Mesothelioma Info

Breast cancer is the most common cancer among women. Estimates indicate that 212,290 American women will be diagnosed with breast cancer in 2006, and about 41,000 women will die annually from this disease. It is estimated that 12% of American women will develop the disease and 3.5% will die from it.


Late in 2006, researchers presented the results of a study of breast cancer rates at a medical meeting showing a significant drop in new cases of breast cancer since 2003. The study showed that new cases declined by 7%. Many experts attribute this decline to decreased post-menopausal hormone use that occurred after a large study that was published in 2002 linked hormone use with breast cancer.

The incidence of breast cancer had been rising in American women for more than 30 years.Scientists have several possible explanations: 1) more cases are reported because methods of finding the disease have improved; 2) more women are living into old age (older women are at greater risk for breast cancer); and 3) many women are choosing to have children after age 30. A hormone called estrogen produced by the ovaries is thought to play a role in breast cancer. A woman who has not had children or who has put off having children will have more exposure to estrogen than a woman who gave birth at an early age.


While the number of cases had been increasing until recently, the death rate seems to be decreasing slightly, particularly for white women, because of early detection and increased use of mammography, as well as improved treatments after surgery.


Breast cancer is not only a serious physical disease, but it is often an emotionally draining disease as well. Intense feelings of fear, despair, loss, and loneliness are common among patients suffering from breast cancer. Issues regarding sexuality (especially if a mastectomy has been performed) often surround breast cancer. Even if you do not have to undergo a mastectomy, cancer is a word that can be very frightening, and you may find yourself needing a great deal of support from family, friends, and other people who have been diagnosed. It is important to talk with your doctor about the psychological side effects of breast cancer you may be dealing with. There are numerous support groups for women and their families to help cope with breast cancer. Your doctor or nurse can help you locate a group near you.
Causes

The precise cause of breast cancer is unknown. Breast cancer can happen to anyone. Most cases of breast cancer occur in women who are not classified as high risk, a reminder that more research must be done in order to uncover possible causes.


Breast cancer runs in families. Having a mother and/or a sister with the disease increases your risk. About a quarter of breast cancer cases occur in women who have the disease in the family.


Breast cancer has a genetic link. Scientists have recently identified two genes (BRCA1 and BRCA2) as having a link with breast cancer. However, defects (or mutations) in these genes seem responsible for only about 5% to 10% of breast cancer cases annually. Women who have these gene mutations are much more likely to develop breast cancer, especially at younger ages, compared to the general population. Studies show that approximately 2% of women of Ashkenazi Jewish origin (Eastern European) are carriers for these mutations. Women with BRCA1 or BRCA2 mutations may be advised to begin screening at age 25 because of their higher risk of developing breast cancer. If you have a strong family history of breast cancer at a young age, have had cancer in both breasts, or were diagnosed with breast cancer before age 30, you should consider being tested for mutations in these genes.


The female hormone called estrogen is linked to breast cancer. The role of estrogen and its relation to breast cancer is not yet completely understood. If you have never given birth, you are at greater risk for breast cancer because you have had more exposure to estrogen than women who have had a baby. This is because your body produces less estrogen when you are pregnant. Taking estrogen after menopause (hormone replacement therapy: HRT) also increases your risk. It is important to remember that taking estrogen after menopause also increases your long-term risk of heart disease and stroke. There has been a lot of discussion over the birth control pill and its possible link to breast cancer, but at this point, doctors generally agree that there is no greater risk if you are on the pill.
Some studies suggest that a diet high in animal fat and protein may be a factor in developing breast cancer, although the results of these studies are not definite.


