Overview Often women fail to pay attention to breast health unless they are forced to while breast feeding a newborn or when a serious condition like breast cancer occurs. Like most bodily processes, the breast can undergo changes over your lifetime, and it is important to pay attention to your breast health and understand these changes so that you can pursue the right course of action. Everyday cells in the body divide, grow and die, but there are times when cells grow uncontrollably and invade other tissues. The resulting mass of cells is known as a tumor. Tumors are classified as being benign (non-cancerous) or malignant (cancerous). It is the cancerous kinds that are responsible for causing breast cancer. Cancer is said to be localized when growth is limited to the breast (the primary site of origin). Metastatic tumors have spread beyond the breast to other parts of the body, like the lungs. A malignant tumor can form long before symptoms occur, which is why early screening is so important in fighting the disease. A breast cancer diagnosis can be an overwhelming experience, especially when women are forced to figure out the next steps to combat the disease. 2 This guide intends to provide you with enough information to allow you to ask the appropriate questions and make informed decisions. It is not meant to replace medical recommendations made by your doctor. By educating yourself on the topic, you can empower yourself to take a stand against breast cancer. Who Gets Breast Cancer? Breast cancer can strike anyone, although it does tend to follow particular trends. The majority of breast cancer cases are found in men. The lifetime risk that a man will develop breast cancer is 1 in 1,000. Most advanced cases of breast cancer occur in older women. Approximately 77% of all cases are diagnosed in women over the age of 50. Less than one percent of women in their 20s will be diagnosed with breast cancer. Caucasians are more likely to develop breast cancer than other ethnic groups. African Americans are more likely to die from the disease. Women in high socioeconomic classes tend to develop the disease more frequently. This is thought to be attributed to having children at older ages. 3
Risk Factors for Breast Cancer There are many factors that affect one s risk of developing breast cancer. Risk factors, such as those resulting from lifestyle choices, can be modified; others, like heredity and race, cannot be controlled. In fact, of the total number of breast cancer cases diagnosed, 55% to 75% of these have no known risks. So which factors contribute to the development of breast cancer? Uncontrollable Factors Age The greatest risk to developing breast cancer is increasing age. In fact, 77% of women diagnosed with breast cancer are over the age of 50. Family history If a first degree relative (i.e., mother, sister, or daughter) has previously developed breast cancer, you are 1.5 times as likely to develop the disease. Personal history of cancer If you have had cancer in one breast, the risk of developing cancer in the other breast increases three- to four-fold. Race While African Americans have lower incidences of breast cancer than Caucasians, they are more likely to die from it than Caucasian women. Menstrual cycle and menopause Menstruating before the age of 12 or entering menopause after the age of 50 increases breast cancer likelihood. Having breast conditions such as atypical ductal hyperplasia increases risk. Exposure of chest area to high doses of radiation while young increases breast cancer risk. Controllable Factors Obesity, especially after the onset of menopause. Diets high in fat or calories have been connected to increased incidences of breast cancer. Exercise Young women who exercise end up decreasing their hormone levels, thereby reducing risk. Breast feeding Women who have breast fed have reported lower incidences of breast cancer. Having no children or having children at a late age. Long term use of hormone replacement therapy. Estrogen and progesterone alone are weak carcinogens, but when combined, can significantly increase the possibility of contracting breast cancer. Oral contraceptives High doses of oral contraceptives, which contain estrogen, place women at greater risk. Drinking excessive alcohol. (2 to 5 drinks daily) Smoking. 04 50
