Breast cancer is the illness that many women fear most, though they’re more likely to die of cardiovascular disease than they are of all forms of cancer combined. Still, breast cancer is second only to lung cancer as a cause of cancer deaths in American women. Although rare, breast cancer can also occur in men ? in the United States, more than 200,000 women and around 1,500 men will develop the disease in 2005.
Yet there’s more reason for optimism than ever before. In the last 30 years, doctors have made great strides in diagnosing and treating the disease and in reducing breast cancer deaths. In 1975 a diagnosis of breast cancer usually meant radical mastectomy ? removal of the entire breast along with underarm lymph nodes and skin and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations.
Signs and symptoms
Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for long-term recovery.
Most breast lumps aren’t cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other signs of breast cancer include:
- A spontaneous clear or bloody discharge from your nipple
- Retraction or indentation of your nipple
- A change in the size or contours of your breast
- Any flattening or indentation of the skin over your breast
- Redness or pitting of the skin over your breast, like the skin of an orange
A number of factors other than breast cancer can cause your breasts to change in size or feel. In addition to the natural changes that occur during pregnancy and your menstrual cycle, other common noncancerous (benign) breast conditions include:
Fibrocystic changes. This condition can cause your breasts to feel ropey or granular. Fibrocystic changes are extremely common, occurring in at least half of all women. In most cases the changes are harmless. And they don’t mean you’re more likely to develop breast cancer. If your breasts are very lumpy, performing a breast self-exam is more challenging. Becoming familiar with what’s normal for you through self-exams will help make detecting any new lumps or changes easier.
Cysts. These are fluid-filled sacs that frequently occur in the breasts of women ages 35 to 50. Cysts can range from very tiny to about the size of an egg. They can increase in size or become more tender just before your menstrual period, and may disappear completely after it. Cysts are less common in postmenopausal women.
Fibroadenomas. These are solid, noncancerous tumors that often occur in women during their reproductive years. A broadensNoama firm, smooth, rubbery lump with a well-defined shape. It will move under your skin when touched and is usually painless. Over time, fibroadenomas may grow larger or smaller or even disappear completely. Although your doctor can usually identify a fibroadenoma during a clinical exam, a small tissue sample is necessary to confirm the diagnosis.
Infections. Breast infections (mastitis) are common in women who are breast-feeding or who recently have stopped breast-feeding, although you can also develop mastitis when you’re not nursing. Your breast will likely be red, warm, tender and lumpy, and the lymph nodes under your arm may swell. You also feel slightly ill and have a low-grade fever.
Trauma. Sometimes a blow to your breast or a bruise also can cause a lump. But this doesn’t mean you’re more likely to get breast cancer.
Calcium deposits (microcalcifications). These tiny deposits of calcium can appear anywhere in your breast and often show up on a mammogram. Most women have one or more areas of microcalcifications of various sizes. They may be caused by secretions from cells, cellular debris, inflammation, trauma or prior radiation. They’re not the result of calcium supplements you take. The majority of calcium deposits are harmless, but a small percentage may be precancerous or cancer. If any appear suspicious, your doctor will likely recommend additional tests and sometimes a biopsy.
If you find a lump or other change in your breast and haven’t yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn’t gone away after a month, have it evaluated promptly.
Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-feeding. Small ducts conduct the milk to a reservoir that lies just beneath your nipple. Supporting this network is a deeper layer of connective tissue called stroma.
The spaces between the lobes and ducts are filled with fat, which makes up about 80 percent to 85 percent of your breast during your reproductive years. Your breasts also contain vessels that transport lymph? a colorless fluid that carries waste products and cells of the immune system? to lymph nodes located primarily under your arm (axillary nodes) but also above your collarbone and in your chest. These nodes are collections of immune system cells that filter harmful bacteria and play a key role in fighting infection.
In breast cancer, some of the cells in your breast begin growing abnormally. These cells divide more rapidly than healthy cells do and may spread through your breast, to the lymph or to other parts of your body (metastasize). The most common type of breast cancer begins in the milk-producing ducts, but cancer may also occur in the lobules or in other breast tissue.
In most cases, it isn’t clear what triggers abnormal cell growth in breast tissue, but doctors do know that between 5 percent and 10 percent of breast cancers are inherited. Defects in one of two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), put you at greater risk of developing both breast and ovarian cancer. Inherited mutations in the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene also make it more likely that you’ll develop breast cancer.
