Breast Cancer

Breast cancer is the most common type of cancer among women in the United States (other than skin cancer). Each year, more than 180,000 women in this country learn they have breast cancer. The National Cancer Institute (NCI) has written this booklet to help patients with breast cancer and their families and friends better understand this disease. We hope others will read it as well to learn more about breast cancer.

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Male Breast Cancer

Breast cancer affects more than 1,000 men in this country each year. Although this booklet was written mainly for women, much of the information on symptoms, diagnosis, treatment, and living with the disease applies to men as well. (The Early Detection section does not apply to men. Experts do not recommend routine screening for men.)

Cancer research has led to real progress against breast cancer–better survival and improved quality of life. And knowledge about breast cancer is increasing. The Cancer Information Service and other NCI resources listed in the National Cancer Institute Information Resources section can provide the latest, most accurate information on breast cancer.

The CIS staff uses a National Cancer Institute cancer information database called PDQ and other NCI resources to answer callers’ questions. The staff can send callers information from PDQ and other NCI materials about cancer, its treatment, and living with the disease, including those listed in the Other Booklets section.

The Breasts

Each breast has 15 to 20 overlapping sections called lobes. Within each lobe are many smaller lobules, which end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat fills the spaces around the lobules and ducts. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.

Each breast also contains blood vessels and vessels that carry colorless fluid called lymph. The lymph vessels lead to small bean-shaped organs called lymph nodes. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest. Lymph nodes are also found in many other parts of the body.

Breast Diagram

Types of Breast Cancer

The most common type of breast cancer begins in the lining of the ducts and is called ductal carcinoma. Another type, called lobular carcinoma, arises in the lobules.

When breast cancer spreads outside the breast, cancer cells are often found in the lymph nodes under the arm (axillary lymph nodes). If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body–other lymph nodes and other organs, such as the bones, liver, or lungs–via the lymphatic system or the bloodstream.

Cancer that spreads is the same disease and has the same name as the original (primary) cancer. When breast cancer spreads, it is called metastatic breast cancer, even though the secondary tumor is in another organ. Doctors sometimes call this “distant” disease.

Risk Factors for Breast Cancer

The risk of breast cancer increases gradually as a woman gets older. This disease is uncommon in women under the age of 35. All women age 40 and older are at risk for breast cancer. However, most breast cancers occur in women over the age of 50, and the risk is especially high for women over age 60.

Research has shown that the following conditions place a woman at increased risk for breast cancer:

  • Personal history of breast cancer – Women who have had breast cancer face an increased risk of getting breast cancer again.
  • Genetic alterations – Changes in certain genes (BRCA1, BRCA2, and others) make women more susceptible to breast cancer. In families in which many women have had the disease, gene testing can show whether a woman has specific genetic changes known to increase the susceptibility to breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or improve the detection of breast cancer in women who have the genetic alterations. For more information about gene testing, read the Causes and Prevention section under The Promise of Cancer Research.
  • Family history – A woman’s risk for developing breast cancer increases if her mother, sister, daughter, or two or more other close relatives, such as cousins, have a history of breast cancer, especially at a young age.
  • Certain breast changes – Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) or having had two or more breast biopsies for other benign conditions may increase a woman’s risk for developing cancer.

Other factors associated with an increased risk for breast cancer include:

  • Breast density – Women age 45 and older whose mammograms show at least 75 percent dense tissue are at increased risk. Dense breasts contain many glands and ligaments, which makes breast tumors difficult to “see,” and the dense tissue itself is associated with an increased chance of developing breast cancer.
  • Radiation therapy – Women whose breasts were exposed to radiation during their childhood, especially those who were treated with radiation for Hodgkin’s disease, are at an increased risk for developing breast cancer throughout their lives. Studies show that the younger a woman was when she received her treatment, the higher her risk for developing breast cancer later in life.
  • Late childbearing – Women who had their first child after the age of 30 have a greater chance of developing breast cancer than women who had their children at a younger age.

Also at a somewhat increased risk for developing breast cancer are women who started menstruating at an early age (before age 12), experienced menopause late (after age 55), never had children, or took hormone replacement therapy or birth control pills for long periods of time. Each of these factors increases the amount of time a woman’s body is exposed to estrogen. The longer this exposure, the more likely she is to develop breast cancer.

Early Detection

When breast cancer is found and treated early, the chances for survival are better. Women can take an active part in the early detection of breast cancer by having regular screening mammograms and clinical breast exams (breast exams performed by health professionals). Some women also perform breast self-exams.

A screening mammogram is the best tool available for finding breast cancer early, before symptoms appear. A mammogram is a special kind of x-ray. It is different from a chest x-ray or x-rays of other parts of the body. Screening mammograms are used to look for breast changes in women who have no signs of breast cancer.