Lower risks of getting breast cancer by: Controlling weight and doing moderate-intensity exercise on most days of the week. Familiarizing yourself with any family history of breast cancer. If your mother, sister, or daughter has the disease, ask your doctor what your risk is of getting breast cancer and how this risk can be reduced. Understanding the risks and benefits of hormone replacement therapy. If you must take estrogen for hormone replacement therapy, take the lowest dose possible. Reducing the amount of alcohol you consume. What s Normal In A Breast? There is no such thing as a normal breast. Breasts come in all shapes and sizes, and all breasts are comprised of three main types of tissue connective, glandular, and fatty tissues. Connective tissue provides the glue that holds fatty and glandular tissues together. Glandular tissues are made up of lobes, lobules, and ducts. Glands for each breast are divided into 15 to 20 lobes. Each lobe is further broken down into lobules, at whose terminus milk is produced. Lobes and lobules are connected together by a network of tubes called ducts. Ducts are responsible for conveying the flow of milk to the nipple. Breasts also contain lymphatic vessels, which carry the infection-fighting lymph fluid to a group of nodes near the breast, in the chest, underarms, and other parts of the body. Glandular and connective tissues often appear as solid white areas on a mammogram due to its density, while fatty tissues appear black. Lumpy or uneven breasts are common in women. This may be the result of hormonal changes, such as having a period, losing or gaining weight, medications, or the simple process of aging. Most lumps are not cancerous and may instead be caused by fibrocystic breast conditions or cysts. However, if you begin to notice lumpiness in one area of the breast, this may point to a tumor. Tumors occur when abnormal breast tissue cells grow uncontrollably. A tumor may or may not be cancerous. Those that do become cancerous continue growing and may break off and form cancers in other parts of the body. 6 7
Get To Know Your Breast Self Breast Exams Get familiar with your breasts do a self breast exam every month. It only takes about 10 minutes each month to give yourself a breast self-examination. Check your breasts a few days after your period, when your breasts are less tender. If you are no longer menstruating, simply select a regular date for your monthly self-exam. 1. Standing in Front of the Mirror: Start with your hands down at your sides. Look for changes in the size, shape, contour, color, dimpling or changes in the skin or nipple on the breast. Slightly raise your arms and feel under your underarms. Inspect your breasts with your hands on your hips, tightening your chest muscles. Lower your chances of developing breast cancer by making healthy choices and visiting your doctor on a regular basis. Early detection greatly increases your chance of survival. 2. Lying Down: Put a pillow under your right shoulder and place your right arm behind your head. Use the pads of your three middle fingers on your left hand to feel lumps in the right breast using overlapping dime-sized circular motions. Move up and down the breast beginning at the underarm until you reach the breastbone and from the collarbone to the ribs. Apply three different pressures with each pass light (for tissue closest to the skin), medium (for deeper tissue) and firm (for tissue close to the ribs and chest). Repeat the process on the left breast, using your right hand. These steps may be repeated while bathing or showering using soapy hands. It is important to check the underarms, nipples, and areas above and between your breasts. MONTHLY SELF-EXAM RECORD KEEPER m January m July m February m August m March m September m April m October m May m November m June m December 8 9
Recognizing the Warning Signs and Symptoms of Breast Cancer Breast tumors usually start off small and have no symptoms. By the time you can feel a lump, the tumor will have had time to grow, causing changes to how the breast looks and feels. Such changes include: A new lump or abnormal thickening on the breast A lump that has changed in size and shape A change in the size and shape of your breast Thickening of tissue or a solid mass in or near the breast or underarms Nipple becomes inverted or feels tender Skin on the breast, areola, or nipple appears red, swollen, or scaly Puckering, discoloration, or dimpling of the skin around the breast area Abnormal discharge from the nipple Pain is localized to a specific area of the breast The appearance of any of the above symptoms should be brought to the attention of a doctor as soon as possible. Screening Routine screening for breast cancer typically involves monthly self breast exams, clinical breast exams by a doctor, and the mammogram. Self Breast Exams Each woman should begin with the monthly self breast exams at age 18. Some experts question the benefits of self breast exams, citing that it does not prolong or add to survivability. However, self breast exams do serve a purpose: it allows you to judge whether your physician is evaluating you correctly. It also provides the following benefits: Self breast exams are a free and simple procedure Self breast exams can be done fairly regularly and are not dangerous to your health It is the way most lumps are discovered and reported to medical professionals 10 11
