Whether you or a loved one are worried about developing breast cancer, have just been diagnosed, are going through breast cancer treatment, or are trying to stay well after treatment, this detailed information can help you find the answers you need. 

Do you know your breasts like the back of your hand?


If your answer is yes, we commend you on your breast awareness. If your answer is no, it’s time to get educated.Your education is about becoming the best (and breast!) ambassador to your own health. Read on to learn about risk factors including genetic links, what risk reduction means, and how to detect any changes in your breast health.

Breast cancer definition

Breast cancer is a malignant tumor (a collection of cancer cells) arising from the cells of the breast. Although breast cancer predominantly occurs in women, it can also affect men. This article deals with breast cancer in women.

What are the statistics on male breast cancer?

Breast cancer is rare in men (approximately 2,300 new cases diagnosed per year in the U.S.) but typically has a significantly worse outcome. This is partially related to the often late diagnosis of male breast cancer, when the cancer has already spread.


What causes breast cancer?

There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know the cause of breast cancer or how these factors cause the development of a cancer cell.

We know that normal breast cells become cancerous because of mutations in the DNA, and although some of these are inherited, most DNA changes related to breast cells are acquired during one's life.

Proto-oncogenes help cells grow. If these cells mutate, they can increase growth of cells without any control. Such mutations are referred to as oncogenes. Such uncontrolled cell growth can lead to cancer.

What are breast cancer risk factors? How do you get breast cancer?

Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with a health-care provider anytime new therapies are started (for example, postmenopausal hormone therapy).

Several risk factors are inconclusive (such as deodorants), while in other areas, the risk is being even more clearly defined (such as alcohol use).

The following are risk factors for breast cancer:

Age: The chances of breast cancer increase as one gets older.
Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk.
Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went through menopause later (after 55) have a slightly increased risk.
Breast tissue: Women with dense breast tissue (as documented by mammogram) have a higher risk of breast cancer.
Race: White women have a higher risk of developing breast cancer, but African-American women tend to have more aggressive tumors when they do develop breast cancer.
Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer.
Having no children or the first child after age 30 increases the risk of breast cancer.
Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer.
Being overweight or obese increases the risk of breast cancer.
Use of oral contraceptives in the last 10 years increases the risk of breast cancer.
Using combined hormone therapy after menopause increases the risk of breast cancer.
Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used. A recent study reviewing the research on alcohol use and breast cancer concluded that all levels of alcohol use are associated with an increased risk for breast cancer. This includes even light drinking.
Exercise seems to lower the risk of breast cancer.
Genetic risk factors: The most common causes are mutations in the BRCA1 and BRCA2 genes (breast cancer and ovarian cancer genes). Inheriting a mutated gene from a parent means that one has a significantly higher risk of developing breast cancer

Breast Cancer Symptoms

Breast cancer may or may not cause symptoms. Some women may discover the problem themselves, while others may have the abnormality first detected on a screening exam. Common breast cancer symptoms include the following:

Non-painful lumps or masses
Lumps or swelling under the arms
Nipple skin changes or discharge
Noticeable flattening or indentation of the breast

Mammograms and Breast Cancer Prevention

Early detection of breast cancer is the key to survival. Mammograms are X-rays of the breast that can detect tumors at a very early stage, before they would be felt or noticed otherwise. During a mammogram, your breasts are compressed between two firm surfaces to spread out the breast tissue. Then an X-ray captures black-and-white images of your breasts that are displayed on a computer screen and examined by a doctor who looks for signs of cancer. Women at average risk have are recommended to have a mammogram every year starting at age 45. Starting at age 54, women are recommended to have a screening mammogram every 2 years as long as they remain healthy.

What are breast cancer medical treatments?

Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with a health care team. The following are the basic treatment modalities used in the treatment of breast cancer.

Surgery

Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast-conserving surgery and mastectomy


Breast-conserving surgery

This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor.

In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (surgical margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.

Mastectomy

During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well, but the overlying skin is preserved.

Radical mastectomy

During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases, a modified radical mastectomy is as effective.

Modified radical mastectomy

This surgery removes the axillary lymph nodes in addition to the breast tissue. Depending on the stage of the cancer, a health care team might give someone a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy.

Preventive surgery

For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

Double mastectomy is a surgical option to prevent breast cancer. This prophylactic (preventive) surgery can decrease the risk of breast cancer by about 90% for women at moderate to high risk for breast cancer.

Such an approach should be carefully discussed with a health care team.

The discussion about whether to undergo any preventive surgery should include

genetic testing for BRCA1 or BRCA2 gene mutations,
full review of risk factors,
family history of cancer and specifically breast cancer, and
other preventive options such as medications.

Radiation therapy

Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy.

