Breast Cancer – Causes, Signs and symptoms

Breast cancer

Also called: Inflammatory Breast Cancer, Medullary Carcinoma

Summary

Breast cancer is a growth of abnormal cells within the breast. Breast cancer is not a single disease but rather a group of diseases that can develop in the ducts (which carry milk to the nipple), the lobules (milk producing areas) or other parts of the breast.

After non-melanoma skin cancer,  breast cancer is the most common form of cancer in women. For 2007, the American Cancer Society (ACS) estimates that more than 178,000 new cases of breast cancer will be diagnosed, adding to the 2 million women who have been diagnosed and treated previously for this disease. In addition, the ACS estimates that nearly 40,500 women are expected to die from breast cancer in 2007, making it the second leading cause of cancer death among women (surpassed only by lung cancer).

Although rare, men can also develop breast cancer. In the United States, about 2,000 men are expected to develop breast cancer in 2007, and about 450 men will die from the disease, according to the ACS. However, breast cancer primarily affects women.

Common ways to screen for breast cancer include monthly breast self-examination, clinical breast examination performed by a physician and screening mammography. However, to confirm a diagnosis of breast cancer, a biopsy is performed in which all or part of the mass is removed and then analyzed by a pathologist who views the specimen under a microscope.

Based on the findings by the pathologist, if the tumor is cancerous (malignant) then additional tests, such as an MRI, ultrasound or PET scan may be ordered. All these tests provide the physician with additional information as to the location and stage (extent of spread) of the cancer and other information about the tumor and how it may respond to treatment. 

There are several options for breast surgery ranging from the breast-sparing lumpectomy to the now rarely used Halsted radical mastectomy, which removes the breast, the chest muscles and nearby lymph nodes.

In addition to surgery, a patient may receive additional treatment based on the type of breast cancer, its size and other important factors. The size of the tumor, the possible spread of the cancer to the lymph nodes and any possible spread to other organs or tissues helps the oncologist (cancer physician) determine the stage of the cancer. This information, in turn, gives the physician the necessary input to select the best treatment options for the patient. These options can include a wide variety of combinations of treatment, including surgery, radiation therapy, chemotherapy, hormone therapy or biological therapy.

A major study released in 2006 indicated that the number of new cases of breast cancer dropped significantly in the reporting period of 2002 to 2003. The ACS has reported a leveling off of new cases from 2001 to 2003, after 20 years of increases.

Overall survival rates for breast cancer are quite high when the disease is detected and treated in its earliest stages. When breast cancer progresses undetected to later stages, the survival rates drop. The 5-year survival rate for cancer that is localized (not spread to the lymph nodes or areas outside of the breast) is 98 percent. If the cancer has spread to nearby tissues, the 5-year survival rate is 83 percent.

According the ACS, large gains in survival rates for several cancers, including breast cancer, have been recorded over the past two decades. The overall survival rate for all stages of cancer at 5 years is 89 percent and at 10 years is 80 percent.

About breast cancer

Breast cancer is a growth of abnormal cells, usually within the ducts (which carry the milk to the nipple) or lobules (glands for milk production) of the breast. In more advanced stages of the disease, these out-of-control cells invade nearby tissues or travel throughout the body to other tissues or organs. More than 178,000 women and 2,000 men are diagnosed each year with breast cancer, according to the American Cancer Society (ACS). For women, this rate is second only to non-melanoma skin cancer.

In women, breasts are glands that are capable of producing milk. Each breast is made up of 15 to 20 sections known as lobes. Each lobe contains a number of smaller lobules which contain the milk secreting cells. The milk is then transported to the nipple by ducts. The lobular cells and the ductal cells can both be affected by cancer.

The breasts also contain lymph vessels that transport a clear fluid called lymph through the body to the lymph nodes. Lymph nodes near the breast are found under the arm, above the collarbone and behind the breastbone.

The body’s organs and glands (including breasts) are made up of tissues, which are made up of cells. Normal cell function requires these building blocks to divide and also to die when they grow old – allowing for new cells to take their place in an organized manner. When old cells do not die and the body continues to create new cells it does not need, a mass of cells form a growth or tumor. These tumors do not always signal cancer, particularly in the breast. They can be benign (noncancerous) or malignant (cancerous).