Clinical Breast Exams The clinical breast exam is performed by a doctor during annual physicals or gynecological check-ups. Clinical breast exams can be administered at any age, but health care experts recommend that women start having one at age 20 every three years. At age of 40, clinical breast exams should occur annually and in tandem with mammograms. You may wonder why a clinical breast exam is necessary when most breast lumps are discovered by self breast examinations. A clinical breast exam is important in that a physician can usually catch something a self breast exam misses. It is also used to diagnose other potential breast conditions, such as mastitis and fibroadenomas. Mammograms Mammograms continue to be the best procedure available for the early detection of breast cancer. Sometimes, mammograms can find signs for the disease as early as three years before any lumps can be felt. Healthcare experts recommend that women schedule a mammogram annually beginning at age 40. Schedule more frequent mammograms if a family history of breast cancer exists. In December 2009, the U.S. Preventive Services Task Force amended its guidelines to recommend that women receive routine biennial mammograms beginning at age 50 through age 74. Despite the new guidelines, health advocacy agencies such as the American Cancer Society continue to recommend that women begin receiving mammograms at age 40. Preparing for a Mammogram Mammograms are x-ray images of breast tissue taken by a technologist. Routine screening mammograms should occur annually starting at age 40. The opportune time for scheduling a mammogram is a few days after the end of the menstrual cycle, when the breasts tend to be less tender. Postmenopausal women may schedule their mammograms at any time. Some women avoid caffeine a few days before the exam in order to minimize any associated discomfort. Also, when scheduling the mammogram, notify the technologist if you have breast implants. During the procedure, each breast is pressed against two plastic plates, and pictures are taken from two different angles. Report any discomfort to the technician in charge. The procedure itself is fairly short, taking 15 minutes to complete with results available in 7-10 days. 12 13
Do not panic if a result comes back as abnormal. Your doctor will recommend more tests (such as an additional diagnostic mammogram, ultrasound, or biopsy) be performed to confirm the results. Most insurance policies generally cover the costs for a screening mammogram. Women who cannot afford to get a screening mammogram and who are between the ages of 40 and 64 can obtain information for free or low-cost mammograms by calling the National Breast and Cervical Cancer Early Detection Program at (800) CDC-INFO. DATE CBE and Mammogram Record Keeper NAME OF DOCTOR CBE OR MAMMOGRAM RESULTS Common Terms Used To Describe Breast Conditions and Breast Cancer Adenosis: A non-cancerous condition in which lumps develop due to enlarged lobules in the breast. Adenocarcinoma: Tumors that start in the glandular tissue (ducts and lobules). Benign breast changes: Non-cancerous changes in the breast that can produce lumpiness, pain, or other problems. Calcification: A build-up of calcium deposits in breast tissue. May consist of macrocalcifications (small white dots on a mammogram) or microcalcifications (small white specks). May require more testing if found in an area of rapidly dividing cells. Carcinoma: Malignant tumor that starts in the epithelial cells of the organ. Almost all breast cancers are carcinomas. Carcinoma in situ: Early stage breast cancer that is isolated to the site of origin. This kind of cancer is also known as non-invasive cancers and inaccurately as pre-cancerous. Cysts: Non-cancerous condition characterized by fluid-filled lumps found in the breast. 14 15
Estrogen receptor (ER) positive: Breast cancer that depends on estrogen to grow. Fibroadenomas: Non-cancerous condition characterized by hard, round lumps found in the breast. Hyperplasia: This term is used to describe minor changes to cells that line the terminal ductolobular unit. It is not considered cancer, but women who are diagnosed with atypical hyperplasia are 2 to 4 times as likely to develop breast cancer. Intraductal papilloma: Wart-like growths found in the milk ducts of the breast which are not considered cancerous. Invasive (infiltrating) carcinoma: This term describes cancer that has spread beyond the site of origin to other tissue systems. Progesterone receptor (PR) positive: Breast cancer that depends on progesterone to fuel its growth. Tumor: