Information for Patients and Caregivers

What is Breast Cancer?
Common Symptoms
What Causes Breast Cancer?
Treatments
After Treatment
Additional Information

The breast is comprised mainly of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures (called lobules) that contain milk glands. Tiny ducts connect the glands, lobules, and lobes and carry the milk from the lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple of the breast). Blood and lymph vessels run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products.

The main forms of breast cancer are:

• Invasive ductal carcinoma — This type of breast cancer develops in the milk ducts and accounts for about 79 percent of cases. It can break through the duct wall and invade the breast's fatty tissue, then metastasize (spread) to other parts of the body through the bloodstream or lymphatic system.
• Invasive lobular carcinoma — This type of breast cancer accounts for about 10 percent of cases and originates in the breast's milk-producing lobules. It also can spread to the breast's fatty tissue and other places in the body.
• Medullary, mucinous and tubular carcinomas — These are three slow-growing types of breast cancer. Together they represent about 10 percent of all breast cancers.
• Paget's disease — This type represents about 1 percent of breast cancers. It starts in the milk ducts of the nipple and can spread to the areola (dark circle around the nipple). Women who get Paget's disease usually have a history of nipple crusting, scaling, itching or inflammation.
• Inflammatory carcinoma —This type accounts for about 1 percent of all cases. Of all breast cancers, inflammatory carcinoma is the most aggressive and difficult to treat, because it spreads so quickly.
• Ductal carcinoma in situ (DCIS) — DCIS occurs when cancer cells fill the ducts but haven't yet spread through the walls into fatty tissue. Nearly all women diagnosed at this early stage can be cured. Without treatment, about 25 percent of DCIS cases will lead to invasive breast cancer within 10 years.
• Lobular carcinoma in situ (LCIS) — LCIS is less common and less of a threat than DCIS. It develops in the breast's milk-producing lobules. LCIS doesn't require treatment, but it does increase a woman's risk of developing breast cancer.

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Common Symptoms?
A woman who has breast cancer may have no problems, or she may find a painless lump in her breast. If women examine their breasts monthly, they can help find lumps or other changes that a doctor should examine.

Most breast lumps are not cancer, but all lumps should be checked out by a doctor to be sure. Non cancerous breast lumps may be scar tissue or cysts (fluid-filled lumps or sacs) or they can be due to normal breast changes associated with hormone changes or aging.

Symptoms of breast cancer include:

• A lump or thickening in the breast or under the arm
• A clear or bloody discharge from the nipple
• Persistent crusting or scaling of the nipple
• Inverted nipples
• Redness or swelling of the breast
• Dimpling on the breast skin resembling the texture of an orange
• A change in the contours of the breast, such as one being higher than the other
• A sore or ulcer on the skin of the breast that does not heal

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What Causes Breast Cancer?
Many cases of breast cancer occur in women with no obvious risk factors. This means that women need to be alert in watching for possible changes in their breasts, performing self-examinations, and scheduling clinical breast examinations and mammograms. It is likely that multiple risk factors influence the development of breast cancer. Some of these include:

Age. The risk of developing breast cancer increases as a woman ages, with the majority of breast cancers developing in women over the age 50. At age 30, a woman's risk of developing breast cancer is one in 2,525. By age 50, her chances are one in 50, rising to one in 14 by age 70.

Race. Although white women are more likely to develop breast cancer, black women are more likely to die from the disease. The reasons for this are unclear and probably involve both socioeconomic and biologic factors.

Previous history of breast cancer. Women who have had breast cancer in one breast have three to four times the risk of breast cancer in their opposite breast.

A history of endometrial or ovarian cancer. The development of these cancers is also associated with exposure to hormones and, therefore, a woman's risk of breast cancer may also be increased. Some BRCA1 or BRCA2 gene mutations may also increase the risk of both ovarian and breast cancers.

A family history of breast cancer. Women who have a first-degree relative (mother, sister, daughter) diagnosed with breast cancer are at increased risk of the disease. More than one first-degree relative with breast cancer elevates that risk.

A genetic predisposition. Mutations to the BRCA1 or BRCA2 genes are associated with increased breast cancer risk. Screening tests are available to test for known mutations to these genes, but are not recommended for everyone and only following appropriate genetic counseling. Researchers estimate that breast cancers caused by these genes make up only 2% to 3% of all breast cancers.

Estrogen exposure. Estrogen is a hormone in women that controls the development of secondary sex characteristics (such as breast development). A woman's production of estrogen decreases at menopause. Doctors think that exposure to estrogen for a long time may increase breast cancer risk:

• A long menstrual history: Women who began menstruating before age 12 or went through menopause after age 55 have a higher risk of breast cancer because their breast cells have been exposed to estrogen for longer periods of time.
• Late or no pregnancies: Women who have their first pregnancy after age 30 or who have never had a full-term pregnancy have a higher risk of breast cancer. Pregnancy may protect against breast cancer because it pushes breast cells into their final phase of maturation.
• Estrogen in medication: Recent use of oral contraceptives or hormone replacement therapy (HRT), or long-term use of HRT, may increase a woman's risk of breast cancer.