Benign breast lumps are common and may be due to fibrocystic changes in the breast tissue. Most benign breast lumps are fibroadenomas or papillomas. In addition, benign tumors:

  • Are rarely life-threatening
  • Can be removed and seldom grow back
  • Do not spread to tissue around them or to other parts of the body

Malignant tumors have significant differences from benign tumors. Malignant tumors:

  • Are generally more serious than benign tumors
  • May be life-threatening
  • Can often be removed but they can grow back
  • Can invade nearby tissues and organs (local invasion)
  • Can break away in the form of cells that enter the bloodstream or lymphatic system and travel to other areas (distant metastasis)

Breast cancer begins with a growth of abnormal cells within the breast tissues. The type of breast cancer is determined by where the cancer began – in the ducts, the lobules or other areas, such as the connective tissue or in the blood vessels. It is also important to determine if the cancer has spread beyond the ducts or lobules and invaded nearby lymph nodes.

The lymph nodes are bean-shaped groupings of immune system cells that help the body fight off infections and other threats. A woman’s breast contains both blood vessels and lymph vessels. Within the lymph vessels is a clear fluid called lymph. Fluid from the breast tissue drains through the lymph vessels to the lymph nodes under the armpit, near the breastbone and above the collar bone. 

Thus, when breast cancer starts to spread, the most common first location is the nearby lymph nodes. If breast cancer has spread to the axillary lymph nodes (located in the underarm region of the body), it can cause swelling of these nodes. After the cancer cells have spread to the lymph nodes it is more likely that the cancer will spread to other areas as well, such as the lungs, bones or brain.

According to the National Cancer Institute  (NCI), breast cancer is the most common cancer among women, excluding non-melanoma skin cancers. It accounts for nearly 1 in 3 cancers diagnosed in women in the United States. Since 1990, the death rate from breast cancer in women has declined. The decreased number of deaths has been attributed to both earlier detection and advances in treatment of the disease.

A study released in 2006 indicated that the incidence, or new cases, of invasive breast cancer declined in the period from mid-2002 to 2003. The ACS statistics for 2001 to 2003 indicate that new breast cancer cases leveled off after 20 years of increases. Many factors may contribute to this change, including changes in early detection or a major decrease in the use of hormone replacement therapy by women after menopause. However, the cause and effect of such changes are difficult to establish, especially in the short term.

Types and differences of breast cancer

There are several different types of breast cancer. Some cancer diagnoses are followed by the words in situ, meaning the cancer is contained to a single area, such as a milk duct or lobule, and shows no sign of invasion. If the cancer breaks through the basement membrane that lines the cells from the surrounding lobules or ducts, it is called infiltrating or invasive carcinoma. From there, the cancer can spread to blood vessels, lymph nodes and other parts of the breast. If not detected early, it also can spread to other parts of the body.

The most common types of breast cancer include:

  • Infiltrating (or invasive) ductal carcinoma. This form of breast cancer is by far the most common, accounting for 70 to 80 percent of all cases, according to the National Cancer Institute (NCI). As the mass grows, it can lead to a dimpling of the breast or the nipple retracting inward. 
  • Ductal carcinoma in situ (DCIS). Also known as intraductal carcinoma or non-invasive ductal carcinoma, DCIS refers to cancer cells confined to the milk duct of the breast with no evidence of invasion into the surrounding tissues.  DCIS is now a common diagnosis due to the widespread use of screening mammography and usually shows up as calcifications on the mammogram. In situ cancers are noninvasive and are considered the earliest stage of breast cancer.
  • Infiltrating (or invasive) lobular carcinoma. This invasive type of breast cancer can be difficult to detect because it often appears as a thickening within the breast and not a clearly defined mass. A small number of women diagnosed with infiltrating lobular carcinoma will develop the disease in both breasts. Lobular carcinoma accounts for less than 10 percent of invasive breast cancers, according the American Cancer Society (ACS).
  • Inflammatory breast cancer. This form of the disease is considered a highly malignant type of breast cancer. Inflammatory breast cancer can spread rapidly producing symptoms of swelling and redness and skin that is warm to the touch. The ACS estimates that approximately 1 to 3 percent of all breast cancer diagnoses are inflammatory breast cancer.
  • Lobular carcinoma in situ (LCIS). Also known as noninvasive lobular carcinoma, LCIS is more common among premenopausal women and often develops in both breasts or in several areas of one breast. Very few women diagnosed with LCIS develop an invasive form of breast cancer.