A tumor is an abnormal mass of tissue or lump. A tumor is classified as benign (noncancerous) or malignant (cancerous). Types of Breast Cancer Once a physician has identified the cancer, it is helpful to understand the type of cancer you have in order to make informed decisions about appropriate courses of treatment. Breast cancer typically includes the following types: Ductal carcinoma in situ (DCIS): This is the most common type of non-invasive breast cancer. It is isolated to the lining of the milk ducts. Physicians may refer to DCIS as stage 0 cancer. Infiltrating (invasive) ductal carcinoma (IDC): This is the most common type of invasive breast cancer, comprising 80% of all breast cancer diagnoses. Cancer that began in the milk ducts has spread to the surrounding tissues and/or organs. IDC is more common in older women. According to the American Cancer Society, approximately two-thirds of women diagnosed with IDC are age 55 or older. Infiltrating (invasive) lobular carcinoma (ILC): This is the second most common type of breast cancer found, comprising 10% of all breast cancer diagnoses. Cancer that began in the milkproducing lobules has spread to the surrounding tissues and/or organs. ILC has a much later age range, tending to occur in the early 60s rather than in the mid 50s. 16 17
Inflammatory breast cancer: Invasive cancer that has spread to the lymph vessels in the skin that covers the breast. Comprises 1% to 6% of all breast cancer cases. Lobular carcinoma in situ (LCIS): Breast cancer that is limited to the lobe and typically involves more than one lobe. LCIS is not very common and tends to be diagnosed from a breast biopsy that confirms the presence of other conditions. Paget s disease of the nipple: This is a rare type of breast cancer that affects the ducts of the nipple and then metastasizes to the nipple s surface and areola. Paget s disease of the nipple occurs in 5% of all breast cancer cases. Recurrent (metastatic) breast cancer: Breast cancer that returns after the initial treatment. This may occur in the same breast, opposite breast, or other organs, particularly the bones, liver, or lungs. Men and Breast Cancer Breast cancer is mostly considered a woman s disease, but it can affect men too. Until puberty, both boys and girls have a small amount of breast tissue under their nipples and areolas. This tissue is comprised of a few ducts. Breasts in girls develop as a result of hormonal changes during puberty. Just like any cell in the body, the remaining ductal cells in men can also undergo cancerous changes that can then spread to other parts of the body through the lymphatic system. Men can be affected by non-cancerous breast conditions such as benign breast tumors and gynecomastia, an enlargement of the breast that can be caused by medications, hormone imbalances, and obesity. A genetic condition known as Klinefelter Syndrome (a rare condition occurring in 1 out of every 1,000 males) can increase a man s risk of developing breast cancer. This is due to the presence of an extra X chromosome that leads to the development of gynecomastia. 18 19
Confirming a Diagnosis What to Expect Whenever a diagnosis of cancer is made from a mammogram, a doctor may refer the patient out for more testing in order to confirm the initial diagnosis. Such testing may include: Ultrasound: Also known as sonography, this procedure employs high frequency sound waves that bounce off tissues and organs to create an image. Ultrasound is used to investigate abnormalities that are hard to distinguish in a mammogram. Liquidfilled cysts will absorb sound waves whereas solid masses will cause sound waves to bounce back. Magnetic resonance imaging (MRI): Magnetic fields are used to generate detailed images of the breast from side-to-side, top-to-bottom, and front-to-back. Patients lie on their stomachs on a scanning table, with the breast hanging into a hollow in the table from which it will be scanned. MRIs can determine the extent of cancer and pinpoint where breast-preserving lumpectomies could be performed. Digital mammogram: This procedure resembles the screening mammography, except that computer code is used to record the x-ray image. Radiologists use computers to zoom in on suspicious areas. Biopsy: Small samples of tissue are removed and examined under a microscope by pathologists. There are several types of biopsies: Needle biopsies - are outpatient procedures performed in a doctor s office that can be used to confirm cancer diagnoses in lumps that can be felt. Doctors apply local anesthesia to numb the area from which cancer cells will be removed. Fine needle aspiration (FNA) - removes cells from the area in question using small needle syringes. A cytopathologist examines the excised cells for the presence of cancer. A positive result confirms the initial diagnosis. A negative result may require further exploration since a negative result can often be false negatives. Core biopsy - removes actual tissue. This procedure provides additional information about the suspected site. A pathologist can distinguish from this sample the type of breast cancer as well as any special characteristics associated with it. 20 21
