Breast Cancer

Causes: The cause of breast cancer is unknown, but research shows that certain risk factors are associated with the disease.

Risk Factors: A risk factor is something that increases your chance of getting a disease or condition. Risk factors for breast cancer include:

  • Sex: Female 

  • Age: 50 or older 

  • Personal history of breast cancer Family members with breast cancer Changes in breast tissue, such as atypical ductal hyperplasia, radial scar formation, and lobular carcinoma in situ (LCIS) 

  • Changes in certain genes (BRCA1, BRCA2, and others)

  • Race: Caucasian 

  • Increased exposure to estrogen over a lifetime through: 

  • Early onset of menstruation 

  • Late onset of menopause 

  • No childbearing or late childbearing

  • Absence of breast feeding 

  • Taking hormone replacement therapy for long periods of time (Prempro for more than 4 years) 

  • Tobacco use 

  • Increased breast density (more lobular and ductal tissue and less fatty tissue) 

  • Radiation therapy before the age of 30 

  • Overuse of alcohol

Note: Studies show that most women with known risk factors do not get breast cancer. And many women who get breast cancer have none of the risk factors listed above, other than the risk that comes with growing older.

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

  • A lump or thickening in or near the breast or in the underarm area or in the neck 

  • A change in the size or shape of the breast 

  • Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast 

  • Ridges or pitting of the breast skin (like the skin of an orange) 

  • A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly)

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

   TYPES OF BREAST CANCER  

The term "breast cancer" actually describes a variety of cancers that occur within the breast. The different breast cancer types are generally categorized by two factors - where the cancerous cells are located and whether the cancer is prone to spreading.

Breast cancer that occurs in the milk ducts of the breast is called ductal carcinoma. The breast cancer that forms in the lobules where breast milk is made is called lobular carcinoma.

Carcinomas that do not spread outside of the duct or lobule are called in situ [in SY-too] cancers, which mean "in place." If ductal or lobular carcinoma spreads into nearby tissue, it is said to be invasive, or infiltrating. Understanding breast cancer types, size and spread will help you and your doctor select a breast cancer treatment option that is appropriate for you. 

Breast Cancer Types:
Ductal Carcinoma

Ductal carcinoma is the most common form of breast cancer. It develops in the ducts that carry the milk from the lobules (milk glands) to the nipple. Ductal carcinomas can be either in situ or invasive breast cancer. 

1. Ductal Carcinoma In Situ (DCIS)

In ductal carcinoma in situ, cancer cells are present inside the milk ducts but they have not yet spread through the walls of the ducts into the fatty tissue of the breast. For this reason, nearly 100% of women diagnosed at an early stage can be cured. The best way to monitor and prevent getting ductal carcinoma in situ is with a yearly mammogram. Left unchecked, it may develop into invasive breast cancer.

2. Invasive Ductal Carcinoma (IDC)

Invasive ductal carcinoma accounts for nearly 80% of breast cancers. It also begins in a milk duct, but unlike ductal carcinoma in situ, it invades the fatty tissue of the breast. This invasive carcinoma has the potential to metastasize [meh-TAS-ti-size], or spread to other parts of the body through the bloodstream or lymphatic system. It is important to detect and treat invasive ductal carcinoma before it has had time to metastasize and spread to other organs. 

Lobular Carcinoma

Lobular carcinoma is found in the milk-producing glands of the breast. It is far less common than ductal carcinoma, but it can present itself in both breasts more often than other types of breast cancer. Lobular carcinoma can be either in situ or invasive breast cancer. 

1. Lobular Carcinoma In Situ (LCIS)

Technically, lobular carcinoma in situ is not even a cancer. Sometimes called lobular neoplasia, it is classified as pre-cancerous growth that begins in the milk-producing glands. Lobular carcinoma in situ does not penetrate through the wall of the lobules, and most researchers believe it does not usually become an invasive breast cancer. However, women who develop lobular carcinoma in situ have a higher future risk of developing invasive breast cancer in the same or opposite breast. If you have been treated for an lobular carcinoma in situ, you will want to have a physical exam two or three times a year, in addition to an annual mammogram.