External beam radiation

This is the usual way radiation therapy is given for breast cancer. A beam of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by a health care team and is based on the surgical procedure performed and whether lymph nodes were affected or not.

The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually, the treatment is given five days a week for five to six weeks.

Brachytherapy

This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer.

Chemotherapy

Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth.

Chemotherapy can have different indications and may be performed in different settings as follows:

Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy. Chemotherapy is not given in all cases, since some women have a very low risk of recurrence even without chemotherapy, depending upon the tumor type and characteristics.
Neoadjuvant chemotherapy: If chemotherapy is given before surgery, it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal.
Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. With cases of metastatic breast cancer, the health-care team will need to determine the most appropriate length of treatment.
There are many different chemotherapeutic agents that are either given alone or in combination. Usually, these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.

Hormone therapy

This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment.

Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive). The following drugs are used in hormone therapy:

Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.
Toremifene (Fareston) works similar to Tamoxifen and is only indicated in metastatic breast cancer.
Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful.
Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples are letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin).
Targeted therapy

As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects than chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy.


Alternative treatments

Whenever a disease has the potential for much harm and death, physicians search for alternative treatments. As a patient or the loved one of a patient, there may be an inclination to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. One should discuss any interest in alternative treatments with a health care team and together explore the different options.

What are breast cancer survival rates by stage? What is the prognosis of breast cancer?
Survival rates are a way for health care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. Patients have to determine if they want to know this number or not and should let their health care providers know.

The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other than breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

All of this needs to be taken into consideration when interpreting these numbers for oneself.
Below are the statistics from the National Cancer Institute's SEER database.

Stage	Five-year survival rate
0	100%
I	100%
II	93%
III	72%
IV	22%

Is my family history relevant to my breast cancer diagnosis?

If you have a strong (positive) family history for breast cancer, ovarian cancer, or even prostate cancer, this information is relevant to your diagnosis. A strong family history in this case usually means that a mother, sibling, child, or father has had a related malignancy. Information about other family members (aunts, nieces, etc.) is also important. This is especially significant if the diagnosis of breast cancer was made at an early age or involved both breasts or a breast and an ovary in the same individual. A positive family history may necessitate a more comprehensive diagnostic workup, more involved treatment, and consideration of genetic testing, not only for you but for other family members.

What other studies should be done on my breast tissue biopsy?

Microscopic evaluation of the slides made from involved tissue provides critical information about the tumor. A reasonably accurate prediction of tumor behavior can be made based on the appearance of the cancer cells, their size and similarity to one another, and the presence or absence of these cells in the lymphatic and blood vessels immediately adjacent to the tumor. This type of evaluation is a standard part of the diagnostic process.

However, there are additional relevant data that the laboratory should obtain, and this analysis is directed by the pathologist at the time of diagnosis. This information includes, at a minimum, an assessment of the estrogen and progesterone receptors on the malignant cells and the status of at least one oncogene, called her-2-neu. An oncogene is a gene that plays a normal role in cell growth but, when altered, may contribute to abnormal cell division and tumor growth.

Currently, these tests (estrogen and progesterone receptors and her-2-neu) have an accurate enough predictive value that their status should be determined in all cases of breast cancer. Test results are available within a few days to a week after removal of the tumor tissue. The results of these tests should then be taken into account in the final decision-making about treatment. These tests are constantly evolving and changing, and your treatment team will be able to discuss the current standard and advanced testing available.

Genomic assays (tests that evaluate gene expression) in the tumor tissue are often performed on certain breast cancers to help determine the likelihood that a tumor will recur (come back) and to help determine whether chemotherapy will be beneficial
Should I stop taking hormone replacement therapy (HRT) after a breast cancer diagnosis?

Breast cells are programmed to respond to certain hormones as signals for growth and multiplication. The most prominent examples of these hormones are estrogens and progesterone. Many breast-cancer cells retain hormone receptors (molecular configurations on the cell surface to which the hormones bind). The hormone receptors, therefore, make the cancer cells responsive to these particular hormones.

In general, taking hormones is not recommended if a diagnosis of breast cancer is under consideration. This does not necessarily mean that you can never resume hormone replacement therapy. This issue is generally reconsidered after the completion of your evaluation and treatment. You should consult with your physician before you stop or start any new medications.

Even though my breast tumor does not have hormone receptors, should I take tamoxifen to reduce the risk of a new tumor?

Following completion of your treatment for breast cancer, whether or not tamoxifen (Nolvadex) is prescribed should at least be addressed. In many cases, the primary breast cancer for which the patient is being treated may not be hormone-receptor positive. In these cases, tamoxifen (which binds to the estrogen receptor in place of estrogen) is not generally part of the treatment protocol.