Again, a negative result does not necessarily rule out the possibility of cancer, requiring instead additional testing to negate the presence of disease. Open biopsies - take place under the direction of a breast surgeon and requires the use of general anesthesia. The procedure involves a removal of some or all of the affected breast tissue. Two forms of open biopsies are practiced today: Excisional biopsy - usually known as a lumpectomy, excisional biopsies aim to preserve the breast by removing lumps in the breast rather than the entire breast. Incisional biopsy - only part of the lump is removed for examination by a pathologist. Hormone receptor testing is performed on tissue removed during a biopsy to determine whether the cancer requires estrogen or progesterone for its growth. HER-2 testing looks for the presence of the human epidermal growth factor-2 gene. Excess protein produced by HER-2 may indicate the return of breast cancer after the initial treatment. Information collected from these tests may then be used to determine a course of treatment. Treatment Options An Overview Depending on the type and staging of cancer found, several treatment options exist to treat breast cancer. Many are based on standards currently in practice; other, possibly more effective, treatments are in the process of clinical trials testing. The five standard treatment types 1. Surgery Most breast cancer patients elect to have the cancer removed from their breast. Two types of surgeries aim to preserve as much of the breast as possible. A lumpectomy removes the lump and a small amount of tissue surrounding the tumor. A partial mastectomy removes the cancerous part of the breast and some of the surrounding tissue. Mastectomies involve the removal of the entire breast and may be chosen for women who do not wish to wait for the prolonged treatment that preservation requires. Types of mastectomies include: Total (simple) mastectomy, which involves removal of the affected breast and some of the lymph nodes under the arm. 22 23
Modified radical mastectomy, in which the affected breast and the lymph nodes under the arm and lining on the chest muscle are removed. May also include removal of parts of the chest wall muscle. Modified radical mastectomies are the most commonly performed procedure of all the mastectomies. Radical mastectomy, which involves the removal of the affected breast, the lymph nodes under the arm, and chest wall muscles under the breast. This procedure is rarely performed. The decision to obtain breast reconstruction should ideally be made before any surgeries are performed. This would allow surgeons to use the most effective technique necessary to achieve the desired reconstruction outcome. Breast reconstruction involves implants or creating a TRAM flap (using abdominal tissue to create a breast mound). Once the decision to reconstruct is made, the actual procedure can then occur immediately after the surgery or at a later date. 2. Radiation Therapy High-energy x-rays are focused on the suspicious site to kill or shrink cancer cells. Two types of radiation therapy are employed. The type used depends on the extent and type of cancer that has been diagnosed. External beam radiation, which is the standard form of treatment, concentrates an external source of radiation on the cancer. Internal radiation targets the cancer using a radioactive source that is placed directly or near the cancer site. 3. Chemotherapy Cytoxic drugs are taken by mouth or injected into a vein. These drugs aim to stop metastasis of the cancer by inhibiting its growth or killing cells. Chemotherapy is often used before radiation therapy and is not interchangeable with radiation therapy. Chemotherapy is also considered necessary whenever the breast cancer exceeds 1 centimeter, regardless of its size. Unfortunately, chemotherapy does not distinguish between healthy and cancerous cells and will destroy both. 4. Hormone Therapy aims to stop, inhibit, or deter the growth of cancer cells. This treatment involves the removal of the actual hormones or blockage of actions by the hormones that propel the growth of the cancer. Hormone therapy is often effective for early stage or metastatic cancers. 24 25