Staging breast cancer helps to determining the course of treatment and the prognosis. Staging is based on the size of the tumor, how much of the breast tissue is cancerous, whether the underarm (axillary) lymph nodes are also cancerous, and whether cancer can be found in other parts of the body. The 5-year survival rate for localized breast cancer (not spread to the axillary lymph nodes) is 96%. If cancer has spread regionally, the rate is 77%. For those women who are diagnosed with metastatic disease, the 5-year survival rate is only 5 to 10%.
The stages for breast cancer are:

• Stage 0: This is characterized by cancer that has not spread from the breast tissue. Both DCIS and LCIS are classified as Stage 0.
• Stage I: This is an early form of the disease; however, the cancer has invaded nearby tissue. At this stage, the tumor is a little bit less than an inch in diameter, and the cancer has not spread beyond the breast.
• Stage II is divided into Stages IIa and IIb. It is an early form of the disease.
• Stage IIa is defined as being either of the following: 1) the cancer is a little less than an inch in diameter, but has spread to the lymph nodes under the arm (the axillary lymph nodes); or, 2) the cancer is between one to two inches, but has not spread to the lymph nodes under the arm.
• Stage IIb is either one of the following: 1) the cancer is between one to two inches and has spread to the lymph nodes under the arm; or, 2) the cancer is larger than two inches, but it has not spread to the lymph nodes.
• Stage III is divided into Stages IIIa and IIIb. This stage is considered to be locally advanced cancer.
• Stage IIIa is defined by either of the following: 1) the cancer is smaller than two inches and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures; or, 2) the cancer is larger than two inches and has spread to the lymph nodes under the arm.
• Stage IIIb is defined by either of the following: 1) the cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest); or, 2) the cancer has spread to lymph nodes inside the chest wall along the breast bone.
• Stage IV: Cancer has spread to other parts of the body (metastatic cancer). The five-year survival rate for cancer diagnosed at this stage is 5 to 10%.
• Inflammatory breast cancer is a rare form of breast cancer that you can see. The breast looks inflamed and red. The skin may show signs of ridges or dimples or pits. Inflammatory breast cancer tends to spread quickly. It is usually classified as Stage IIIb, with a five-year survival rate of 50%.
• Recurrent cancer: In recurrent cancer, the disease has come back despite treatment. The cancer can grow in the breast or chest wall (local recurrence), or in distant organs, bones, or lymph nodes (distant metastases). Some local recurrences can be curable, but distant metastases are almost never curable, even though some patients can live a long time. Most recurrences happen two to three years after the initial cancer diagnosis, although recurrences have been known to happen much earlier and much later.

Different types of tumors cause different types of breast cancer and grow in different areas of the breast.


Breast cancer is classified as being non-invasive or invasive. Non-invasive cancer (in situ carcinoma) is an early form of cancer that has not attacked any other tissue or grown beyond the breast ducts or lobules. Depending on when it is discovered and other factors, it can be cured. Two types of non-invasive cancer are ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). Both can turn into invasive cancer. Both of these types of cancer are considered to be Stage 0. Invasive cancer is cancer that has spread to other tissues. There are several different types of invasive cancer.
Figure 1. Anatomy of the female breast
The two types of non-invasive cancer (DCIS and LCIS) are early forms of the disease. Ductal carcinoma in situ (DCIS) generally starts in the channels that carry milk out of the breast (milk ducts). DCIS can be felt during a breast examination, but lately, it is more often detected by mammography. DCIS can develop before or after you stop menstruating (menopause). Surgery is often used to treat DCIS.


Lobular carcinoma in situ (LCIS) generally starts in the milk-producing glands of the breast. LCIS is not usually detected during a breast examination or a mammogram, but may be an incidental finding by a biopsy. A biopsy is a test done to determine whether or not a lump is cancerous. For a biopsy, a small amount of tissue is taken from the site and sent to a lab for testing. LCIS, which tends to develop before a woman reaches menopause, was once considered to be a pre-cancerous mass of cells. It is now thought to indicate an increased risk for developing a common type of invasive cancer. A woman who is diagnosed with LCIS is watched very carefully to detect any changes and to determine what kind of treatment should follow.


Invasive breast cancer is cancer that has spread outside the ducts and lobules to the surrounding breast tissues.


The two main types of invasive breast cancer are invasive ductal carcinoma and invasive lobular carcinoma. About 70% of breast cancer patients have invasive ductal carcinoma. This cancer develops in the milk ducts and can spread into the fatty breast tissue. In many cases it may then spread to other parts of the body such as the lymphatic system. Only about 10% of breast cancer patients have invasive lobular carcinoma. This cancer develops in the milk-producing lobes and can spread to the fatty breast tissue and elsewhere in the body.