Atypical hyperplasia. This is a condition characterized by abnormal, but not cancerous, cells. Atypical hyperplasia is a risk factor of breast cancer.

Lobular carcinoma in-situ. This is associated with an increased risk of developing a cancer in either breast when found within an otherwise benign breast biopsy.

Lifestyle factors. As with other types of cancer, studies continue to show that various habits may contribute to the development of breast cancer. These include:

• Obesity: According to a new study, being obese or even overweight increases a woman's risk of breast cancer.
• Lack of exercise: Exercise lowers hormone levels and boosts the immune system; lack of exercise contributes to obesity.
• Alcohol use: Drinking more than one alcoholic drink per day may raise the risk of breast cancer.

Radiation. High doses of radiation may increase a woman's risk of breast cancer. An increased risk of breast cancer has been observed in long-term survivors of atomic bombs, patients with lymphoma treated with radiation therapy to the chest, patients undergoing large numbers of x-rays for tuberculosis or non-malignant conditions of the spine, and children treated with radiation for tinea capitis (ringworm).

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Treatments for Breast Cancer
Even though the doctor will tailor the treatment for breast cancer to the patient's disease and personal situation, there are some general steps in the logic of treating the disease. Primarily, the initial therapy for early stage disease is aimed at eliminating any visible tumor. Therefore, doctors will recommend surgery to remove the tumor with or without radiation therapy.

The next step in the management of early stage disease is to reduce the risk of the disease recurring and to eliminate any cancer cells that may remain. If a tumor is of a certain size or lymph nodes are involved, the doctor may recommend additional therapy, such as radiation therapy, chemotherapy, or hormonal therapy. If the cancer recurs, the patient may choose additional surgery, depending on where the cancer is found, or a variety of treatments designed to fight distant metastases.

Surgery

Generally, the smaller the tumor, the more surgical options a patient has. The general types of surgery include the following:

• Lumpectomy - A lumpectomy removes the tumor and a small "clean," or disease-free, margin of tissue around the tumor. Follow-up radiation therapy is given to the disease site.
• Partial Mastectomy - A partial mastectomy removes the tumor, an area of normal tissue, and part of the lining over the chest muscle where the tumor was. This surgery is similar to a lumpectomy. It is also called a segmental mastectomy and requires follow-up radiation.
• Modified Radical Mastectomy - A modified radical mastectomy removes the breast, some of the underarm lymph nodes, and the lining over the chest muscles.
• Total Mastectomy - A total mastectomy removes the entire breast, leaving the underarm lymph nodes intact. This surgery is also called simple mastectomy.
• Radical Mastectomy - A radical mastectomy removes the breast, chest muscles, all lymph nodes under the arm, and additional fat and skin. It used to be the standard surgical treatment for breast cancer, but is an uncommon procedure today. About 15% of women who have had radical mastectomies experience lymphedema, the buildup of fluid in the lymph system.

Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery is not always better and may result in additional complications.

Choosing Between Lumpectomy and Mastectomy
One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for several weeks of radiation after surgery. But some women who have a mastectomy will still need radiation. For most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.

Possible side effects of mastectomy and lumpectomy include infection and blood or fluid collecting at the place where the incision is made. If lymph nodes are removed, there could be other side effects as well such as swelling of the arm (lymphedema).

Radiation Therapy and Chemotherapy are often used after lumpectomy or mastectomy to make sure that all the cancer cells are destroyed and do not grow back.

• Radiation therapy almost always is recommended after lumpectomy to destroy any cancer cells left behind and to prevent the cancer from returning. Without radiation therapy, the odds of the cancer returning increase by about 25 percent.
• The need for Chemotherapy depends on how much the cancer has spread. In some cases, chemotherapy will be recommended before surgery to shrink a large tumor so that it can be removed more easily. Chemotherapy is almost always necessary if cancer recurs. A form of chemotherapy called hormonal chemotherapy usually is recommended when the pathology report shows that the cancer is estrogen-receptor positive.

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After Treatment
After the first course of treatment is finished, it is very important to keep all follow-up visits to your doctor. Be sure and tell the doctor about any symptoms or side effects that concern you.

Lymphedema is a swelling of the arm caused by fluid build up that may occur after treatment for breast cancer. It's hard to tell which women will develop lymphedema. It can happen right after surgery, or months or even years later.

With care, lymphedema can often be avoided or kept under control. Injury or infection of the arm on the affected side can cause lymphedema or make it worse. Tell your doctor right away about any swelling, tightness, or injury to the hand or arm. There are ways to help prevent problems. More information about lymphedema is available through our toll-free number or on our Web site.

Treatment for breast cancer can affect the pleasure from touching the breast. In a reconstructed breast, the feeling of pleasure from touching the nipple is largely lost because a preserved or rebuilt nipple has much less feeling than a natural one. The skin of the breast itself may be less sensitive, too. Some feeling can return after time, though.