5. Targeted Biologic Therapy uses drugs or substances that attack specific substances in cancer cells. Examples of targeted biologic therapies include monoclonal antibodies and tyrosine kinase inhibitors. New treatments being considered that are in clinical trials testing include: Sentinel lymph node biopsy followed by surgery, which involves the removal of the first lymph node that receives drainage from the tumor, followed by removal of the actual tumor. High-dose chemotherapy with stem cell transplant, which replaces cells destroyed by chemotherapy by infusing the patient with stem cells which grow and replace damaged blood cells. Remember that treatment options are determined by the type and extent of breast cancer diagnosed. Usually, DCIS and invasive cancers utilize a combination of lumpectomy and radiation or are removed by mastectomy alone. LCIS requires only the lumpectomy. Talk with your doctor about the pros and cons of each type of treatment so you can select a course that is right for you. Genetic Testing for BRCA Genes Mutations in the tumor suppressing BRCA1 or BRCA2 genes tend to increase a woman s lifetime risk for developing hereditary breast and ovarian cancer. BRCA Mutations account for 5% to 10% of all breast cancer cases diagnosed in the United States. Genetic testing can help those at an increased risk for breast cancer make informed choices and decide on the future of their health care and quality of life needs. Genetic testing methods vary, but most look for changes in the BRCA1 and BRCA2 DNA. A blood sample is required to start testing, and several weeks may pass before results become available. Costs vary from several hundred to several thousand dollars per test, and these tests may or may not be covered by insurance. Insurance carriers should be consulted for coverage determinations prior to testing. 26 27
Genetic testing may be good for women who: Are of Ashkenazi Jewish descent. Mutations of the BRCA genes are five times higher within Ashkenazi populations than for all non-jewish populations Norwegian, Dutch, and Icelandic peoples also have higher frequencies of the mutation Have family histories of breast cancer: two first degree relatives (sisters, daughters, mothers) diagnosed with breast cancer, one of whom is age 50 years or younger; a combination of first and second degree relatives diagnosed with breast and ovarian cancer; or a male relative diagnosed with breast cancer While a positive test indicates increased risk for developing the disease, it is important to understand that not every woman who carries the mutation will develop breast cancer. Similarly, a negative result indicates that a woman is not likely to inherit the susceptibility to breast cancer; however, she may still carry the same risks to the disease as the general population. Genetic counseling by a healthcare professional experienced in cancer genetics is recommended before and after the testing. During the counseling session, a cancer geneticist will take detailed personal and family history information in order to assess your risk for developing breast cancer. The Cancer Risk Assessment is good for women who have: A personal history of breast cancer Benign breast disease, LCIS, or DCIS Used HRT for the relief of menopausal symptoms More than one risk factor that increases their chances of developing the disease When genetic testing yields a positive diagnosis, take some time to process and interpret the diagnoses before deciding on an appropriate course of action. 28 29
Talking with Your Physician about Breast Changes Talk with your physician about any changes to your breast that you ve noticed. Be sure to include your personal or family medical history in your discussions with the doctor. Breast Changes or Problems: Breast changes I ve noticed: Personal Medical History Breast problems I ve experienced previously: Breast tests and exams I ve received: Date of last mammogram: Describe what the breast change feels like (i.e., is the new lump hard or soft, is your breast swollen, color of nipple discharge): Date when last menstrual period began: Medicines or herbs currently taken: Describe where the change occurs: I first noticed the change: Since then, the change (i.e., has gotten better, worse?): q I am pregnant q I have implants q I am breast feeding Cancers I ve had previously: 30 31
When it comes to breast cancer, you are not alone. Over 200,000 women are diagnosed with breast cancer every year. ef Changes will occur in your breasts during your lifetime. It is critical for you to understand what changes are normal and what are not. ef Have a plan in place that helps you detect the disease in its early stages. ef Make healthy lifestyle choices! If you smoke, quit. Cut the amount of alcohol you drink. Get physical. Keep a healthy weight. ef Early detection saves lives. 2012 Better Life Line. ASI 40390. SAGE: 66974. UPIC: BETTER. Item #9057.