Breast Cancer Education

Breast cancer touches more than one in eight women every year. Understanding that each diagnosis is unique and deeply personal, we’ve created this page to educate you about the complexities of breast cancer, including risk factors and treatment options. Knowledge is empowering; you can take control of your care and make confident decisions by becoming more informed.

What Is Breast Cancer?

Breast cancer is a disease in which breast cells change and grow out of control. Eventually, these cells may form a mass or lump. The breast comprises the milk glands (or lobules), the ducts that bring milk to the nipple, and lymphatic and connective tissue.

Breast cancer begins in the lobules or ducts and is categorized as either ‘in situ’ (in the original place) or invasive. In situ cancer has not grown beyond the origination point. Invasive cancer has grown beyond the point of origin into other areas of the breast or body.

Breast Cancer Statistics

Breast cancer survival rates are continually improving due to advancements in breast cancer treatments, such as surgery, improved tumor-suppressing drugs and chemotherapy, and more targeted radiation methods.

Deaths from breast cancer have declined by 34% since 1990, largely due to early detection via increased use of mammograms. This decline may also be credited in part to decreased use of menopause hormone replacement therapy in response to the Woman’s Health Initiative study, which found that these hormones increase the risk of breast and uterine cancer.

White women are more likely to develop breast cancer, but the mortality rate is higher among Black women. Trends for newly diagnosed breast cancer cases have remained stable since 2002, but death rates have been falling by almost 2% per year. The latest data from the National Cancer Institute indicates that the 5-year breast cancer survival rate is now nearly 90%.

It’s estimated that 235,000 new cancer cases will be diagnosed this year, and about 1% of these are men.

Symptoms of Breast Cancer

Breast cancer is usually detected when a mass or lump is found through a physical breast examination or as a result of an imaging test such as a mammogram. Most lumps aren’t cancerous, but further testing must be done to rule out cancer.

Other symptoms of breast cancer include:

• Sudden discharge from the nipple
• Itchy, scaly rash on the nipple
• Swelling or redness
• Change in shape or size of a breast
• Puckering or dimpling of the skin on the breast
• Pain in one spot that doesn’t go away

These symptoms can be due to other factors but must be thoroughly checked out by a breast specialist to diagnose the source of these symptoms.

Risk Factors for Breast Cancer

The strongest risk factors for breast cancer are one’s sex and age. Breast cancer is 200 times more common in women than men and 400 times more common in women aged 50 than women aged 20.

There is no single cause of breast cancer; environmental factors, lifestyle choices, and genetics all play a role. Most women who develop breast cancer have no identifiable risk factors other than being a woman in the western hemisphere in the 21st century.

Some women do have different risk profiles:

• Caucasian and Jewish women have the highest incidence of breast cancer.
• Women of color have a lower rate of breast cancer but higher mortality.
• Asian women have the lowest risk of breast cancer.

It is interesting to note that once Asian women move to the United States, their risk of getting breast cancer rises for every year of residence, demonstrating an environmental connection.

Personal History of Breast Cancer

Women with a history of breast cancer have a lifetime increased risk of getting another breast cancer. Due to this increased risk, these women must be monitored closely for the rest of their lives for early signs of recurring or new cancer.

Five-year survival history is encouraging but not completely foolproof. Women with a history of breast cancer may develop a second cancer or a recurrence of the original cancer after more than 20 years. It is vital to know your risks so you can modify the risk factors you can control and monitor those you can’t.

Family History of Breast Cancer

Although hereditary breast cancer accounts for only 5 to 10% of cases, a family history of breast cancer—especially if associated with ovarian cancer—does increase the risk of breast cancer. However, most breast cancer is thought to be a spontaneous mutation of cells related to environmental carcinogens such as pollution or chemical exposure and genetic makeup.

BRCA 1 and BRCA 2 Genes

A woman with a strong family history of breast cancer should be tested with the BRCA genetic test for the presence of the BRCA 1 and BRCA 2 genes—genes that produce tumor-suppressing proteins. These proteins repair damaged DNA, which ensures that the cells function properly. DNA may not be adequately repaired if either of these genes is mutated, which can lead to cancer.

