the chest wall. A woman is at risk of developing breast cancer as long as breast tissue remains in the body
Myth: Chemotherapy Will Make a Woman’s Hair Fall Out.
Fact: The loss of hair (alopecia) is only one of the temporary side effects of chemotherapy. Hair loss and other side effects of chemotherapy depend on the types of drugs administered, their dosage, and the length of treatment. Some women experience few if any adverse effects from drug treatment. For women who experience alopecia, hair loss usually begins about three weeks after chemotherapy has begun. In most all cases, the hair will regrow after chemotherapy has ended. According to the National Alliance of Breast Cancer Organizations, the early chemotherapy regimen of cyclophosphamide, methotrexate, and flouracil (CMF) causes fewer side effects in most women than other regimens containing Adriamyacin (generic name, doxorubicin).
Myth: Women Who Have Had Breast Cancer in the Past Should Not Become Pregnant.
Fact: Studies show that the hormonal and metabolic changes that occur during pregnancy do not typically pose any significant risk of recurring breast cancer. Additionally, neither the number of pregnancies nor the time lapsed between treatment for breast cancer and pregnancy appear to have any noticeable effect on long-term breast cancer prognosis. Breast cancer survivors who are thinking of becoming pregnant should discuss their medical situation with their physician
BREAST CANCER IN MEN
Breast cancer in men is rare– less than 1% of all breast carcinomas occur in men. The American Cancer Society estimates that in 2004 about 1,450 new cases of invasive breast cancer will be diagnosed among men in the US. The average age at diagnosis is between 60 and 70, although men of all ages can be affected with the disease.
What are risk factors for breast cancer in men?
Risk factors may include:
• Radiation exposure
• Estrogen administration
• Diseases associated with hyperestrogenism, such as cirrhosis or Klinefelter’s syndrome
•Also, there are definite familial tendencies for developing breast cancer:
• An increased incidence is seen in men who have a number of female relatives with breast cancer.
•An increased risk of male breast cancer has been reported in families in which a BRCA2 mutation has been identified.
What is the most common type of breast cancer in men?
Infiltrating ductal cancer is the most common tumor type, but intraductal cancer, inflammatory carcinoma, and Paget’s disease of the nipple have been described as well.
Lobular carcinoma in situ has not been identified in men.
What are the symptoms of breast cancer in men?
The following are the most common symptoms of breast cancer in men. However, each individual may experience symptoms differently. Symptoms may include:
• Breast lumps
• Nipple inversion
• Nipple discharge (sometime bloody)
• A pain or pulling sensation in the breast
The symptoms of breast cancer may resemble other conditions or medical problems. Consult a physician for diagnosis.
What are the similarities to breast cancer in women?
Lymph node involvement and the hematogenous pattern of spread are similar to those found in female breast cancer. The staging system for male breast cancer is identical to the staging system for female breast cancer.
Prognostic factors that have been evaluated include the size of lesion and the presence or absence of lymph node involvement, both of which correlate well with prognosis.
Overall survival is similar to that of women with breast cancer. The impression that male breast cancer has a worse prognosis may stem from the tendency toward diagnosis at a later stage.
What are the treatment options for men with breast cancer?
Specific treatment for male breast cancer will be determined by your physician(s) based on:
• Your overall health and medical history
• Extent of the disease
• Your tolerance for specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference
The primary standard treatment is a modified radical mastectomy, just as it is with female breast cancer. Adjuvant therapy may be considered on the same basis as it is for a woman with breast cancer– since there is no evidence that prognosis is different for men or women.