Types of breast cancer

Determining what type of breast cancer you have is an important step in treating the disease. Get the facts on types of breast cancer and how they differ.

Your doctor suspects that you have breast cancer. As part of the diagnosis process, your doctor sends a tissue sample (biopsy) to the lab for analysis. After the test results come in, you'll learn whether you have breast cancer and, if so, what type of breast cancer you have.

Knowing what type of breast cancer you have plays a big role in selecting your treatment. Understand the differences among types of breast cancer, including common and less common types.

I. Common types of breast cancer - The most common types of breast cancer originate in either your breast's milk ducts (ductal carcinoma) or lobules (lobular carcinoma). The point of origin is determined by the microscopic appearance of the cancer cells from a biopsy.

A. In situ breast cancer - In situ breast cancer refers to a type of cancer in which the breast cancer cells have remained contained within their place of origin - they haven't invaded breast tissue around the duct or lobule.

1. Ductal carcinoma in situ (DCIS) - DCIS refers to abnormal cells in the lining of a milk duct that haven't invaded the surrounding breast tissue. This is early-stage breast cancer. Some experts consider DCIS a "precancerous" condition. Almost all women with DCIS can be successfully treated, and no evidence suggests that DCIS affects a woman's life span. However, if left untreated, DCIS may eventually develop into invasive breast cancer.

2. Lobular carcinoma in situ (LCIS) - LCIS means that abnormal cells are contained within a lobule of your breast, but they haven't invaded the surrounding breast tissue. Whether LCIS is an early form of breast cancer or is just a marker for the future development of cancer remains a point of controversy in the medical community. However, experts do agree that if you have LCIS, you're at an increased risk of developing breast cancer in either breast in the future. In the breast that had the LCIS, you're more likely to develop invasive lobular breast cancer. If cancer develops in the other breast, it's equally likely that it could be invasive lobular or invasive ductal carcinoma.

B. Invasive breast cancer

1. Invasive (infiltrating) breast cancers are those that break free of where they originate, invading the surrounding tissues that support the ducts and lobules of your breast. The cancer cells can travel to other parts of your body, such as the lymph nodes.

2. Invasive ductal carcinoma (IDC) - IDC accounts for the majority of invasive breast cancers. If you have IDC, cancer cells form in the lining of your milk duct, break free of the ductal wall and invade surrounding breast tissue. The cancer cells may remain localized - staying near the site of origin - or they can spread (metastasize) even farther throughout your body, carried by your bloodstream or lymphatic system.

3. Invasive lobular carcinoma (ILC) - Although less common than IDC, this type of breast cancer acts in a similar manner. ILC starts in the milk-producing lobule and invades the surrounding breast tissue. It can also spread to more distant parts of your body. With ILC, you might not be able to detect a breast lump. You may perceive only a general thickening - or a sensation that your breast tissue feels different. ILC can be harder to detect by touch, and it's also less likely to appear on a mammogram.

II. Less common types of breast cancer - Not all types of breast cancer originate in a duct or lobule. Less common types of breast cancer include:

A. Inflammatory breast cancer - This is a rare but aggressive type of breast cancer. The skin on your breast becomes red and swollen and may take on a thickened, pitted appearance - similar to an orange peel. This results from cancer cells blocking lymph vessels located near the surface of your breast.

B. Medullary carcinoma - This is a specific type of invasive breast cancer in which the tumor's borders are clearly defined, the cancer cells are large, and immune system cells are present around the border of the tumor.

C. Mucinous (colloid) carcinoma - With this type of invasive breast cancer, the cancer cells produce mucus and grow into a jelly-like tumor. The prognosis for mucinous carcinoma is better than for other, more common types of invasive breast cancer.

D. Paget's disease of the breast - This rare type of breast cancer affects your nipple and the dark area of skin surrounding your nipple (areola). It starts in a milk duct, as either an in situ or invasive cancer. If associated with carcinoma in situ, the prognosis is very good.

E. Tubular carcinoma - This rare type of breast cancer gets its name from the appearance of the cancer cells under a microscope. Though it's an invasive breast cancer, the outlook is more favorable than it is for invasive ductal carcinoma or invasive lobular carcinoma.

F. Phylloides tumor - A large, bulky tumor may be an indication of a phylloides tumor. Phylloides tumors develop in the connective tissue of the breast, rather than in a duct or lobule. The outlook for a phylloides tumor is uncertain. If the tumor can't be removed, it's difficult to treat.

G. Metaplastic carcinoma - Metaplastic carcinoma represents less than 1 percent of all newly diagnosed breast cancers. This lesion tends to remain localized and contains several different types of cells that are not typically seen in other forms of breast cancer. Prognosis and treatment is the same as for invasive ductal carcinoma.

