Breast cancer is the most common type of cancer in women in the U.S. This type of cancer starts in the breast and occurs when cells change and grow. The ducts and lobules are the two parts of the breast where cancer is most likely to start.
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Cancer is a disease caused by uncontrolled growth of abnormal cells. Just like in other organs, cancer can grow in breast tissue. The breast is composed of two types of tissue: epithelium and stroma.
Epithelium is a type of tissue that is composed of glands that make breast milk and transport it to the nipple. Epithelial tissue is made of small units called duct-lobular units, which connect to form 20–30 large channels called lactiferous ducts. These ducts open into the nipple.
Stroma is breast tissue that is made of fat, blood vessels and fibrous tissue and acts as the connective tissue, supportive framework for the epithelial tissue.
Cancer can grow in both types of tissue. The most common types of breast cancer cells grow from epithelial tissue.
Ductal carcinoma in situ (DCIS). This type of cancer grows in the cells of your breast ducts and is confined to that area. DCIS is the most common type of breast cancer in the epithelial tissue. DCIS can be classified as low-grade, or less aggressive, or high-grade/comedo type, or more aggressive. Low-grade DCIS is usually discovered during a mammogram, but high-grade DCIS may produce a lump that can be felt during a self-breast exam; this is a noninvasive cancer.
Invasive ductal carcinoma (IDC). This type of cancer begins in the breast duct like DCIS, but breaks the “basement membrane,” or the barrier around the ducts. When the cancer cells break the basement membrane, they travel into the stroma tissue, which is called invasion. This means the cancer can grow in both types of tissue and spread, or metastasize, to other parts of the body.
Invasive lobular carcinoma (ILC). This type of cancer begins growing in the milk-producing glands of the breast called lobules. Much like invasive ductal carcinoma, the cancer cells break the barrier that separates the breast tissue from the normal tissue, giving the breast cancer cells the opportunity to metastasize to other areas of the body. Invasive lobular carcinoma not only looks different than IDC but is also different in the way it spreads and responds to treatment.
Paget’s disease. This is a malignant condition in which ductal carcinoma in situ (DCIS) cells spread from the ducts of the breast to the skin of the nipple and areola. Characterized by a rough, red, irregular appearance, like a scaly rash, this type of cancer is usually associated with aggressive types of DCIS and/or invasive ductal carcinoma. Cancer underlying the Paget's disease may or may not form a lump.
Estrogen Receptor (ER) & Progesterone Receptor (PR) Breast Cancer
Approximately 75% of all breast cancers are hormone receptor-positive, which means they have estrogen receptors (ER) and/or progesterone receptors (PR). These cancers need hormones, such as estrogen, to grow. Doctors often refer to hormone receptor-positive breast cancers as ER-positive or PR-positive.
HER2+ (Positive) Breast Cancer. HER2+ breast cancer is a type of breast cancer that is characterized by the over-expression of the HER2 protein. This leads to the breast cancer cells growing and dividing at a much faster rate than normal. In about 20-25% of breast cancers, the HER2 protein is over-expressed. This makes HER2+ breast cancer more aggressive and difficult to treat. However, there are now several effective treatments available for this type of breast cancer.
Triple-negative breast cancer. This is a type of breast cancer that doesn't have estrogen receptors and progesterone receptors. It also doesn't have an excess of the HER-2 protein on the breast cancer cells' surfaces. Triple-negative breast cancer tends to occur more often in younger women and in African American women. It tends to grow and spread faster than most other types of breast cancer. Because these cancer cells don't have hormone receptors or excess HER-2, medicines that target these changes don't work. The most common kind is triple-negative invasive ductal carcinoma.
The main breast cancer symptoms that you should be aware of, include the following:
A lump or thickening in the breast or underarm area
A change in the size, shape, or appearance of the breast
Dimpling or puckering of the skin on the breast
An itching, burning, or soreness of the nipple area
A discharge from the nipple (may be clear or bloody)
A change in the appearance of the nipple, such as it becoming inverted (pulled inward)
Peeling, scaling, crusting, or flaking of the nipple area or breast skin
Any new mass or lump in the breast or underarm area
Swollen lymph nodes in the armpit
It is important to note that these symptoms can also be caused by conditions other than breast cancer. However, if you experience any of these symptoms, it is important to see a doctor so that the cause can be properly diagnosed.