Metastatic breast cancer refers to cancer that has left the breast and spread to distant sites. The most common sites are the lungs, liver, bones, brain, and skin. Cancer can appear in these areas years after the initial diagnosis. Metastatic breast cancer is not curable, although women can live many years with the disease.
Symptoms

In the early stages of breast cancer, there are often no symptoms, although this changes as the disease progresses. Signs and symptoms of breast cancer can include the following:

• A lump in the breast that feels distinctly different from other breast tissue or that does not go away
• Swelling of the breast that does not go away
• Thickening of breast tissue
• Dimpling or pulling of the skin on the breast, which may then resemble the skin of an orange
• Any change in breast shape or contour
• Nipple discharge
• Retraction of the nipple
• Scaliness of the nipple
• Pain or tenderness of the breast
• Swollen bumps or festering sores

These signs can be caused by many conditions, not just breast cancer. It is very important to tell your doctor if you experience any of these symptoms so that the right diagnosis can be made.
Risk Factors

There are two main risk factors for breast cancer: older age and having had breast cancer before.
Table 1. Recognized Risk Factors for Breast Cancer

High riskModerate riskLow riskOlder ageNever having given birthModerate alcohol intakeNorth American or Northern European country of birthHistory of breast cancer in any first-degree relativeMenstruation before age 12Personal history of breast cancer (in situ or invasive)Personal history of a primary cancer of the ovary or endometriumMenopause after age 55Family history of breast cancer in premenopausal women or familial cancer syndromeAge >30 y at first pregnancy Biopsy showing a proliferative breast lesion with atypiaSignificant radiation treatment of the chest Postmenopausal obesityUpper socioeconomic classGarber JE, Henderson IC, Love SM: Management of high-risk groups. In Breast Diseases, edn 2. Edited by Harris JR, Hellman S, Henderson IC, et al.. Philadelphia: JB Lippincott; 1991, 153-164.
Older women are at greater risk for breast cancer. If you have been diagnosed in the past, you are more likely to get breast cancer again, even though you have had a successful recovery. Other risk factors associated with the development of breast cancer in women include:

• Having a mother or sister who has had the disease
• Never having children, or having a first full-term pregnancy after the age of 30
• Having had two or more breast biopsies for non-cancerous (benign) conditions, or experiencing changes in the breasts such as atypical hyperplasia or lobular carcinoma in situ
• Having had an early onset of menstruation, before 12 years of age
• Having had a late onset of menopause, after 55 years of age
• Being obese, especially in the postmenopausal years
• Using alcohol excessively
• Having breast cancer in the family, and having over 75% dense breast tissue (if the tissue is mostly glandular tissue), especially in women who are at least 45 years of age
• Having had previous radiation therapy—especially during childhood, for the treatment of Hodgkin’s disease
• Having had increased exposure to estrogen due to the use of hormone replacement therapy, and also having had a strong history of breast cancer in the family.
• Living in North America or Western Europe

Diagnosis

If a lump in the breast is found, either by breast self-exam or mammography, other tests will be performed in order to make a diagnosis.

• Ultrasound scanning. This procedure is generally not part of routine screening for breast cancer, although it can be helpful in determining the difference between a cyst and a solid tumor. It uses high-frequency sound waves to image the breast tissue. Breast MRIIf you have breast cancer diagnosed by ultrasound or mammogram, your doctor may order a breast MRI. This test can be useful for evaluating the extent of breast cancer in your breast and for determining if you have any cancer tumors in your other breast.
• Fine needle aspiration. A thin needle is inserted into the lump and a sample is withdrawn. This test helps to determine if the lump is fluid-filled (a cyst, usually not cancerous) or a solid tumor. It can be performed in a doctor’s office with local anesthesia. The sample, regardless if it is fluid or solid, is sent to the laboratory for further analysis.
• Core biopsy. A larger needle is inserted into a lump or an area of abnormality seen on a mammogram, and a sample of tissue is removed. The sample is analyzed for cancer cells. This procedure is usually performed at a hospital with local anesthesia.
• Surgical biopsy. The lump and surrounding tissue is removed surgically before being sent to a laboratory for analysis. This procedure needs to be done in a hospital with either a local or general anesthetic.

Once a lump is found to be cancerous, further tests are performed to analyze the tumor itself. The tumor can be examined to find out how fast it is growing, and what kinds of treatment might work best.