2. Invasive Lobular Carcinoma (ILC)

Similar to invasive ductal carcinoma, invasive lobular carcinoma has the potential to metastasize and spread to other parts of the body. It begins in the milk-producing glands, where it extends into the fatty tissue of the breast. About 10% to 15% of breast cancers are invasive lobular carcinomas. Invasive lobular carcinoma also can be more difficult to detect by mammogram than LCIS, making it important to have mammograms annually.

Inflammatory Breast Cancer

This rare type of invasive breast cancer accounts for about 1% of all breast cancers. Inflammatory breast cancer makes the skin of the breast look red and feel warm, as if it were infected. The skin develops a thick, pitted appearance that doctors often describe as resembling an orange peel. Sometimes the breast develops ridges and small bumps that look like hives. Cancer cells blocking lymph vessels or channels in the skin over the breast cause these symptoms.

Medullary Carcinoma

This special type of invasive breast cancer has a relatively well-defined boundary between the tumor tissue and normal tissue. This prevents rapid spreading of the cancer, and it often can be treated more effectively compared to other types of invasive breast cancer. Medullary carcinomas [MED-u-lair-ee kar-sin-OE-ma] account for about 5% of breast cancers.

Mucinous Carcinoma

Mucinous carcinoma is another rare type of invasive breast cancer. It is formed in the breast by mucus-producing cancer cells which spread the disease into the surrounding breast tissue. This type of breast cancer is treatable and offers a higher rate of recovery compared with other types of invasive breast cancer. 

Paget's Disease of the Nipple

This type of breast cancer starts in the milk ducts and spreads to the skin of the nipple and areola (the dark circle around the nipple). The nipple and areola will often appear crusted, scaly and red. The patient may experience burning, itching or notice some bloody discharge from the nipple.

Paget's Disease is a rare form of breast cancer, occurring in only 1% of all cases. It can be associated with in situ carcinoma as well as invasive carcinoma. If no lump can be felt in the breast tissue and the biopsy shows the growth to be in situ and not invasive, treatment for Paget's Disease is very effective.

Phyllodes Tumor

This rare breast tumor forms from the stroma (connective tissue) of the breast, in contrast to carcinomas which develop in the ducts or lobules. Phyllodes tumors are usually benign, but on rare occasions have been found to be malignant (cancerous with the potential to metastasize). These occurrences are extremely rare, with fewer than 10 women dying each year as a result of this breast cancer.

Phyllodes tumors do not respond to hormonal therapy and are less likely to respond to other breast cancer treatments such as chemotherapy or radiation therapy. As a result, benign phyllodes tumors are treated by removing the mass and a narrow margin of the surrounding breast tissue. Malignant phyllodes tumors are removed in the same manner with a wider margin of breast tissue, or by mastectomy.

Tubular Carcinoma

Tubular carcinoma is similar to invasive ductal carcinoma (IDC) and accounts for approximately 2% of all breast cancers. However, the treatment for tubular carcinoma is more effective than that of other invasive breast cancers.

Diagnosis: The doctor will ask about your symptoms and medical history, and perform a physical exam.

Tests may include:

  • Clinical Breast Exam - The doctor carefully feels the breast lump and the tissue around it. The doctor examines the size and texture of the lump and determines whether the lump moves easily. The doctor will examine both breasts, since the tissue can be very “lumpy” throughout the breast in some patients.

  • Mammography - x-rays of the breast used to see lumps or other changes in breast tissue

  • Ultrasonography - the use of high-frequency sound waves to see whether a lump is a fluid-filled cyst (usually not cancer) or a solid mass (which may or may not be cancer)

  • Biopsy - removal of tumor tissue to be tested for cancer cells. Types of biopsies for breast cancer include:

  • Fine-needle aspiration - removal of fluid and/or cells from a breast lump using a thin needle 

  • Needle biopsy - removal of tissue with a needle from an area that looks suspicious on a mammogram but cannot be felt

  • Surgical biopsy: [A] Incisional biopsy - cutting out a sample of a lump or suspicious area; [B] Excisional biopsy - cutting out all of a lump or suspicious area and an area of healthy tissue around the edges

*A new method, called the BLN ASSAY (GeneSearch Breast Lymph Node Assay) examines 50% of a lymph node, instead of the 5% used in current touch prep cytology. BLN promises to yield greater accuracy and to spare patients the anxiety of inconclusive test results or additional surgery.