However, the Breast Cancer Prevention Trial (a study of the use of tamoxifen) demonstrated a significant reduction in the development of new cancers in the opposite breast in patients who were treated with tamoxifen. So, the possible use and benefits of tamoxifen should not be ignored. A thoughtful evaluation of all the factors in a particular case will lead to a recommendation which balances the benefits of tamoxifen against the potential risks. Your treatment team should address this issue with you.


Should I start chemotherapy before surgery for breast cancer?

The classical concept of breast-cancer treatment has been a sequence of tumor-removing surgery followed by chemotherapy and/or radiation therapy. The goal of surgery and radiation therapy is to destroy or remove the primary cancer. Follow-up chemotherapy is designed to eliminate any cancer cells, as yet undetectable, at remote sites.

Recently, there have been new findings suggesting a potential benefit in some patients when chemotherapy is started before surgery. However, initial chemotherapy (neoadjuvant chemotherapy) should be considered primarily in patients with larger tumors and those with strong evidence of lymph-node involvement at the time of initial diagnosis.

If you are enrolled in a clinical trial, the advantages and disadvantages of all protocols should have been explained to you, giving you the opportunity to make an informed decision.

If I am advised to have a mastectomy, what are the risks and benefits of immediate breast reconstruction?

If a mastectomy is necessary, immediate reconstruction offers a great psychological benefit to most women. However, as is often the case in medicine, there are trade-off risks that must be considered. If the reconstruction is done during the same surgery as the mastectomy (immediate reconstruction), the final results of the pathology tests on the removed tumor and tissue is not yet known and will not be known for at least a day or two.

There are sometimes findings on the final pathology report that make chest-wall radiation advisable in order to reduce the risk of local recurrence. If a prosthesis for the breast has been implanted, the radiation treatment will still work, but the radiation may significantly compromise the cosmetic appearance of the prosthesis. There may also be healing problems that delay chemotherapy, potentially increasing the risk of breast-cancer recurrence. These and other factors should be discussed and carefully considered before committing to immediate breast reconstruction

Should breast cancer patients have their lymph nodes removed?

Lymph nodes are small glandular structures that filter tissue fluids. They filter out and ultimately try to provide an immune response to particles and proteins that appear foreign to them. There are thousands of these nodes scattered in groups throughout the body. Each cluster is more or less responsible for the drainage of a particular region of the body.

The lymph nodes under the arm (axillary nodes) are the dominant drainage recipients from the breast. When cancer cells break free from a breast cancer, they may travel through the lymph tubes (vessels) to the lymph nodes. There, the cancer cells may establish a secondary growth site. The presence of cancer cells in the lymph nodes proves that cancer cells have traveled away from the primary breast tumor. Therefore, the presence or absence of cancer cells in these regional nodes is an important indicator of the future risk of recurrence. This information is often important in making decisions about whether to use chemotherapy and what type of chemotherapy should be employed.

Unfortunately, removal of the lymph nodes also carries a potential risk of lymphedema, a condition that may cause the arm to swell. Lymphedema can occur early after surgery or many years later. It can be a difficult and disabling condition. Here again, there are tradeoffs in risk. When more lymph nodes are removed, more accurate information about tumor spread is obtained and the chance for tumor recurrence is less. But there is a greater incidence of lymphedema.

There are alternatives to standard lymph-node removal (called axillary node dissection). These alternatives should be considered in each patient's situation. They include

replacing standard axillary-node removal with sentinel node biopsy (explained below);
not doing lymph-node removal in patients who will receive chemotherapy anyway based on other information; and
not doing lymph-node removal in patients with very small or "favorable" tumors.
Again, these alternatives must be selectively applied with the benefits and risks carefully evaluated.

What is a sentinel lymph node biopsy, and what are its benefits and risks?

A sentinel node biopsy takes advantage of a peculiar physiologic and anatomical finding. Although there may be many lymph nodes in a particular drainage region, it appears that only one or two are the first recipients of the regional fluids.

This means that if any nodes will be involved by tumor spread, the sentinel node will be the first. It also means in general that if the sentinel node is not involved, then no other nodes will be affected. Therefore, only the sentinel node needs to be removed. There are techniques for removing just the sentinel nodes. A sentinel node biopsy allows the pathologist to more intensively study this node and apply specialized techniques that are capable of detecting even a few cancer cells.

Are there any other questions I should ask my doctor about breast cancer?

Yes. There are surely other questions you will wish to ask. Do not hesitate to be very open about your concerns with your doctor. The foregoing questions and comments should demonstrate that the diagnosis and treatment of breast cancer may not be a simple process. Even when all the information is available, there may be difficulties in deciding a proper course of action. However, this decision-making process has a better chance of success when you and the doctor are well-informed and communicating effectively. Although the information here cannot be all-inclusive, we hope it will help you work through this process