Although less than 10% of women with breast cancer have these genes, there is an extremely high risk of developing breast, ovarian, colon, lung, and pancreatic cancers for those who do. As unwelcome as this result is, knowledge of this risk factor opens the door to the various available preventive treatment options. Aggressive surveillance is indicated using diagnostic imaging, physical exams, and blood work. Another preventive treatment is using Tamoxifen anti-hormone drug therapy, which controls hormone receptors in cells. Surgery such as a prophylactic mastectomy may also be indicated to remove the site of a future cancer proactively.

Dense and Cystic Breasts

Dense and cystic breasts make mammograms less accurate at finding early cancers. Lumpy breasts and multiple breast biopsies for even benign masses indicate a “proliferative” or lump-making breast, which slightly increases the risk of developing breast cancer. Additional imaging studies such as breast ultrasound and MRI and more frequent physical exams by a health professional may be recommended.

Obesity

Excess body fat is a risk factor in multiple cancers, including breast cancer. Postmenopausal obese women have at least twice the risk of breast cancer as their ideal weight peers. Estrogen is stored in body fat, and it’s believed that the higher estrogen levels in obese postmenopausal women may contribute to their increased risk.

Sedentary Lifestyle

Regular moderate exercise, 30 minutes 3 times a week, has been shown to decrease the risk of breast cancer independent of weight loss.

Precancers

Atypical ductal or lobular hyperplasia (ADH, ALH), identified by biopsy, also increases the risk of developing breast cancer. Lobular carcinoma in situ is not itself a cancer but is considered a marker indicating an increased risk for breast cancer. Increased surveillance is recommended. More aggressive treatment may be indicated if an individual has additional risk factors.

Reproductive Hormones

Women who’ve never had children and, to a lesser extent, those who had children later in life have a slightly increased risk of developing breast cancer. Pregnancy interrupts the hormone cycle and decreases the risk of breast cancer, particularly if a woman has children before age 30. Breastfeeding has a modest protective effect.

Longer exposure to hormones increases the risk of breast cancer. Being younger when you start menstruating and/or being older when you enter menopause is linked to the risk of developing breast cancer.

Hormone Therapy

Postmenopausal hormones, particularly the combination of estrogen and progesterone, increase the risk of breast cancer. This is especially true if hormones are taken longer than 10 years.

Premenopausal hormones such as birth control pills don’t seem to increase breast cancer risk significantly and actually decrease ovarian cancer risk. However, birth control pills taken after menopause act as postmenopausal hormones and have added risks not found in younger women.

The hormone regimens prescribed to treat infertility haven’t been studied adequately to draw conclusions regarding their cancer risk.

Cancer Pathology

The size of a breast cancer and whether it has spread to an axillary (armpit) lymph node are the critical features that have traditionally been used to predict a tumor’s aggressiveness and on which treatment has been based.

Recent advances in technology that analyze a cancer’s molecular makeup are proving more accurate in providing prognostic (predictive) and therapeutic information. Specific information about a tumor enables a specific individualized treatment targeted to a particular case. This minimizes under- and over-treating a patient and optimizes the curing process while avoiding unnecessary therapy with potential side effects.

Normal breast tissue contains estrogen and progesterone hormone receptors. The more closely a breast cancer resembles normal breast tissue, the more favorable and less aggressive that tumor is. All breast cancers are assessed for estrogen and progesterone receptors. Tumors are also evaluated for the number of cells dividing (Ki67) and how much they look like normal breast tissue. The lower the Ki67 and the fewer cells dividing, the better.

Definitions

A “well-differentiated” tumor looks more like breast tissue than one that is “poorly differentiated” and has a more favorable prognosis.

“HER2/neu” is a gene found in a small percentage of breast cancers (10 to 20%) that indicates an aggressive cancer that almost always requires intravenous chemotherapy in addition to a specific anti-HER2/neu drug such as Herceptin.