  Four Stages of Breast Cancer: TNM Staging  

Stage 1: A T-1 tumor and clear lymph nodes with no evidence of metastasis - T1N0M0.

Stage 2: Has at least three subdivisions which are a combination of T1, T2 or T3 tumor, positive or negative lymph nodes and no metastasis - Ex.: T1N0M0.

Stage 3: Has also at least three subdivisions which come from a mix of any size of tumor, positive lymph nodes or nodes located in the collarbone area and no metastasis - Ex.: T3N1M0. 

Stage 4: Also called metastatic breast cancer and is rated by having any size of tumor, positive lymph nodes and obvious metastasis - Ex.: T1N1M1.

Treatment: Once breast cancer is found, staging tests are performed to find out if the cancer has spread and, if so, to what extent.

Treatments include:

  • Surgery: Surgery is the removal of the cancerous tumor and nearby tissues, and possibly nearby lymph nodes. The most common procedures performed today are the lumpectomy (which may be called a tylectomy, segmentectomy, or quadrantectomy) and the modified radical mastectomy.

  • Lumpectomy -removal of the breast cancer and some normal tissue around it. Often, some of the lymph nodes under the arm are removed.

  • Segmentectomy -removal of the cancer and a larger area of normal breast tissue around it.

  • Simple Mastectomy -removal of the breast, or as much of the breast as possible, without the intentional removal of the lymph nodes.

  • Radical Mastectomy -removal of the breast, both chest muscles, the lymph nodes under the arm, and some additional fat and skin. This procedure is only considered in rare cases if the cancer has spread to the chest muscles, and is rarely performed in the United States at this time.

  • Modified Radical Mastectomy -removal of the whole breast, the lymph nodes under the arm and, often, the lining over the chest muscles.

  • Axillary Lymph Node Dissection -removal of the lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system.

  • Sentinel Lymph Node Biopsy - the placement, by the surgeon, of a small amount of blue dye and/or a radioactive tracer in the area where the tumor was located. The dye or tracer is then followed into the armpit and only those lymph nodes picking up the substance are removed. The accuracy rate for this procedure exceeds 95% in experienced hands and reliably identifies those lymph nodes that may contain cancer. Presently, those remaining lymph nodes should be removed if any sentinel nodes contain cancer. This method is usually done in women who do not have lymph nodes that can be felt in the armpit. The potential side effects are far less than seen after a standard lymph node dissection.

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

  • External Radiation Therapy - radiation directed at the breast from a source outside the body.

  • Internal Radiation Therapy - radioactive materials placed into the breast in or near the cancer cells.

  • Chemotherapy: Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be given in many forms including pill, injection, and via a catheter. The drugs enter the bloodstream and travel through the body killing mostly cancer cells, but also some healthy cells.

  • Biologic Therapy: Biologic therapy is the use of medications or substances made by the body to increase or restore the body's natural defenses against cancer. It is also called biologic response modifier (BRM) therapy.

 

Prevention: Because the cause of breast cancer is unknown, finding it early and treating it is the best way to prevent dying from the disease. And because it does not cause symptoms in the early stages, it is important to have screening tests to find the cancer before symptoms appear.

  • Women age 20 or older should perform a breast self-exam (BSE) every month. 

  • Women between the ages of 20 and 39 should have a clinical breast exam by a health professional every 3 years. A breast exam should be performed more regularly if there is a family history or there have been previous breast biopsies. 

  • Women age 40 and older should have a screening mammogram every year. Some advocate a mammogram should be given sooner for patients with a strong family history or in a patient who has had previous breast biopsies performed. 

  • After age 40, women should have a breast exam by a health care professional every year.

Sources: Mayo Clinic, American Cancer Society, National Cancer Institute, http://about.com  & www.breastbiopsy.com/bioresults_typesofbreastcancer.jsp

 

 

Addendum
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.

1. 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.

2. 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. 

3. 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. 

4. Invasive breast cancer - 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.

 (a.) 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. 

(b.) 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:

1. 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. 

2. 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. 

3. 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. 

4. 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. 

5. 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. 

6. 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. 

7. 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. 

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

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

10. 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. 

III. Recurrent breast cancer

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.