In addition to the more common forms of breast cancer, there are other rarer types of invasive breast cancers. These are:

  • Paget’s disease. This disease is slow-growing cancer of the areola (pink area around the nipple) and nipple. Starting in the milk ducts of the nipple, Paget’s disease eventually grows onto the nipple itself. It is sometimes mistaken for eczema as it can create itchiness or a crusty appearance around the nipple. This form of breast cancer accounts for about 1 percent of all cases of breast cancer, according to the ACS.
  • Medullary carcinoma. This type of infiltrating cancer is characterized by large cancer cells and a distinct margin between cancerous and normal tissue. It accounts for less than 5 percent of breast cancers, according to the ACS.
  • Tubular carcinoma. This invasive cancer is a slow-growing form of breast cancer that is tube-shaped. It accounts for approximately 2 percent of all breast cancers, according to the ACS.
  • Mucinous (colloid) cancers. This type of breast cancer contains a mucous protein within the cancer cells.

Other, extremely rare breast cancers include:

  • Angiosarcoma, which is sometimes referred to as hemangiosarcoma
  • Phyllodes tumor, which is normally seen in women of middle age who have a prior medical history of fibroadenomas
  • Primary lymphoma

The NCI labels these as tumor subtypes that occur in the breast, but are not considered typical breast cancers.

Risk factors and causes of breast cancer

Breast cancer is a common form of cancer among women in the United States, Canada and Europe. However, in Africa and Asia, the prevalence is much lower, indicating the possibility of environmental triggers as well as a genetic predisposition.

While the number one risk factor is simply being female, other risk factors include:

  • Age. Breast cancer occurs more often in women over 50 and is less common in premenopausal women. Nearly 80 percent of all newly diagnosed invasive breast cancer cases occur in women aged 50 and older, according to the American Cancer Society (ACS). 
  • Family history. Women with family history of breast cancer have a greater risk of developing the disease. The risk is highest when the breast cancer occurs in a first-degree relative (mother, sister or daughter) and when the cancer occurs before age 50. A family history of ovarian cancer also increases the risk of breast cancer in women.
  • Genetic factors. Inheriting mutations or alterations of certain genes called BRCA1 and BRCA2 increases the risk of developing breast cancer. The ACS estimates that 5 to 10 percent of breast cancer cases result from inherited mutations of these genes.  A woman with these genes has an 80 percent chance of developing breast cancer in her lifetime, according to the ACS. Women with a family history of breast cancer may be tested for the mutated gene. However, interpretation of the test results and decisions about treatment are complicated. Recent studies have identified other genes and gene mutations that may be associated with breast cancer. Several studies have shown nearly 200 gene mutations that are associated with some breast tumors.
  • Ashkenazi Jewish heritage. This segment of the population has a higher incidence of the BRCA 1 and 2 genes and a higher prevalence of breast cancer.
  • Previous history of breast cancer or of benign breast tumors. This includes being diagnosed with breast cancer as well as noncancerous tumors. Research has demonstrated the risk of developing breast cancer varies with the actual type of benign breast disease found in a woman.
  • Race. Breast cancer is more common in white women than in those of other races, including Hispanic, Asian or black American. Race also affects the survival rate of breast cancer patients. White women with breast cancer have a 90 percent chance of surviving five years. African American women, however, have a 76 percent chance of surviving five years. The difference in survival may be attributed to later stage diagnosis and poorer treatment options. In addition, recent studies have indicated that African American women may be more likely to get a form of breast cancer that is less responsive to treatment.
  • Hormone factors. Hormones may increase the risk of breast cancer. Hormonal influences that are believed to raise the risk include:
    • Early menarche. Women who started their period before 12 years of age.
    • Late menopause. Women who go through menopause after age 55.
    • Pregnancy history. Women who have their first child after the age of 30 or who have had fewer pregnancies or no pregnancies.
    • Hormone drugs. The use of oral contraceptives has been linked to a slight increase in breast cancer risk. However, women who have stopped using oral contraceptives for 10 years or more share the same risk as those women who never used them. Hormone replacement therapy (HRT) that uses a combination of estrogen and progestin may increase a woman’s risk. The risk increases with the length of use. HRT has been a common treatment for some of the symptoms experienced during menopause, although rates dropped greatly after a 2002 study linked the practice to increased risks for breast cancer, stroke and heart disease. When estrogen is used alone (estrogen replacement therapy [ERT]), the breast cancer risk appears to be lower than with combination HRT including progesterone.
  • Breast density. Women with less fatty, denser breasts, which are normally older women, have an increased chance of breast cancer.
  • Exposure to DES (diethylstilbestrol). A synthetic estrogen widely prescribed from the early 1940s through the early 1970s for pregnant women, DES is believed to slightly increase a woman’s risk of breast cancer. For years, DES was also linked to rare vaginal and cervical cancers in the daughters exposed to the drug during their mothers’ pregnancies. New research shows that these DES daughters also have an increased risk of developing breast cancer.
  • Obesity after menopause. In postmenopausal women, estrogen is primarily produced by fat tissue. If a woman is significantly overweight, she has more fat tissue and more estrogen is being produced in their body.  In a recent study conducted by the ACS, women who were overweight based on a body mass index (BMI) greater than 25 are 1.3 to 2.1 times more likely to die from breast cancer than women with a normal BMI. Women who are obese prior to menopause do not demonstrate the same increased risk.
  • Radiation to the chest area. For women treated for Hodgkin’s lymphoma with radiation to the chest before age 30, the chances of developing breast cancer are higher than the general population.
  • Sedentary lifestyle. Women who are physically inactive have a higher rate of breast cancer, possibly due to a sedentary lifestyle leading to a person becoming overweight or obese, which is also an independent risk factor for breast cancer.
  • Use of alcohol. Several studies have concluded that the more alcohol consumed by a woman, the higher her risk of breast cancer becomes. Analysis of these studies suggests that the equivalent of two alcoholic drinks per day may increase the risk of breast cancer by 21 percent. The risk is thought to be related to alcohol causing an increase in the body’s hormone levels.
  • Smoking. Smoking significantly increases the risk of developing this disease, particularly for those with a family history of breast cancer.

Although the specific causes of breast cancer are unknown, some associations are becoming clearer. The effect of hormones on tumors and development is apparent, as are changes in the DNA of numerous genes. 

Signs and symptoms of breast cancer

At its earliest stages, signs of breast cancer may not be apparent during a breast self-examination, clinical breast exam or on mammography. As it grows, over a period of months and sometimes several years, breast cancer can cause several outward symptoms that can be noticed. Anyone (male or female) experiencing any of these symptoms should seek advice from a qualified physician. These symptoms may include:

  • Rash on the skin of the breast, areola or nipple that makes it appear scaly, red or swollen
  • Ridges, pitting or dimpling of the breast
  • Fluid from nipples (discharge), especially containing blood
  • A lump or thickening in the breast
  • A lump in the underarm area
  • Nipple tenderness
  • A change in the size or shape of the breast
  • A nipple partially or completely retracted inward (into the breast)

As the undetected breast cancer progresses, the symptoms may become more noticeable. The cancer may start with cells that have not yet formed a lump. As the cancer progresses, the tumor will grow and the lump may be felt (palpable) by the individual or a physician. In addition, the lymph nodes may become enlarged indicating possible spreading of the cancer.

In the majority of breast cancer diagnoses, there is no pain associated with the development of breast cancer. Some individuals, however, have reported pain around the lump in the breast. If  a woman is experiencing a persistent or unexplained painful area of the breast regardless if a lump is present, she should consult a physician.

Diagnosis methods for breast cancer

Regular physical examinations and maintaining an accurate medical history are important for maintaining good health, especially when screening for cancer before symptoms are present. In this way, physicians are more likely to detect and be able to treat cancer in its earliest stages. When breast cancer is caught in its earliest stages, the survival rates are dramatically increased and the adjuvant therapies may be more tolerable.