The pathologist also looks for vascular (blood vessels) and lymphatic “invasion,” in which tumor cells travel outside the mass. The absence of vascular or lymphatic invasion is favorable.

After lumpectomy or mastectomy, margins—areas of normal tissue around the cancer—are included in the pathology report confirming whether all cancer has been removed. Lymph nodes are analyzed for cancer involvement as part of the analysis.

All this information is included in the pathology reports. Some may be on the biopsy report, with the remainder on the final surgical report. Ask your surgeon or oncologist to review this information with you so you’ll understand your personal tumor characteristics. This will help you better understand and participate in decisions regarding your breast cancer treatment.

Types of Breast Cancer & Their Treatment

Although controversy exists, ample evidence indicates that noninvasive cancer can evolve into invasive cancer with time. Noninvasive cancer is generally treated similarly to invasive cancer with regard to surgery and radiation.

Chemotherapy is never given for noninvasive cancer. The controversy lies in how likely the noninvasive cancer is to become invasive and how aggressively it should be treated. Until we have better tools to predict an individual’s likely course, we tend to be aggressive in all cases.

Paget’s Disease of the Breast

Paget’s disease of the breast is a noninvasive cancer of the nipple, meaning the cancer is limited to the nipple itself and has not entered the ducts or the tissue within the breast. Symptoms of the disease include a subtle but persistent area of dry, scaly skin or eczema of the nipple and areola.

Patients and physicians frequently misdiagnose the condition as a skin issue or allergy and treat it with creams. With time, the nipple and surrounding areola may become crusty and ulcerated.

Any persistent dry, itchy, or painful nipple should be biopsied to rule out Paget’s disease. Anyone diagnosed with the disease should undergo a mammogram and MRI to confirm there’s no associated deeper (often invasive) malignant tumor within the breast. In 30% of cases, an associated tumor is found during diagnostic screening.

Treatment of Paget’s disease depends upon any associated tumors discovered. Treatment generally involves the removal of the nipple with radiation therapy

of the remaining breast. Plastic surgery can fashion a new nipple with excellent cosmetic results.

A total mastectomy may be indicated in some cases. The nipple-areola complex and breast are entirely removed with or without reconstruction. The prognosis depends upon associated tumors but is generally excellent.

Ductal Carcinoma in Situ (DCIS)

DCIS is a noninvasive cancer of the ducts (limited to the breast ducts only). It’s generally diagnosed by a mammogram finding of suspicious calcifications or masses, prompting a needle biopsy. Occasionally, it’s a palpable lump found during a breast self-exam or clinical exam.

Further diagnostics include a breast ultrasound and an MRI. Once DCIS is confirmed by pathology, the entire area will be removed with a rim of normal breast tissue around the cancer. This ensures no cancer tentacles are left behind. An axillary lymph node biopsy is generally recommended.

Radiation therapy is indicated in all cases except for patients with tiny tumors and wide margins (a surgical term for the distance of “normal” tissue from the tumor) to minimize the risk of cancer returning. Chemotherapy isn’t required in a noninvasive cancer, but an anti-hormone pill may be indicated to protect both the affected and opposite breast.

Extensive DCIS that can’t be removed entirely without acceptable breast distortion may require total mastectomy with or without breast reconstruction. In these cases, radiation isn’t required.

Lobular Carcinoma in Situ (LCIS)

LCIS is confusing to patients and non-breast specialists alike. Although it has “carcinoma” in its name, it isn’t considered a cancer. Rather, it’s regarded as a marker that indicates a higher risk of developing breast cancer in either breast.

If discovered by needle or core breast biopsy, an open larger biopsy is performed to confirm that no cancer is associated. Needle biopsy is a sample biopsy. If any atypical or suspicious cells are identified, such as LCIS, a larger area of tissue around the needle biopsy site is taken to make sure nothing more serious lies beside the area. Treatment generally involves close surveillance, including frequent breast exams, mammograms, and MRIs.