Mammograms can often detect breast cancer before it can be felt. Also, a mammogram can show small deposits of calcium in the breast. Although most calcium deposits are benign, a cluster of very tiny specks of calcium (called microcalcifications) may be an early sign of cancer.

Some women perform monthly breast self-exams to check for any changes in their breasts. When doing a breast self-exam, it’s important to remember that each woman’s breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman’s breasts to be swollen and tender right before or during her menstrual period. Remember that for women in their forties and older, a monthly breast self-exam is not a substitute for regularly scheduled screening mammograms and clinical breast exams by a health professional.

Symptoms

Early breast cancer usually does not cause pain. In fact, when breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause changes that women should watch for:

  • A lump or thickening in or near the breast or in the underarm area;
  • A change in the size or shape of the breast;
  • Nipple discharge or tenderness, or the nipple pulled back (inversion) into the breast;
  • Ridges or pitting of the breast (the skin looks like the skin of an orange; or
  • A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly).

A woman should see her doctor about any symptoms like these. Most often, they are not cancer, but it’s important to check with the doctor so that any problems can be diagnosed and treated as early as possible.

Diagnosis

An abnormal area on a mammogram, a lump, or other changes in the breast can be caused by cancer or by other, less serious problems. To find out the cause of any of these signs or symptoms, a woman’s doctor does a careful physical exam and asks about her personal and family medical history.

  • Palpation – The doctor can tell a lot about a lump (its size, its texture, and whether it moves easily) by palpation, carefully feeling the lump and the tissue around it. Benign lumps often feel different from cancerous ones.
  • Mammography – X-rays of the breast can give the doctor important information about a breast lump. If an area on the mammogram looks suspicious or is not clear, additional mammograms may be needed.
  • Ultrasonography – Using high-frequency sound waves, ultrasonography can often show whether a lump is solid or filled with fluid. This exam may be used along with mammography.

Based on these exams, the doctor may decide that no further tests are needed and no treatment is necessary. (In such cases, the doctor may need to check the woman regularly to watch for any changes.)

Often, however, fluid or tissue must be removed from the breast to make a diagnosis. A woman’s doctor may refer her for further evaluation to a surgeon or other health care professional who has experience with breast diseases. These doctors may perform:

  • Fine needle aspiration – A thin needle is used to remove fluid from a breast lump. This procedure may show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). Clear fluid removed from a cyst may not need to be checked by a lab.
  • Needle biopsy – Using special techniques, tissue can be removed with a needle from an area that is suspicious on a mammogram but cannot be felt. Tissue removed in a needle biopsy goes to a lab to be checked by a pathologist for cancer cells.
  • Surgical biopsy – The surgeon cuts out part or all of a lump or suspicious area. A pathologist examines the tissue under a microscope to check for cancer cells.
When a woman needs a biopsy, these are some questions she may want to ask her doctor:

  • What type of biopsy will I have? Why?
  • How long will it take? Will I be awake? Will it hurt?
  • How soon will I know the results?
  • If I do have cancer, who will talk with me about treatment? When?

Treatment

Through continuing research into new treatment methods, women now have more treatment options and hope for survival than ever before. The treatment options for each woman depend on the size and location of the tumor in her breast, the results of lab tests (including hormone receptor tests), and the stage (or extent) of the disease. To develop a treatment plan to fit each patient’s needs, the doctor also considers a woman’s age and menopausal status, her general health, and the size of her breasts.

Many women want to learn all they can about their disease and their treatment choices so that they can take an active part in decisions about their medical care. They are likely to have many questions and concerns about their treatment options.

The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are, how successful her treatment is expected to be, and how much it is likely to cost. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. Also, the patient may want to talk with her doctor about taking part in a clinical trial, a research study involving people, of new treatment methods. Look at the Clinical Trials section of The Promise of Cancer Research for more information.

Many patients find it helpful to make a list of questions before seeing the doctor. To make it easier to remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also find that it helps to have a family member or friend with them when they see the doctor–to take part in the discussion, to take notes, or just to listen.

Here are some questions a woman may want to ask the doctor before treatment begins:

  • What are my treatment choices?
  • What are the expected benefits of each kind of treatment?
  • What are the risks and possible side effects of each treatment?
  • Are new treatments under study? Would a clinical trial be appropriate for me?

There is a lot to learn about breast cancer and its treatment. Patients should not feel that they need to ask all their questions or understand all the answers at once. They will have many other chances to ask the doctor to explain things that are not clear and to ask for more information.