In addition to examining the tumor, your doctor will run tests to assess your state of health and help determine whether your tumor has spread. Your doctor will take a full medical history, and will give you a complete physical examination. Your doctor will also look for cancer in the other breast. A chest x-ray will be done to look for cancer in other organs, and a bone scan may be done to look for cancer in the bones. This is done if the tumor is large, if the lymph nodes are enlarged, or if you are having symptoms such as bone pain.
Prevention and Screening

Because estrogen is linked to the development of breast cancer, limiting exposure to estrogen may decrease the risk. Hormone-blocking therapy, or antiestrogen therapy, is drug therapy that reduces the effects of estrogen, a hormone believed to increase the rate of breast cancer. Studies have shown that young women who have their ovaries removed are at a much lower risk of developing breast cancer than women with intact ovaries. The antiestrogen drug tamoxifen has been used for many years for metastatic and early breast cancer. In the 1990s, tamoxifen was studied as a drug to prevent breast cancer in high-risk healthy women.


This study showed that women who took tamoxifen for 5 years had nearly 50% fewer breast cancers than the women who took placebo. However, women on tamoxifen also had other side effects due to the drug, including more blood clots and cancers of the uterus. The use of tamoxifen for prevention should be discussed thoroughly with your doctor. There are current clinical trials looking at two different antiestrogens for prevention as well as other drugs such as retinoids.


Some women who feel they are at an especially high risk for developing breast cancer may opt to have both breasts removed. This is an extreme measure and is not done very often.


A mammogram is a type of x-ray used to detect breast cancer. Mammography uses low-level x-rays to find abnormal areas in the breast tissue. Mammography can also be useful in detecting small deposits of calcium in the breast tissue. These can be early signs of breast cancer. Although early detection is not always a guarantee that the cancer will be cured, survival is highest among early stage breast cancer and yearly mammograms for women aged 40 and over are highly recommended.
Figure 2. A woman having a mammogram
The best way to reduce the risk of dying from breast cancer is by having regular mammograms after the age of 50. The American Cancer Society recommends that women over 40 years of age have a mammogram once a year. Although a decrease in breast cancer mortality through screening mammography has only been demonstrated in women between the ages of 50 and 75, there is some suggestion that women in their forties may benefit as well. Mammography is less effective in younger women due to the lower incidence of breast cancer as well as the increase in breast density compared to older women. It is best to talk with your doctor about when and how often you should have a mammogram.


Mammography is not a perfect detection system, but it is the best one available for now. There is the chance of false negatives with a mammogram, which can happen when the cancer is not seen by the scan and therefore not diagnosed. False positives can occur when an area that is not cancerous is diagnosed as being cancer.


In about 80% of breast cancer cases, the woman detects the lump herself. Breast self-exam can allow for the detection of smaller tumors than those found by a doctor or nurse, since you are more familiar with how your breasts feel and are more aware of changes in your breasts.


Because breast tissue can often feel somewhat lumpy, some women are reluctant to perform breast self-exams, and become terrified at the discovery of a mass. Some lumps are normal, and many women find that their breasts feel differently depending on where they are in their menstrual cycles. Breast self-examination should be performed once a month at the same time each month—about one week after your period. Since your breasts change over the course of your menstrual cycle, if it is done at the same time each month, you will be able to detect changes in your breasts more accurately. Your doctor or nurse can teach you the proper technique for performing a breast-self exam.
Figure 3. Breast self-exam instructions
The differences between what a benign (not cancerous) lump often feels like and what a malignant (cancerous) lump might feel like are important to keep in mind. Most lumps are not cancer, but if you feel any lumps or changes, you should notify your physician. Your doctor will be able to make a proper diagnosis.
Table 2. Characteristics of Benign and Malignant Lumps

BenignMalignantSoft, spongyHard (feels like a bead)Easily movableImmobileSkin is smoothSkin looks dimpledNo change to nippleNipple retraction: nipple becomes inverted.Treatment

Urgent Care

Treatment usually begins within a few weeks after diagnosis. Unless the cancer is detected at an extremely advanced stage and your life is in immediate jeopardy, you generally have time to get a second opinion and discuss the various treatment options available, which may include a combination of such things as chemotherapy, radiation and surgery.


