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Breast Cancer

Definition

Breast cancer is a disease in which cancer cells grow in the breast tissue. Cancer occurs when cells in the body divide without control or order. If cells keep dividing uncontrollably, a mass of tissue forms. This is called a growth or tumor. The term cancer refers to malignant tumors. They can invade nearby tissue and spread to other parts of the body.

Although most people think of breast cancer as affecting women, men can develop breast cancer as well. Breast cancer in men can be more aggressive.

Causes

The cause of breast cancer is unknown. Research shows that certain risk factors are associated with the disease.

Risk Factors

Factors that increase your risk for breast cancer include:

• Sex: female, although men can also get breast cancer
• Age: 50 or older
• Personal history of breast cancer
• Family members with breast cancer
• Changes in breast tissue, such as atypical ductal hyperplasia (unusual and extra cells in the milk ducts), radial scar formation, and lobular carcinoma in situ (abnormal tissue growth that occurs within milk glands located at the end of the breast ducts.
• Changes in certain genes (BRCA1, BRCA2, and others)
• Race: Caucasian
• Increased exposure to estrogen over a lifetime through:
  • Early onset of menstruation
  • Late onset of menopause
  • No childbearing or late childbearing
  • Absence of breast-feeding
• Taking hormone replacement therapy (eg, Prempro )
• Tobacco use
• Increased breast density (more lobular and ductal tissue and less fatty tissue)
• Radiation therapy before the age of 30 years old
• Overuse of alcohol

Note: Studies show that most women with known risk factors do not get breast cancer. Many women who get breast cancer have none of the risk factors listed above except age.

Symptoms

When breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause the following changes:

• A lump or thickening in or near the breast or in the underarm area or in the neck
• A change in the size or shape of the breast
• Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast
• Ridges or pitting of the breast skin (like the skin of an orange)
• A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly)

Note: These symptoms may also be caused by other, less serious health conditions. Anyone experiencing these symptoms should see a doctor.

Diagnosis

The doctor will ask about your symptoms and medical history. A physical exam will be done.

Tests may include:

• Clinical breast exam: the size and texture of the lump is manually examined to determines whether the lump moves easily
• Mammography: x-rays of the breast to see lumps or other changes in breast tissue
• Ultrasonography: the use of high-frequency sound waves to see whether a lump is a fluid-filled cyst or a solid mass
• CT Scan: a type of x-ray that uses a computer to make pictures of structures inside the body
• PET/CT Scan: a type of imaging test that combines two types of imaging techniques
• Biopsy: removal of tumor tissue to be tested for cancer cells

• Fine needle aspiration: removal of fluid and/or cells from a breast lump using a thin needle
• Needle biopsy: removal of tissue with a needle from an area that looks suspicious on a mammogram but cannot be felt
• Incisional biopsy: cutting out a sample of a lump or suspicious area
• Excisional biopsy: cutting out all of a lump or suspicious area and an area of healthy tissue around the edges
• Tissue evaluation: breast cancer tissue is tested for the presence of estrogen and progesterone receptors, as well as the presence of the gene HER2/neu; these are used to help plan therapy
• Genetic testing: blood is evaluated for the presence of specific gene mutations in certain patients

Treatment

Once breast cancer is found, staging tests are done. This will help to find out if the cancer has spread and to what extent. Treatments include:

Surgery

• Lumpectomy: removal of the breast cancer and some normal tissue around it. Often, some of the lymph nodes under the arm are also removed.
• Segmentectomy: removal of the cancer and a larger area of normal breast tissue around it.
• Simple mastectomy: removal of the breast, or as much of the breast as possible. The surgeon will try not to remove lymph nodes.
• Radical mastectomy: removal of the breast, both chest muscles, the lymph nodes under the arm, and some additional fat and skin. This procedure is only considered in rare cases. It is done if the cancer has spread to the chest muscles and is rarely done in the US at this time.
• Modified radical mastectomy: removal of the whole breast, the lymph nodes under the arm and, often, the lining over the chest muscles.
• Sentinel lymph node biopsy: a small amount of blue dye and/or a radioactive tracer is placed in the area where the tumor was located. The dye or tracer is then followed into the armpit. The lymph nodes that pick up the substance are removed. The accuracy rate for this procedure exceeds 95% in experienced hands. It reliably identifies those lymph nodes that may contain cancer. Presently, those remaining lymph nodes should be removed if any sentinel nodes contain cancer. This method is usually done in women who do not have lymph nodes that can be felt in the armpit. The potential side effects are far less than seen after a standard lymph node dissection.
• Axillary lymph node dissection: removal of the lymph nodes under the arm. This is done to help determine whether cancer cells have entered the lymphatic system.

Radiation Therapy

This is the use of radiation to kill cancer cells and shrink tumors. Two main types of radiation may be used:

• External radiation therapy: radiation directed at the breast from a source outside the body
• Internal radiation therapy: radioactive materials placed into the breast in or near the cancer cells

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. It may be given in many forms including pill, injection, and via a catheter. The drugs enter the bloodstream. They travel through the body destroying mostly cancer cells. Some healthy cells are destroyed as well.

Biologic Therapy

Biologic therapy is the use of medicines or substances made by the body. They can increase or restore the body's natural defenses against cancer. It is also called biologic response modifier (BRM) therapy.

Hormonal Therapy

Hormonal therapy is designed to take advantage of the fact that many breast cancers are "estrogen sensitive." Estrogen binds to the "estrogen sensitive" cells and stimulates them to grow and divide. Anti-estrogen drugs prevent the binding of estrogen. This stops the cells from growing and, in doing so, prevents or delays breast cancer recurrence.

Prevention

Finding breast cancer early and treating it is the best way to prevent death from the disease. Breast cancer does not cause symptoms in the early stages. It is important to have screening exams and tests. These steps can help to find the cancer before symptoms appear. The following recommendations are for women with no symptoms who are not at high risk for breast cancer:

Mammograms

• Age 40-49: recommendations vary from waiting until age 50 to having the screening every 1-2 years.
• Age 50-74: ranges from every year to every two years

Clinical Breast Exam

• Age 20-39: ranges from every year to every 3 years
• Age 40 and older: every year
• Age 20 and older: talk to your doctor about the risks and benefits

If you have an increased risk of breast cancer, you may need to start getting mammograms earlier. You and your doctor can decide on the best screening schedule. Also, if you are at very high risk for breast cancer, surgery to remove your breasts before you get cancer (called prophylactic mastectomy) may be an option.

RESOURCES

• American Cancer Society
• CancerCare

References

Badash M. Other treatments for breast cancer. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated September 2009. Accessed September 30, 2009.

Breast cancer screening: research and guidelines. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated November 2009. Accessed January 19, 2010.

Cancer of the female breast. National Cancer Institute website. Available at: http://seer.cancer.gov/publications/survival/surv%5Fbreast.pdf . Accessed July 11, 2008.

Carson-DeWitt R. PET/CT scan. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated November 2009. Accessed August 17, 2010.

Learn about breast cancer. American Cancer Society website. Available at: http://www.cancer.org/docroot/LRN/LRN%5F0.asp?dt=5 . Accessed July 11, 2008.

12/21/2006 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L; Trial Management Group. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial. Lancet . 2006;368:2053-2060.

1/19/2010 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Lee C, Dershaw D, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010;7(1):18.

1/28/2011 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance: Lostumbo L, Carbine N, Wallace J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev. 2010;(11):CD002748.

Revision Information

• Reviewer: Mohei Abouzied, MD
• Review Date: 09/2010 -
• Update Date: 01/28/2011 -

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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