The grade of cancer describes how abnormal the cancer cells look under the microscope. Understanding the grade helps your doctors predict how fast the cancer may grow and spread. To grade your cancer, the pathologist gives a number from 1 to 3. Slower-growing tumors score a 1, while faster-growing tumors score a 3. A grade 3 cancer detected at a very early stage may have a better prognosis than a grade 1 cancer that is undiscovered until after it has spread to other organs. Ask your doctor to explain the grade of your cancer.
The stage of your cancer is how doctors communicate the size of a tumor and how far it has spread. The stage and grade of a cancer are unrelated. However, the two categories combined describe the status of the cancer in such a way that your doctor can figure out appropriate treatment. The stage is based on the size and extent of your tumor, the number of nodes involved and whether the cancer has spread. Your oncologist will determine your stage from tests, including a breast biopsy and lymph node evaluation. Usually, the stage of a cancer is more important in determining a treatment strategy than its grade.
After breast cancer has been diagnosed, the next step is to determine the stage of the disease. The stage of the disease is a way of describing how far cancer has spread in the body. There are four main stages of breast cancer:
Stage 0: This is also called non-invasive breast cancer or ductal carcinoma in situ (DCIS). In this stage, the cancer is still confined to the milk ducts and has not spread to the surrounding breast tissue.
Stage 1: In this stage, cancer has spread beyond the milk ducts and into the surrounding breast tissue. The tumor is no longer than 2 centimeters in size and has not spread to the lymph nodes.
Stage 2: In this stage, cancer has spread beyond the breast tissue and into the lymph nodes. The tumor is no longer than 5 centimeters in size.
Stage 3: In this stage, cancer has spread to the surrounding tissues and may have also spread to the lymph nodes. The tumor is larger than 5 centimeters in size.
Stage 4: This is also called metastatic breast cancer. In this stage, cancer has spread to other parts of the body, such as the liver, lungs, or bones.
This is a rare type of cancer in which the breast looks inflamed because of its red appearance and warmth. Skin may show signs of ridges and wheals or it may have a pitted appearance. It is considered stage IIIB (3B) unless it has spread to distant lymph nodes or organs, in which case it is considered stage IV.
Local and regional recurrence is cancer that returns in the same general area of previous breast surgery, skin, breast tissue, or chest wall and/or nearby lymph nodes.
This is cancer that returns in other parts of the body.
The place in the body that cancer begins is called the primary site or primary tumor. When cancer spreads to other parts of the body, it is called metastatic cancer or metastasis. Usually breast tumors use the nearby lymph nodes and lymph vessels or blood stream to travel from the breast to other organs.
The lymph nodes under your arms are usually the first area where breast cancer spreads. In some cases, breast cancer spreads to distant parts of your body including the bones, lungs, liver, brain or other organs. It may also spread to your skin. Although the cancer has spread, it is not a new cancer. For instance, if breast cancer spreads to your liver, it is not considered liver cancer. It is called metastatic breast cancer, and its treatment will be for advanced breast cancer.
There are approximately 240,000 new cases of invasive breast cancer as well as 50,000 new cases of noninvasive breast cancer diagnosed every year in the United States. Ideally, we would like to identify risk factors that can predict which women will develop breast cancer. The major identified risk factor categories relate to hormone history and family history.
Other past medical problems including prior history of premalignant breast biopsies, dense breast tissue and history of chest wall radiation can also increase a woman's risk to develop breast cancer. Although these risk factors are important, 70% of newly diagnosed women have no special risk factors except female sex and advancing age.
Because 99% of breast cancer occurs in women, it is important to consider endogenous (natural body produced) and exogeneous (supplemental) hormones as risk factors that lead women to develop breast cancer and breast disease. Having your first menstrual period (menarche) before age 11, or your last menstrual period (menopause) after age 55 increases a woman's risk for breast cancer. Likewise, women who have never had a full-term pregnancy, or delay their first full-term pregnancy until after age 30, are also at a slight increased risk for breast cancer.
Women who receive supplemental hormones may also be at increased risk for the development of breast cancer. Hormone replacement therapy (HRT) is frequently prescribed to control symptoms of menopause. Combined hormone therapy uses two types of hormones called estrogen and progesterone. This type of hormone therapy is generally prescribed for women who have not had their uterus removed (hysterectomy).