Your health care team may include surgeons, oncologists, plastic surgeons, radiation oncologists, as well as your own physician. Breast cancer is a serious disease that often requires the attention of numerous medical specialists. Coordinating all of the information from each of these doctors can become overwhelming. That is why it is generally a good idea to have someone accompany you to the doctor when discussing your treatment options.


Treatment for breast cancer is often complex and depends on a variety of factors. Treatment for breast cancer can involve surgery, chemotherapy, radiation therapy, and hormone-blocking medications. There is no one standard treatment plan. You and your doctor together will need to discuss the best course. Treatment will depend on size, type and location of the tumor, stage of the disease, your age, menopausal status, general health, and the size of your breasts. Women with small breasts are usually not good candidates for breast-preserving surgery. Different types of tumors respond to different types of medication.
Drug Therapy

Your doctor is the best source of information on the drug treatment choices available to you.
Other Therapies

Radiation therapy, which uses high-energy rays, is often used with surgery to kill any remaining cancerous cells. Radiation may be used before surgery to help shrink tumors, after lumpectomy, and after mastectomy if the tumor was large or if many lymph nodes were involved. There are two types of radiation treatments: external and internal.


In external radiation, the rays come from a machine positioned outside of the body. Patients generally have to go to the hospital every day for approximately 6 weeks in order to receive treatments. In internal radiation, the radiation comes from an implant—radioactive material is placed directly into the breast by way of thin plastic tubes. This latter form is much less common.


Radiation, like chemotherapy, is associated with certain side effects, although they are less severe. Side effects of radiation therapy may include: fatigue, reddening or blistering of the skin, and changes in the color of the skin. Rare side effects may include rib fractures, lung inflammation, cough, and shortness of breath.


Newer therapies are constantly being developed and tested. Ask your doctor about becoming involved with a clinical trial to test experimental drugs or treatments for breast cancer. The Physician Data Query system (Cancer.gov - URL Changed), which is produced by the National Cancer Institute, has been established to give both patients and physicians information on clinical trials.


Some treatments being used experimentally involve trying to change the body’s immune system so that it fights cancer cells. Bone marrow transplant is also an experimental approach to treating breast cancer that is currently being studied.
Surgery

Removal of the tumor and some normal tissue gives the best chance of preventing cancer from recurring within the breast. There are several surgical treatment options available to women who have been diagnosed with breast cancer. Which option is chosen will in part depend on the size and location of the tumor, the stage of the tumor, the size of the breast, and your personal desires. The types of surgical interventions include:

• Lumpectomy: For small tumors, this procedure removes the lump and surrounding breast tissue. Radiation to the breast is recommended after lumpectomy.
• Quadrantectomy: Removes one-fourth of the breast tissue
• Mastectomy: Complete removal of the breast. This is generally recommended for larger tumors, or for women with small breasts
• Simple mastectomy: All breast tissue is removed, but the underlying muscles are left intact and enough underlying skin is left to cover the wound
• Modified radical mastectomy: Removes all breast tissue and lymph nodes under the arm and often the lining over the chest muscle.
• Radical mastectomy: Removes all of the breast tissue, chest muscles, all of the lymph nodes under the arm and some additional fat and skin. Today, this is only used for advanced cases where the cancer has spread to the chest muscles.

After a mastectomy, many women chose to have breast reconstruction surgery. The breast is rebuilt using implants or tissue removed from other parts of the body. You can have this procedure done immediately following a mastectomy, or you can wait until after any additional treatment such as radiation and chemotherapy is finished.


Depending on the situation, one to several lymph nodes under the arm may be removed during surgery to determine whether the cancer has spread from beyond the original lump. This is done because the lymph system acts as a collection point for waste products from cells. If cancer cells have broken away from the tumor, they will most likely travel to the nearest lymph node. If the node does not hold cancerous cells, then the tumor may not have spread. However, removing the lymph nodes can result in swelling of the arm, a complication called lymphedema.


A new procedure called “sentinel” lymph node biopsy can now determine which specific lymph node needs to be removed. A tracer dye and/or radioactive compound is injected into the patient at the site of the tumor. By following the path of the dye (which is either colored blue or slightly radioactive), surgeons can determine which node the cancer would first spread to. The optimal use of sentinel lymph node biopsy is still being studied.