Mammography is the single most effective way to detect early breast cancer because it can often identify the disease several years before the appearance of symptoms. Mammograms are x-ray pictures of the breast that can show a tumor before it is large enough to be felt. Mammograms, which use minute amounts of radiation, can also pick up abnormal microcalcifications, which are minute deposits of calcium. Most calcification deposits are not cancer.

Digital mammography, a new, more accurate type of mammography is being examined as another form of breast cancer detection. This methods appears to provide a more detailed image of breast tissue and may be particularly useful for women with dense breasts. Digital mammography continues to be studied for its use in breast cancer screening.

The National Cancer Institute (NCI) and American Cancer Society (ACS) recommend that all women age 40 or older receive mammograms every one to two years. Women who are at higher risk for breast cancer may be advised to receive mammograms more often or earlier in life. 

On average, mammography will detect approximately 80 to 90 percent of breast cancers in women without symptoms, according to the ACS. It is important for a woman to know that while mammograms offer the best way to detect breast cancer at its earliest stages, mammography is not a fail-safe way of detecting breast cancer. For example:

  • A mammogram can give a false-negative result, which means that cancer is present but it does not show on the x-ray.
  • A mammogram can give a false-positive result and areas of concern turn out not to be cancer.
  • Certain breast cancers are fast-growing and can spread (metastasize) to other parts of the body before a regularly scheduled mammograms can detect their presence.

Women younger than 40 but who are at an elevated risk of developing breast cancer, such as those with a genetic predisposition, should discuss risk factors and additional screening with their physician.

In addition to mammograms, clinical breast exams (CBE) and breast self-examinations(BSE) are two more ways to screen for breast cancer. The clinical breast exam, which takes about 5 minutes, is performed carefully and systematically by a physician who feels the breasts with the pads of the fingers. Using this method, the physician will check the entire breast area, including under the arms, around the collarbone area and nearby lymph nodes. Ideally, the CBE should be a part of a regular health examination and should be scheduled shortly before a woman’s mammogram.

Many women perform a breast self examination every month checking for possible changes in their breasts. While some changes can be the result of pregnancy, menstrual cycle, aging, menopause, birth control pills or other hormones, any unusual changes should be discussed with a physician. Breast self examinations are not intended to replace clinical exams or mammograms.

If a mammogram returns results that prove to be inconclusive, a physician may send the patient for a breast ultrasonography.The ultrasound test works by sending and receiving harmless high-frequency sound waves to create images of internal organs or tissues. Sound waves pass through the tissues of the area being examined. These sound waves are recorded and displayed on a computer screen or television-type monitor or printed out for a physician to review for any abnormalities.

If the clinical breast exam, mammogram or ultrasound shows an area of possible concern, a biopsy is usually the next step. A biopsy is the removal of cells or tissues of concern so that they can be viewed under a microscope and further tested by a pathologist. The pathologist will determine whether or not the cells are cancerous.

Biopsies are conducted using various methods and can be performed in a physician’s office, outpatient clinic or hospital. The four most common types of biopsy include excisional, incisional, core and needle.

Another technique used to diagnose breast cancer is ductal lavage. With this procedure, the physician inserts a small catheter into a duct within the breast since this is where the majority of breast cancers develop. Through the catheter, a sample of cells is removed and examined for precancerous changes that take place long before tumors can be detected by a mammogram.

Most breast biopsies are benign (noncancerous). However, if the biopsy turns out to be malignant (cancerous), other tests may be recommended to further determine the course of treatment and whether or not the cancer has spread beyond the breast. Further tests also help to follow the course of therapy, such as a test for tumor markersSome tests also help determine changes in the state of the tumor.

These tests may help determine the best treatment options for the individual patient. Reactivity for two female hormones, estrogen and progesterone, is tested within the cancer cells. The result will give the estrogen-receptor status and the progesterone-receptor status. These results have impact on the type of treatment for the cancer.

For those breast cancer patients with an invasive form of breast cancer, the tumor should also be tested for another receptor called HER2/neu. When cancer cells overexpress the HER2/neu oncogene, they grow more rapidly and respond better to specific combinations of adjuvant therapy.