Methods of Treatment

Methods of treatment for breast cancer are local or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have just one form of treatment or a combination. Different forms of treatment may be given at the same time or one after another.

Surgery is the most common treatment for breast cancer. Several types of surgery may be used. The doctor can explain each of them in detail, discuss and compare the benefits and risks of each type, and describe how each will affect the patient’s appearance. An operation to remove the breast (or as much of the breast as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system.

Diagram of lumpectomy

In lumpectomy, the surgeon removes the breast cancer and some normal tissue around it. Often, some of the lymph nodes under the arm are removed.

Diagram of segmental mastectomy

In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some of the lymph nodes under the arm may also be removed.

In total (simple) mastectomy, the surgeon removes the whole breast. Some of the lymph nodes under the arm may also be removed.

Diagram of modified radical mastectomy

In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm, and often the lining over the chest muscles. The smaller of the two chest muscles is also taken out to help in removing the lymph nodes.

Diagram of radical mastectomy

In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, the chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered the standard one for women with breast cancer, but it is very rarely used today and only in cases of advanced cancer in which the cancer has spread to the chest muscles.

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells and stop them from growing. The rays may come from radioactive material outside the body and be directed at the breast by a machine (external radiation). The radiation can also come from radioactive material placed directly in the breast in thin plastic tubes (implant radiation). Some women receive both kinds of radiation therapy.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given by mouth or by injection. Either way, chemotherapy is a systemic therapy because the drugs enter the bloodstream and travel throughout the body.

Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment, and so on. Most patients have chemotherapy in an outpatient part of the hospital, at the doctor’s office, or at home. Depending on which drugs are given and the woman’s general health, however, she may need to stay in the hospital during her treatment.

Hormonal therapy is used to keep cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work or surgery to remove the ovaries, which make female hormones. Like chemotherapy, hormonal therapy is a systemic treatment; it can affect cancer cells throughout the body.

Treatment Choices

Treatment decisions are complex. They are often affected by the judgment of the doctor and by the desires of the patient.

A patient’s treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size, location, and stage of the tumor; whether the doctor can feel lymph nodes under her arm; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered. The most important factor is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread.

Side Effects of Treatment

It is hard to limit the effects of cancer treatment so that only cancer cells are removed or destroyed. Because healthy cells and tissues may also be damaged, treatment often causes unwanted side effects.

The side effects of cancer treatment are different for each person, and they may even be different from one treatment to the next. Doctors try to plan treatment to keep problems to a minimum. They also watch patients carefully so that they can help with any problems that occur. The National Cancer Institute booklets Radiation Therapy and You, Chemotherapy and You, and Understanding Breast Cancer Treatment: A Guide for Patients have helpful information about these cancer treatments and coping with their side effects.

Nutrition for Cancer Patients

Loss of appetite can be a problem for cancer patients. People may not feel hungry when they are uncomfortable or tired. Also, some of the common side effects of cancer treatment, such as nausea, vomiting, and mouth sores, can make it hard to eat. The doctor can prescribe medicine to help with these problems. Good nutrition is important. Patients who eat well often feel better and have more energy. Eating well means getting enough calories and protein to help prevent weight loss, regain strength, and rebuild normal tissues.

Doctors, nurses, and dietitians can explain the side effects of treatment and can suggest ways to deal with them. Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

Follow Up Care

Regular followup exams are important after breast cancer treatment. The doctor will continue to check the woman closely to be sure that the cancer has not returned. Regular checkups usually include examinations of the breasts, chest, underarm, and neck. From time to time, the woman has a complete physical exam and a mammogram. Some women may also have additional tests.

A woman who has had cancer in one breast has an increased risk of developing cancer in her other breast. She should report any changes in the treated area or in the other breast to her doctor right away.

Also, a woman who has had breast cancer should tell her doctor about other physical problems if they come up, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. She should also report dizziness, coughing or hoarseness, headaches, backaches, or digestive problems that seem unusual or that don’t go away. These symptoms may be a sign that the cancer has returned, but they can also be signs of various other problems. It’s important to share your concerns with a doctor.

Nutritional Supplementation

(A) retinol and zinc;

(B) riboflavin and niacin; (C) vitamin C and molybdenum; and vitamin A, vitamin E, and selenium. Iron, zinc, folic acid and calcium

Research has shown that deficiencies in micronutrients such as zinc and vitamins A and D reduce natural killer cell function, whereas supplemental zinc and vitamin C enhance their activity

Selenium is one of the most powerful anti-cancer substances ever discovered and has a role to play in treatment as well as prevention.

Coenzyme Q10 is another antioxidant with immune stimulating abilities. Coenzyme Q10 may work by increasing oxidative metabolism and free radical damage within these cancer cells.