H. Sarcoma - A sarcoma is a tumor that develops in the connective tissue of the breast. This type of tumor is usually cancerous (malignant).

I. Micropapillary carcinoma - This invasive type of breast cancer tends to be relatively aggressive, often spreading to the lymph nodes even when very small.

J. Adenoid cystic carcinoma - This type of breast cancer is characterized by a large, local tumor. It's an invasive but slow-growing type of breast cancer that's unlikely to spread.

Your breast cancer may come back after you've been treated. It may recur in your breast or the soft tissue of your chest (chest wall), or it may appear in another part of your body - such as your lungs, liver or bones. When breast cancer returns in this manner, it is known as recurrent breast cancer.

If the cancer recurs in your breast, then surgery to remove it along with chemotherapy, radiation or both may rid your body of the cancer. However, if the recurrence occurs in another part of your body, though it may respond to some therapies, it's unlikely that it will ever be cured.

If you've had breast cancer in the past and you notice any changes in your breasts, see your doctor as soon as possible.

Stages of breast cancer: Stages 0 to IV

Your stage of breast cancer refers to how extensive your breast cancer is. This includes both the size of the tumor and whether or not any cancer cells have spread from the breast to other areas of your body, including your lymph nodes. Your doctor will determine your stage of breast cancer at the time he or she removes your cancer during a mastectomy or lumpectomy and through close examination of the lymph nodes under your arm.

Your stage of breast cancer can be as low as stage 0 or as high as stage IV. The higher the stage, the larger the tumor or the more the cancer has spread. Stage 0 cancer, for instance, indicates a non-invasive breast cancer that is contained within the duct and hasn't spread within the breast. Some doctors consider stage 0 cancer not a true cancer at all but a predictor of breast cancer.

TREATMENT OF BREAST CANCER

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. In most cases no one right treatment exists for breast cancer. Instead, you'll want to find the approach that's best for you.

To do that, you'll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites, and information from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.

I. Surgery - Breast Cancer Surgery

At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

Breast cancer operations include the following:

1. Lumpectomy - This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy - often followed by radiation therapy - instead of mastectomy, and in most cases survival rates for both operations are the same. In addition, many more women are satisfied with their appearance after lumpectomy. But lumpectomy may not be an option if a tumor is deep within your breast, or if you have already had radiation therapy, have two or more areas of cancer in the same breast that are far apart, have a connective tissue disease that makes you sensitive to radiation, or are pregnant.

In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy - especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone. A study in the "New England Journal of Medicine" found that it might be reasonable for some women 70 and older who were taking tamoxifen after a lumpectomy to forgo radiation. In the study of 600 older women, the five-year survival rate for the half treated with tamoxifen and radiation after lumpectomy and the half treated with tamoxifen alone was essentially the same, although breast cancer recurred more often in the women who took only tamoxifen. Ultimately, a number of factors will influence your decision regarding radiation after lumpectomy, including the type of cancer you have and how far it has spread, other health conditions you may have, the side effects of radiation, whether you're a candidate for treatment with tamoxifen or aromatase inhibitors, and your own concerns and personal preferences. For some women, the risks of radiation therapy may seem too daunting. For others, fear of cancer recurrence may outweigh all other factors. That's why it's important to review with a radiation oncologist your options and the risks and benefits of treatment.

2. Partial or segmental mastectomy - Also considered a breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. Some lymph nodes under your arm also may be removed. In almost all cases, you'll have a course of radiation therapy following your operation.

3. Simple mastectomy - During a simple mastectomy, your surgeon removes all your breast tissue - the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.

4. Modified radical mastectomy - In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. This makes breast reconstruction less complicated. But serious arm swelling (lymphedema) - a common complication of mastectomy - is more likely to occur in modified radical mastectomy than in simple mastectomy with sentinel node biopsy. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.

Until recently, surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of numbness, recurrent infections and serious swelling of the arm. That's why a procedure has been developed that focuses on finding the sentinel nodes - the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

7. Reconstructive surgery - Most women who undergo mastectomy are able to choose whether to have breast reconstruction. This is a very personal decision, and there's no right or wrong choice. You may find, however, that you have feelings you didn't expect about your breasts. It's important to understand these feelings before making any decision.

If you would like reconstruction but aren't a candidate for the procedure, you'll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.

If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.

(a.) Reconstruction with implants - Using artificial materials to reconstruct your breast involves implanting a silicone shell filled with either silicone gel or salt water (saline). If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander. This is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid - usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. In general, an implant makes your breast firmer than a normal breast. Implants may cause pain, swelling, bruising, tenderness or infection. And they do age over time, requiring replacement. There is also a long-term possibility of rupture, deflation, contracture, hardening and shifting.