Estrogen therapy alone can also treat menopausal symptoms, and it is the preferred option for women who have previously had a hysterectomy. Studies suggest that women who use combined hormone replacement therapy are at increased risk for the development of breast cancer. This increased risk occurs after more than four years of usage and in older women. Usually the risk returns to normal within five years of discontinuing use. Current guidelines recommend using the lowest doses of HRT and for as short a time as possible.
Currently there are no studies confirming a definite link between birth control (oral contraception) pills or fertility drugs and the development of breast cancer.
After the breast cancer diagnosis, it is recommended that all forms of exogenous (supplemental) hormones be discontinued.
Research has indicated that women with the following risk factors have an increased chance of developing breast cancer.
Alcohol use: Studies have indicated that drinking alcohol and other use of alcohol is linked to an increased risk of developing breast cancer. This risk appears to increase in proportion to the amount of alcohol consumed daily. Women who consume 2–5 drinks daily have about one and a half times greater risk than women who don't participate in drinking alcohol at all.
Smoking: Evidence suggests a link between smoking and a risk for developing breast cancer, particularly in premenopausal women. In addition, not smoking is one of the best things you can do for your overall health.
High weight or obesity: Many studies suggest that postmenopausal women who are overweight are at increased risk for breast cancer development. Being overweight is not an identified risk factor for premenopausal women. Maintaining a normal body mass index after the diagnosis of breast cancer is associated with better outcome as well.
Limited exercise: Women who are physically inactive throughout their life may have an increased risk of breast cancer. Regular exercise is important part of breast cancer prevention.
Poor diet: Eating a low-fat diet appears to offer only a slight reduction in the risk of breast cancer. However, a healthy diet can also help maintain a healthy weight, which is a key factor in breast cancer prevention.
The Breast and Ovarian Cancer High Risk Program exists to promote awareness about breast and ovarian cancer risk to patients, families and healthcare providers. The
program provides an expert evaluation for patients who are identified as high risk for either breast or ovarian cancer.
After a patient is evaluated, he or she is offered appropriate counseling, testing and primary prevention measures to reduce the likelihood of cancer development. This multidisciplinary approach to women's cancer risk assessment and management (RAMP) will utilize the services of breast imaging and genetics along with surgical oncology, medical oncology, and gynecologic oncology.
A person who has one or more first-generation relatives with breast or ovarian cancer before the age of 50.
An individual who has one first-generation relative with bilateral breast cancer.
Individuals with a known personal or family genetic abnormality in a breast cancer-causing gene, such BRCA or CHEK-2.
A person with prior breast biopsy showing atypical ductal hyperplasia or lobular neoplasia.
Individuals with a Gail Model breast cancer risk of greater than or equal to 1.67% over the next five years or greater than 20% lifetime risk.
An individual with a history of chemoradiotherapy to treat Hodgkin's disease.
As with most cancer types, early detection is known to improve the chances of positive treatment outcomes.
Proactive breast screening methods are comprehensive exams that may offer additional procedures, such as MRIs, or more frequent examinations compared to regular annual screening evaluations. The appropriate surveillance procedures and frequency will be determined by your breast team of physicians.
A clinical breast exam is much like the self-breast exams you perform regularly at home, but a doctor or nurse practitioner conducts this physical exam. The examination will include visual inspection and palpation of the breast and underarm areas to detect changes or abnormalities.
Mammography can detect abnormalities in breasts before more obvious symptoms are present. Mammography remains the most reliable screening method for early signs of breast cancer. Annual mammograms are recommended for average-risk women beginning at age 40.
Some women who have an increased risk for breast cancer may begin at an earlier age. In some cases, there are limitations to the effectiveness of mammograms. For example, in women younger than 40 and those with denser than normal breast tissue, mammography may not be as effective in detecting abnormalities.
Ultrasound may be used in addition to mammography for women with dense breast tissue seen on their mammogram. Mammograms are the first choice for breast cancer screening in all women. Adding an annual breast ultrasound may assist in better identifying lumps in dense breast tissue. However, ultrasonography tends to find noncancerous lesions more often than mammography. This may lead to additional testing and biopsy to exclude cancer.
A breast MRI should be used as a screening tool in addition to mammography for women who have dense breasts or an increased risk for breast cancer, especially those who are at high-risk.
The standard breast cancer treatment for most types of breast cancer is surgery, followed by systemic therapy [chemotherapy or hormonal therapy] and/or radiation therapy. Hormone therapy can also be used in three main ways: after surgery to lower the risk of cancer coming back, before surgery to shrink the breast tumors, or to treat cancer that has spread to other parts of your body.