Other tests include the following:

  • Chest x-ray. The purpose of the chest x-ray is to determine if the breast cancer has spread to the lungs. This is normally done before any breast cancer surgery takes place.
  • Bone scan. A common place for breast cancer to spread is to the bones. A bone scan is often done with breast cancer patients to assure there is no detectable metastasis to the bones. The bone scan involves a small amount of a radioactive substance injected into a vein. The substance is attracted to areas of the bone that may be abnormal, which would appear on the films.
  • Computerized axial tomography (CAT) scan. If metastasis to other organs is suspected or needs to be ruled out for any reason, the physician may order a CAT scan. This is normally used for more advanced or later stages of breast cancer.
  • Magnetic resonance imaging (MRI). Powerful magnets linked to a computer are used to create detailed pictures of the breast tissue for use with the mammogram.  MRI may be used to detect breast cancer in some women at higher risk, although it should not replace mammography. MRI can also be used before surgery to identify areas of the breast affected by the tumor.
  • Positron emission tomography (PET) scan. A noninvasive test that takes a three–dimensional image of tissue using relatively harmless radioactive tracers injected into the body. A camera inside the machine detects any sign of radioactivity.
  • Blood tests. A complete blood count (CBC), as well as blood chemical and enzyme tests are normally requested prior to any surgery to determine if the blood has the correct number of blood cells and to give a quick glimpse into the patient’s overall health.

None of these tests is foolproof or 100 percent accurate, but the results give important information to treating physicians about the stage of the cancer and its response to therapy.

Treatment options for breast cancer

There are many treatments available for women and men diagnosed with breast cancer.  The best treatment options for breast cancer come with an early diagnosis. One of the most important elements of the treatment decision will depend on the stage of the breast cancer, which is an indication of whether or not the breast cancer has spread and, if so, how far and to what areas of the body. However, the proper treatment protocol will depend on a number of factors, including:

  • Size of the tumor

  • Location of the tumor within the breast

  • Stage of the disease (information on the size of the tumor and on whether or not the disease has spread to the nearby lymph nodes or other areas of the body)

  • Type of breast cancer

  • Estrogen-receptor status and progesterone-receptor levels. Breast cancer cells may have receptors that react with these hormones and thus the tumor may be more likely to respond to hormone therapy.

  • HER2/neu status.  Protein that promotes growth. Up to 25 percent of breast cancers are HER2-positive, meaning that the protein can stimulate tumor growth. Such tumors are more likely to respond to biological therapy.
  • Patient’s age, general health and (for women) menopausal status

  • Personal opinions and preferences of the patient

Other factors that are normally taken into consideration include whether or not the breast cancer has just been diagnosed or if it is a recurrence. After patients are diagnosed with breast cancer, their treatment plan will be designed by a cancer care team. This group of health care professionals may include:

  • Medical oncologist
  • Radiation oncologist
  • Surgeon
  • Plastic surgeon
  • Oncology nurse
  • Social worker

The type of treatment for breast cancer varies with the location, type and severity of the tumor. Breast cancer is staged according to the information obtained in the biopsy and staging tests, including imaging, history, physical examination and blood tests. After the cancer is staged, a treatment plan will be designed for the patient.

Therapy options for breast cancer include breast cancer surgery, chemotherapy, radiation therapy, biological therapy and hormonal therapy. Most breast cancers are treated with a combination of these options based on the stage and type of cancer. A brief overview of each option includes:

  • Breast cancer surgery. There are several options with breast cancer surgery and much will depend on the size and type of tumor involved, as well as its location within the breast. Some of the more common options include a lumpectomy or segmental (partial) mastectomy, which are both ways of sparing much of the breast. Following this type of surgery, most women will also receive radiation therapy to destroy any remaining cancer cells within the breast.

    To determine whether or not the cancer has spread, many surgeons will also perform an axillary node dissection. This procedure removes some or all of the axillary (underarm) lymph nodes for inspection by the pathologist for evidence of cancer. An alternative to a complete lymph node dissection is a sentinel node biopsy, a relatively new procedure that requires removal of the lymph node where the cancer is most likely to spread first. Research indicates that if the sentinel node does not contain cancer, it is likely there will be no cancer in the remaining lymph nodes. Sentinel node biopsy may cause fewer complications associated with an axillary node dissection but it cannot be used with all patients.