(b.) Reconstruction with a tissue flap - Also known as a Transverse Rectus Abdominis Myocutaneous (TRAM) Flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen. Sometimes your surgeon may also use tissue from your back or buttocks. Because the procedure is fairly complicated, recovery may take six to eight weeks. You may also need future adjustments to the breast. Complications include the risk of infection and tissue death. If you have little body fat, this type of reconstruction may not be an option for you. On the other hand, a breast reconstructed from your own tissue doesn't seem to interfere with the detection of tumors. It is also permanent and has the look and feel of a normal breast.

(c.) Deep inferior epigastric perforator (DIEP) reconstruction - In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional breast reconstruction. You may also have less pain, and your healing time may be reduced. Active women, in particular, tend to opt for this procedure because it maintains the abdominal wall muscles.

(d.) Reconstruction of your nipple and areola - After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

For many women, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells - especially fast-growing cells in your digestive tract, hair and bone marrow - as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control some of them.

New drugs can help prevent or reduce nausea, for example. Relaxation techniques, including guided imagery, meditation and deep breathing, also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

One side effect for which no treatment exists is "Chemobrain" the common term for cognitive changes that occur during and after cancer treatment. Women undergoing adjuvant chemotherapy for breast cancer were the first to call attention to this problem. Since then, researchers have found that chemotherapy can affect your cognitive abilities in a number of ways, including:

Up to one-third of people undergoing cancer treatment will experience cognitive impairment, though some studies report that at least half the participants have memory problems. Memory changes often continue for at least a year or two after your treatment and may last longer.

Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when you begin treatment, the more likely you are to develop these problems. In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) - often years after treatment ends.

Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancer. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor that has spread to more than four lymph nodes in your armpit.

Radiation is usually started three to four weeks after surgery. You'll typically receive treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become quite tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation.

Hormone therapy is most often used to treat women with advanced (metastatic) breast cancer or as an adjuvant treatment - a therapy that seeks to prevent a recurrence of cancer - for women diagnosed with early-stage estrogen receptor positive cancer. Estrogen receptor positive cancer means that estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to certain sites in your breast and in other parts of your body. But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.

Medications that reduce the effect of estrogen in your body include:

1. Tamoxifen (Nolvadex) - This is a synthetic hormone belonging to a class of drugs known as selective estrogen receptor modulators (SERMs). It's used as a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women with early-stage estrogen receptor positive breast , and as a preventive agent in high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anticancer drugs. But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, and vaginal itch, discharge or dryness. Less common but potentially life-threatening side effects also can occur. These include blood clots in your lungs (pulmonary embolism) and legs (deep vein thrombosis) and endometrial cancer. Older women, especially those with other medical conditions, may be at greater risk of these side effects than are younger women. In addition, some studies have shown that side effects of systemic adjuvant therapies - chemotherapy and tamoxifen - may be more long-term than originally thought.

2. Aromatase inhibitors - This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen. The substance occurs in fat, adrenal gland and ovarian tissues. In a series of clinical trials conducted over several years, the three aromatase inhibitors were tested in various settings. In all cases, women receiving aromatase inhibitors fared better than did those receiving tamoxifen, and the benefits continued even after treatment ended. Women treated with aromatase inhibitors also had a lower incidence of blood clots and endometrial cancer than women taking tamoxifen did. To date, the primary drawback of aromatase inhibitors is an increased risk of osteoporosis. But although some experts recommend that aromatase inhibitors replace tamoxifen as the primary adjuvant treatment for post-menopausal women with breast cancer promoted by estrogen, others urge caution. The main question seems to be whether women should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor from the start. More research will likely be needed to answer these and other questions about adjuvant therapies.

V. Biological therapy - Also called Biological Response Modifier or Immunotherapy

This treatment tries to stimulate your body's immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body's natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials. One medication, trastuzumab (Herceptin), is a monoclonal antibody - a substance produced in a laboratory by mixing cells - that's available for treating certain advanced cases of breast cancer. Herceptin is effective against tumors that produce excess amounts of a protein called HER-2.

A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis - which targets the blood vessels that supply nutrients to cancer cells - is also being studied.

Of particular interest to both women and their doctors are methods of removing breast cancer without actually cutting into or removing the breast. Nonsurgical methods being studied include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.

One of the most researched techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor where it creates heat that destroys cancer cells. In early tests, the procedure has proved successful. Still, not all women would be candidates for the procedure if it eventually were approved for widespread use.

Some of these new treatments are available through clinical trials - the standard way new therapies are tested in people. If you have advanced breast cancer and are interested in participating in a clinical trial, talk to your doctor or contact the National Cancer Institute's Cancer Information Service at (800) 422-6237 for more information.