Two surgical options for breast cancer are a lumpectomy and a mastectomy. A lumpectomy removes the tumor and a margin of normal tissue while a mastectomy removes nearly all the breast tissue. People who need a mastectomy procedure may choose to have breast reconstruction as well.
Chemotherapy is a cancer treatment that uses medications to kill cancer cells. It is often used in combination with other cancer treatments, such as surgery, radiation therapy, and/or targeted therapy. Chemotherapy can be given intravenously (IV), which means it is injected into a vein, or it can be taken in pill form.
There are many different types of chemotherapy drugs regimens and they are usually given in cycles, with each cycle lasting for a certain period of time followed by a rest period. The type of systemic therapy [ chemotherapy or targeted therapy] and the length of treatment depends on the type of breast cancer you have, the stage of the disease, your age, and your overall health.
Radiation therapy is a cancer treatment that uses high-energy beams, such as X-rays, to kill cancer cells.
There are two types of radiation therapy used most often: external beam radiation therapy and internal beam radiation therapy. External beam radiation therapy is when the beams are directed at cancer from a machine outside of the body. Internal beam radiation therapy is when the beams are directed at cancer from inside the body.
The length of treatment depends on the type of breast cancer you have, the stage of the disease, your age, and your overall health.
Hormone therapy works by decreasing or blocking certain hormones in the body. The types of hormone therapy used for breast cancer include the following:
Aromatase inhibitors: These drugs work by lowering the amount of the hormone estrogen in the body by blocking the aromatase enzyme. Estrogen can fuel the growth of breast cancer cells, so lowering its levels can help to slow down or stop the growth of breast cancer. Aromatase inhibitors are often used after surgery to lower the risk of cancer coming back or in other scenarios when indicated.
Selective estrogen receptor modulators (SERMs): These drugs work by blocking the effects of estrogen on breast cancer cells. This can help to slow down or stop the growth of breast cancer. SERMs like aromatase inhibitors are often used before after surgery to lower the risk of cancer coming back or in other scenarios for eg. To shrink the size of the tumor before surgery or to treat cancer when spread in different areas of the body.
Selective Estrogen Receptor Degraders (SERDs): These drugs also block the effect of estrogen in the body and are used to treat cancer in advanced stages when spread to other parts in the body.
Targeted therapies are also now available for HER2+ breast cancer. These are drugs that target the and attack specific cancer cells that contain HER2 protein and can help to shrink or slow down the growth of HER2+ breast cancer. These drugs are often used in combination with each other, or with chemotherapy.
There are targeted therapies in breast cancer nowadays which are specific for certain mutations found in breast cancer and help control the spread or growth of cancer. Some of them are oral pills which you can take at home and some in intravenous form through your vein. These agents have changed the landscape in certain types of breast cancer providing more options for treatment before using chemotherapy. Research is ongoing to find additional targets in breast cancer to improve overall outcomes.
If you have been diagnosed with breast cancer, you may be eligible to participate in a clinical trial. Clinical trials are research studies that test new treatments – such as drugs, surgical procedures, or lifestyle changes – to see if they are safe and effective.
Participating in a clinical trial is generally voluntary, and you will be able to discuss all of your treatment options with your doctor before making a decision to participate in clinical trials. If you do decide to participate in a clinical trial, you will be closely monitored by the research team during the course of the study.
New treatments for breast cancer are being developed all the time, and clinical trials offer hope for many people with this disease. If you would like more information about clinical trials for breast cancer, please
Prophylactic surgery involves removing a noncancerous body part to prevent breast cancer from developing. Women at high risk for breast cancer including some genetic mutation carriers will sometimes opt to undergo a prophylactic mastectomy.
Chemoprevention involves prescribing medications known to reduce disease to healthy people who are at risk of developing a disease. This practice is used in many other disease states such as the prescribing of statin drugs to reduce cholesterol and eventually heart disease.
Currently there are three oral medications — tamoxifen, raloxifene, and aromatase inhibitors — that have been extensively tested and approved to reduce breast cancer risk. For some high-risk women, taking one of these medications can reduce the chances of developing hormone-responsive breast cancer by as much as 50–60%. Although generally these medications are very well tolerated, side effects can occur.
It is important for all high-risk women to discuss chemoprevention. Ongoing clinical research is being conducted to explore other possible drug interventions.
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