  • Radiation therapy. High-energy x-rays (radiation) are concentrated on the site of where the tumor was removed to kill any remaining cancer cells or to shrink a tumor prior to surgical removal. A common treatment combination includes lumpectomy followed by radiation therapy.

  • Chemotherapy. Chemotherapy drugs are used to treat cancer by destroying cancer cells before they divide, reproduce and spread throughout the body. Treatment with chemotherapy may be used before primary therapy to shrink the tumor (neoadjuvant therapy) or after surgery or radiation to try to prevent the emergence of undetectable cancer cells (adjuvant therapy). Chemotherapy may also be used to try to slow the spread of metastatic cancer and/or make it regress (shrink).

  • Hormone therapy. This type of therapy is commonly prescribed for women with breast cancer that has spread to other areas of the body. However, for certain early stage breast cancers, adjuvant hormone therapy may be used for deposits of cancer cells too small to detect. This may help prevent a recurrence. Tamoxifen (the most common estrogen blocker) and aromatase inhibitors are commonly used in this form of adjuvant therapy. This type of therapy keeps cancer cells from gaining access to the hormones they need to grow. In many cases, tamoxifen is prescribed for up to five years to prevent recurrence. Although tamoxifen has shown good results, it may increase a woman’s risk of developing endometrial cancer.  Another less common type of hormone therapy is removal of or radiation to the ovaries, which is where female hormones are produced.

  • Biological therapy. Treatment designed to bolster the body’s natural defenses against cancer. Biological therapy is very different from chemotherapy, but is often used in combination with chemotherapy. Biological therapy includes the use of artificially created monoclonal antibodies such as trastuzumab. This therapy can treat  HER2/neu-positive tumors by binding only to cells that overexpress HER2/neu and not other cancer cells or normal cells. Other biological therapies are being tried with some metastatic breast cancers. Bevacizumab works as an angiogenesis inhibitor, blocking the growth of blood vessels that feed the tumor.

Prevention methods for breast cancer

There are no known ways to prevent breast cancer. However, for women who are at increased risk of developing breast cancer and even for those who have just an average risk, there are tangible ways to reduce the risk of the disease advancing to an incurable stage, including:

  • Having a clinical breast exam every three years (for women who are under the age of 40)
  • Getting a mammogram every one to two years after age 40 (or possibly sooner or more often if at higher risk for developing breast cancer)

The following life styles may contribute to a decreased risk of disease development:

  • Limiting alcohol consumption
  • Maintaining a healthy weight
  • Consulting a physician regarding alternatives to taking estrogen or other hormones
  • Incorporating physical activity into daily life
  • Eating foods high in fiber and low in fat
  • Eating plenty of fruits and vegetables
  • Avoiding exposure to pesticides

Because there are no known ways to prevent breast cancer, one of the most important actions is to follow early detection guidelines. Early detection greatly increases the chances of successful treatment.

Recent research has been conducted into reducing the risk of breast cancer in women who are at higher risk for the disease, such as older women, women with BRCA1 and BRCA2 genes and women with a family history of the disease. The estrogen blocker tamoxifen, which is used to treat breast cancer, has also been approved for use in breast cancer risk reduction. Tamoxifen has also been used to prevent recurrence of breast cancer in women already treated for the disease. Tamoxifen has been shown to reduce the risk of invasive breast cancer by about 50 percent in postmenopausal women. Other drugs are also being studied for their potential use in risk reduction.

Women at extremely high risk for breast cancer, such as those with BRCA gene mutations and a strong family history of the disease, may consider preventive surgery. This may include preventive mastectomy or oophorectomy (removal of the ovaries). Some studies have shown that women with the BRCA1 gene mutation who have their ovaries removed before age 40 have much lower risk for breast cancer.

Ongoing research for breast cancer

In the past several years, there have been major advances in breast cancer research. The advances include understanding key information into the causes of breast cancer, as well as advancing current therapies to offer less invasive and, at times, less aggressive treatments without sacrificing survival rates. Currently there are many studies under way in nearly every aspect of breast cancer research, including ways to prevent, detect, diagnose and treat breast cancer, as well as tackling the psychological effects of the disease.