If a patient has multiple risk factors for breast cancer besides LCIS, the likelihood that she may develop the disease warrants more aggressive preventative treatment. This may include removing both breasts as a preventive measure—a highly personal decision that requires serious discussion with a breast specialist. Removing only the affected breast isn’t adequate protection, as LCIS predicts a higher risk of getting breast cancer in both breasts.

Invasive Ductal Carcinoma

Invasive or infiltrating ductal carcinoma is a cancer that has broken through the wall of the milk duct and begun to invade the breast tissues. This is the most common type of breast cancer in women, representing about 80% of all breast cancers.

Invasive Ductal Carcinoma is found 50% of the time when the patient or her physician finds a lump. The remaining cancers are identified by mammogram and ultrasound. The prognosis is excellent if found early and treated promptly.

Treatment usually involves lumpectomy, in which the cancer is removed with a rim of normal tissue (margin) and an axillary lymph node biopsy to determine whether the cancer has spread to the armpit nodes. This is followed by radiation, chemotherapy, and anti-hormone medication.

Radiation is recommended in all patients undergoing breast preserving surgery to minimize the potential for cancer recurrence in the breast. In 30% of women treated with lumpectomy with clear margins (areas of normal tissue around the cancer) who don’t receive radiation, the cancer will recur within 10 years.

Chemotherapy is given to patients whose tumors are likely to spread outside the breast even after surgery. Chemotherapy consists of drugs administered by mouth or vein, which circulate throughout the body to kill any cancer cells that may have been missed.

Anti-hormone therapy targets hormone-sensitive tumor cells, dramatically reducing the risk of these cancers returning in the breast or body. However, anti-hormone medications don’t decrease the risk of hormone-negative cancers from recurring or spreading. 

Invasive Lobular Carcinoma

Invasive lobular carcinoma is a type of breast cancer that begins in the breast’s milk-producing glands (lobules). It’s less common than invasive ductal cancer but is generally treated the same. Stage for stage, the prognosis for this type of cancer is the same. Invasive lobular cancer does have some unique qualities that must be considered in the diagnosis, surgical treatment, and postsurgical follow-up.

Invasive lobular cancer tends to grow in sheets rather than lumps and may be difficult to discover by physical exam or imaging studies, such as a mammogram. Once identified, the tumor size may be underestimated preoperatively, which requires re-operation to ensure the entire tumor is removed with clear margins.

Invasive lobular carcinoma has a higher risk of occurring in the opposite breast—as high as 50% in some studies. Removing both breasts (bilateral mastectomy) should be considered and discussed in all cases. Treatment is then tailored to the individual. Postsurgical treatment depends upon the final pathology and may include radiation (in all breast-preserving procedures), chemotherapy, and/or anti-hormone therapy.

Triple-Negative Cancer

Triple-negative cancer refers to invasive cancers of either ductal or lobular origin, which either express no estrogen or progesterone receptors or have the HER2/neu gene. These are such aggressive tumors that chemotherapy is recommended in all cases to optimize cure.

Anti-hormone medications aren’t useful in this type of cancer. However, this cancer is still curable, with research ongoing to determine the optimal chemotherapeutic regimen to achieve the best survival rates.

Tubular Carcinoma

Tubular carcinoma is a rare type of invasive ductal carcinoma that derives its name from its microscopic appearance, in which the cancer cells resemble small tubes. It represents 2% of breast cancers and has a very favorable prognosis.

Adenocystic Carcinoma (Cystadenocarcinoma, Adenoid Cystic Carcinoma)

Cystadenocarcinoma of the breast is a rare cancer that forms in glandular tissues. It occurs in less than 1% of breast cancers and is generally nonaggressive. It rarely involves lymph nodes and is more likely to be hormone-negative than the more common breast cancers. It doesn’t have the aggressive features of hormone-negative invasive ductal or lobular cancers.

Treatment generally includes lumpectomy and lymph node biopsy followed by radiation and anti-hormone therapy (if indicated). Mastectomy is necessary only if there are multiple tumors in the breast or if partial mastectomy can’t remove the entire tumor or is cosmetically unfavorable. The prognosis is excellent.