Even though the breast is not removed during a conserving surgery such as lumpectomy, the treated breast can change in appearance. It can become smaller, or the contour can change. Breast-conserving surgery is not recommended for everyone. People who should not have this type of surgery include:

• Women with tumors larger than 5 cm
• Women with smaller tumors but who have small breasts
• Tumors involving the nipple area
• Tumors that involve many parts of the breast
• Women unable to take radiation therapy after lumpectomy, including pregnant women and those with a serious collagen vascular disease, such as lupus.

As with all surgeries, there are side effects of breast surgery to be aware of. These include: pain, risk of infections, poor wound healing, bleeding, reduced strength, and numbness and tingling in the chest, underarm, and shoulder.


You hand and arm may swell as a result of the removal of the lymph nodes. You may also experience back and neck pain because removing the breast may cause your weight to shift and become distributed differently.
Special Circumstances

More than 1,000 men in the U.S. get breast cancer every year. While men are 150 times less likely to develop breast cancer than women, male breast cancer should not be ignored. Usually, the first sign is a lump in the breast, which tends to be misdiagnosed. In general, men are diagnosed at a later stage of the disease. However, when matched against women with the same stage and age, the prognosis for men is the same.


Any mass in the breast of a man should be thoroughly examined. The risk for developing breast cancer is higher for men with enlargement of the breast tissue (gynecomastia). A modified radical mastectomy is the usual course of treatment for men. Radiation may also be given. Almost 90% of men with breast cancer have the type of tumors that respond to hormone therapy.


Male breast cancer is similar to female breast cancer in that the information on symptoms, diagnosis, treatment, and living with the disease is the same. Men, however, do not need routine screening. Support and counseling may be beneficial to men with breast cancer, since it is so rare.
Prognosis

There are factors that can help determine the prognosis of the patient with early breast cancer. However, it is almost impossible to predict an outcome in each case. The number of lymph nodes involved, the size of the tumor, the grade (or aggressiveness) of the tumor, and whether the tumor has hormone receptors are the major factors that doctors rely on to make a prognosis. In general, the following often account for a poor prognosis in early breast cancer:

• Patients with many lymph nodes that are positive for cancer
• Inflammatory breast cancer
• Patients with large tumors
• Patients whose tumors are the type that will not respond to hormone treatment
• Patients with tumors whose tissue is very different from normal breast tissue. Some tumors have cells that are still closely related to normal breast cells, and some tumors have cells that barely resemble breast cells. Tumors that are very different from normal tissue are often stronger and more aggressive (referred to as high grade).

Thirty percent of patients without node involvement and 75% of patients with node involvement at diagnosis will develop metastatic disease (cancer that has spread to other tissues). Metastatic disease generally develops within five years after the initial diagnosis, although it can occur as many as 10 or more years later. Metastatic disease (Stage IV) is incurable. The five-year survival rate is about 5 to 10%.
Follow-up

Follow-up will require frequent doctor visits, often every three to four months for the first five years after the initial diagnosis. Follow-up visits should focus on determining whether cancer has appeared in the opposite breast, in the same breast, or in areas other than the breasts. In general, signs and symptoms often lead to the diagnosis of a recurrence. That is why it is important to inform your physician about any changes in your health such as coughing, dizziness, headaches, or pain, no matter how minor they seem. While these symptoms may be due to common problems, such as a cold, recurrence needs to be considered a possibility. The use of routine x-rays and blood tests is not recommended, as these tests have not been found to find disease earlier or to improve survival.


You may find that you need a great deal of emotional support after diagnosis and throughout treatment. There are many survival groups that can help you and your family cope with the feelings of depression, fear, anger, and pain that you may experience. You may find yourself overwhelmed with thoughts of the future.



You may wonder why cancer had to happen to you, or what made you deserve the diagnosis. You will need to be very resilient, both physically and emotionally, to withstand diagnosis and treatment.



It is important that you and your loved ones understand the issues of cancer so that the depression and fear can turn into acceptance and courage. Talk to your doctor about your feelings and ask for assistance in finding support groups. Communicating with other survivors can be extremely comforting.