Some of the main areas of research on possible causes and risks of breast cancer include:

  • Diet
  • Hormonal factors
  • Genetic predisposition
  • Environmental factors
  • Sedentary lifestyle

Other research being conducted focuses on detection and diagnosis, including:

  • Standard mammography vs. digital mammography
  • The use of MRIs and PET scans
  • Tumor markers to detect recurrences

Some of the major areas of research in cancer prevention and treatment include:

  • Hormone therapy drugs. The estrogen blocker tamoxifen has been used to treat breast cancer and to prevent new disease in high risk women and recurrence. A recently concluded study, the Study of Tamoxifen and Raloxifene (STAR), investigated the use of tamoxifen or raloxifene (an osteoporosis drug) for breast cancer prevention in high risk menopausal women. Both drugs reduced the rate of invasive breast cancer by about 50 percent. Other studies continue to investigate hormone therapy drugs for breast cancer treatment.
  • Biological therapy drugs. New studies in the use of the monoclonal antibody trastuzumab have shown improvement both in early stage breast cancer and for patients with advanced disease. Trastuzumab has also been used as targeted therapy with chemotherapy drugs.
  • Antiangiogenesis drugs that block the growth of blood vessels feeding tumors.
  • Other targeted therapies. Recent research on the drug lapatinib, which inhibits certain enzymes, has shown progress in cases of inflammatory breast cancer and some HER2-positive cancers that no longer respond to trastuzumab.
  • Identification of other genes and proteins that affect tumor growth.
  • Over the counter drugs (e.g., aspirin) for risk reduction.
  • Tumor cell analysis and molecular genetics.
  • Targeted therapies for delivering chemotherapy drugs.
  • Accelerated partial breast irradiation (APBI).

There are many clinical trials being conducted in the area of breast cancer. Patients should discuss their participation in appropriate clinical trials with their cancer care team.

Research also continues into the genetic mutations associated with breast cancer. Some studies have identified nearly 200 gene mutations in breast cancer. Another study produced a genetic combination, or “signature” of tumors that may be useful to predict the course of the disease or potential response to treatment. Further genetic research may indicate more patterns in the gene expressions seen in breast cancer and help adapt classifications of tumors to improve treatment.

Staging of breast cancer

Physicians use a staging method to classify breast cancer diagnoses. This information allows them to choose the best treatment options based on the stage and type of cancer. The stages are as follows:

  • Stage 0. Includes ductal and lobular carcinoma in situ (noninvasive cancer)
  • Stage I. When the cancer has spread beyond a milk duct or lobe, but not outside the breast. The tumor size for this stage is equal to or less than 1 inch across (2 centimeters [cm]).
  • Stage II. Like Stage I, Stage II is considered an early stage of breast cancer. Tumors can range from 1 inch across (2 cm) to more than 2 inches across (5 cm). They may or may not have spread to the axillary lymph nodes.
  • Stage III (A-C). This is considered a locally advanced form of breast cancer. It has spread to the axillary lymph nodes, to tissues near the breast (such as the skin or chest wall) or to lymph nodes inside the chest wall. Tumors can range from smaller than 2 inches (5 cm) to larger than 2 inches.
  • Stage IV. Metastatic cancer, which is cancer that has spread to other more distant organs of the body. Frequent metastatic sites for breast cancer are the bones, lungs, liver or brain. Stage IV is also the classification given to inflammatory breast cancer or breast cancer that has spread to the lymph nodes in the neck near the collarbone.

Questions for your doctor about breast cancer

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their condition. Patients may wish to ask their doctor the following questions about breast cancer:

  1. Am I at high risk for breast cancer?
  2. What type of abnormality does my mammogram show?
  3. Will I need a biopsy and if so, how will it be done?
  4. Will I need a lymph node dissection?
  5. What type of cancer do I have and what stage is it?
  6. What are the best treatment options for my cancer?
  7. Will I need hormone therapy following my primary treatment?
  8. What is the prognosis for my breast cancer?
  9. What are my chances of a recurrence?
  10. Am I at risk for other cancers now that I have breast cancer?
  11. Do you recommend any type of genetic testing?
  12. Can you refer me to a breast cancer support group?
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