Inflammatory Breast Cancer

Inflammatory breast cancer is a rare but aggressive form of breast cancer that either grows very rapidly or has been neglected and becomes very large due to slow long-term growth. The hallmark of the disease is the reddened, thickened skin of the breast, which is commonly mistaken for an infection.

Inflammatory breast cancer doesn’t respond to treatment with antibiotics. A lump may or may not be palpable, but a biopsy of the affected area will determine whether cancer is present in the lymph nodes.

Treatment has resulted in many cures for a disease that was once considered universally fatal. Treatment includes a combination of chemotherapy, surgery (mastectomy and lymph node dissection), and radiation therapy.

Angiosarcoma

Angiosarcoma of the breast is a rare, extremely aggressive malignancy that starts in the cells that line the blood vessels of the breast and presents as a bruise or ill-defined purplish mass. Only about .04% of breast cancers are angiosarcoma and are generally associated with prior radiation to the breast, although some angiosarcomas develop without a history of radiation.

Treatment is similar to that prescribed for other types of breast cancer. However, lymph node involvement is rare in angiosarcoma, so lymph node biopsy is generally not done. The prognosis is poor.

It’s important to understand that angiosarcoma is rare and not a contraindication for radiation therapy. Radiation has proven to be a safe, life and breast-preserving treatment that allows for a cure without sacrificing a woman’s breasts in many cases. Despite the remote possibility of angiosarcoma, the value of radiation therapy in breast cancer treatment can’t be overstated.

Secondary Breast Cancer

Multiple cancers from other parts of the body can spread to the breast, including lymphoma (cancer originating in the lymph nodes) and melanoma. Pathology can determine the source of the tumors and the appropriate treatment prescribed. However, the vast majority of breast tumors come from the breast itself.

Stages of Breast Cancer

Staging categorizes a patient’s prognosis (likely outcome) based on tumor size, lymph node involvement, and whether cancer has spread to organs outside the breast. While still helpful, staging has become less important as we find more accurate data from individual tumor genetics.

Stage 0 (Ductal Carcinoma in situ)

• No tumor is found in the axillary lymph node.
• The cancer is contained within the breast duct.

Stage 1

• Cancer has spread to other parts of the breast.
• The tumor is less than or equal to 2 centimeters.
• There is no cancer in the axillary lymph node.
• The cancer has not spread to other parts of the body.

Stage 2

• Cancer is found in other parts of the breast. The tumor(s) is between 2 and 5 centimeters, with no involvement of axillary lymph nodes. The cancer has not metastasized to other parts of the body.
• Cancer, less than 2cm in size, is found in other areas of the breast, which may include no identifiable tumor at all. There are positive movable lymph nodes on the same side of the body. Cancer has not spread to other parts of the body.
• Cancer, between 2 and 5cm, has been found in another area of the breast. It has spread to movable axillary lymph nodes on the same side of the breast. It has not metastasized.
• The tumor is over 5cm, with no cancer in the axillary lymph nodes. Cancer has not spread to other parts of the body.

Stage 3

• No evidence of a primary tumor. Cancer has spread to axillary lymph nodes on the same side of the chest.
• Tumor size is less than or equal to 2cm. It has spread to axillary lymph nodes. The cancer has not spread to other areas of the body.
• Tumor size is between 2 and 5cm and has spread to axillary lymph nodes. Cancer has not spread to other areas of the body.
• Tumor size is over 5cm and has spread to moveable or fixed axillary lymph nodes on the same side of the body but has not spread to other parts of the body.
• Tumor extends to the chest wall, any axillary nodal involvement, and has not spread to other parts of the body.
• Primary tumor of any size has spread to internal mammary nodes on the same side of the body, with no cancer in other parts of the body.

Stage 4

• Cancer has spread to other parts of the body.

Prognosis and life expectancy decrease with each stage. Survival in Stage 1 approaches 97%. Stage 4 is believed to be treatable—often for many years— but not curable. The smaller the tumor and the less it has spread, the better. Early detection and treatment are critical for the best possible outcome.

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