Yet most genetic mutations related to breast cancer aren’t inherited but instead develop during your lifetime. These acquired mutations may result from radiation exposure ? women treated with chest radiation therapy in childhood, for instance, have a significantly higher incidence of breast cancer than do women not exposed to radiation. Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.
In the long run, establishing a link between genetic mutations and cancer is just the first step. Now researchers are trying to learn if a relationship exists between genetic makeup and environmental factors that may increase the risk of breast cancer. Although these studies are still preliminary, breast cancer eventually may prove to have a number of causes.
A risk factor is anything that makes it more likely you’ll get a particular disease. Yet all risk factors aren’t created equal. Some, such as your age, sex, and family history can’t be changed, whereas others, including smoking and a poor diet are personal choices over which you have some control.
But having one or even several risk factors doesn’t necessarily mean you’ll become sick? most women with breast cancer have no known risk factors other than simply being women. In fact, being female is the single greatest risk factor for breast cancer. Although men can develop the disease, it’s 100 times more common in women.
Other factors that may make you more susceptible to breast cancer include:
Age. Your chances of developing breast cancer increase as you get older. The disease rarely affects women younger than 25 years of age, whereas close to 80 percent of breast cancers occur in women older than age 50. At age 40, you have a one in 252 chance of developing breast cancer. By age 85, your chance is one in eight.
A personal history of breast cancer. If you’ve had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.
Family history. If you have a mother, sister or daughter with breast or ovarian cancer or both, or even a male relative with breast cancer, you have a greater chance of also developing breast cancer. In general, the more relatives you have with breast cancer who were premenopausal at the time of diagnosis, the higher your own risk. If you have one close relative with the disease, your risk is doubled. If you have two or more relatives, your risk increases even more. Just because you have a family history of breast cancer doesn’t mean it’s hereditary, though. Most people with a family history of breast cancer (familial breast cancer risk) haven’t inherited a defective gene, such as BRCA1 or BRCA2. Rather, cancer becomes so common in women who live into their 80s and beyond that random, noninherited breast tumors may appear in more than one member of a single family.
Genetic predisposition. Between 5 percent and 10 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren’t as effective at protecting you from cancer.
Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you’re more likely to develop breast cancer later in life. The younger you were when you received the treatments, the greater your risk.
Excess weight. The relationship between excess weight and breast cancer is complex. In general, weighing more than is healthy for your age and height increases your risk if you’ve gained the weight as an adult and especially after menopause. The risk is even greater if you have more body fat in the upper part of your body. Although women usually have more fat in their thighs and buttocks, they tend to gain weight in their abdomens starting in their 30s, which can increase their risks.
Exposure to estrogen. The longer you’re exposed to estrogen, the greater your breast cancer risk. In general, if you have a late menopause (after age 55) or you began menstruating before age 12, you have a slightly higher risk of developing breast cancer. The same is true for women who never had children, or whose first pregnancy occurred when they were age 35 or older.
Birth control pills. The hormone therapy studies have raised questions about the relationship between birth control pills and breast cancer. Unfortunately, there are no clear answers. A large study of women between the ages of 35 and 64 published in June 2002 in the “New England Journal of Medicine” concluded that current or former use of oral contraceptives didn’t increase the risk of breast cancer. For the latest information on the pill and breast cancer, talk to your doctor.
Smoking. A Mayo Clinic study published in April 2001 found that smoking significantly increases the risk of breast cancer in women with a family history of breast and ovarian cancers. And a 2005 study published in the “International Journal of Cancer” found that exposure to secondhand smoke also increases the risk of breast cancer in premenopausal women. Researchers think that higher estrogen levels combined with cancer-causing agents in tobacco spark the development of breast tumors.
Precancerous breast changes (atypical hyperplasia, carcinoma in situ). These changes are often discovered only after you have a breast biopsy for another reason, but they can double your risk of developing breast cancer. If you have carcinoma in situ, discuss treatment and monitoring options with your doctor.
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.
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:
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.
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.
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.
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.
Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That’s why all women with invasive cancer need to have these nodes examined. If your surgeon doesn’t plan to do this, be sure you understand the reason why. 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.
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.
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.
Reconstruction with a tissue flap. 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.
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.
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.
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.
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.