All About Breast Cancer
Christopher Dolinsky, MD and Christine Hill-Kayser, MD
Updated by Karen Arnold-Korzeniowski, BSN RN
Abramson Cancer Center of the University of Pennsylvania
Last Modified: January 20, 2016
- What is the breast?
- What is breast cancer?
- Am I at risk for breast cancer?
- Male Breast Cancer
- How can I prevent breast cancer?
- What screening tests are available?
- What are the signs of breast cancer?
- How is breast cancer diagnosed and staged?
- What are the treatments for breast cancer?
- Early/Moderate Stage Breast Cancer
- Advanced Breast Cancer
- Follow-up care and survivorship
- Resources for more information
- Appendix: Complete Breast Cancer Staging
The breast is a collection of glands and fatty tissue that lies between the skin and the chest wall. The glands inside the breast produce milk after a woman has a baby. Each gland is also called a lobule, and many lobules make up a lobe. There are 15 to 20 lobes in each breast. The milk gets to the nipple from the glands by way of tubes called ducts. The glands and ducts get bigger when a breast is filled with milk, but the tissue that is most responsible for the size and shape of the breast is the fatty tissue. There are also blood vessels and lymph vessels in the breast. Lymph is a clear liquid waste product that gets drained out of the breast into lymph nodes. Lymph nodes are small, pea-sized pieces of tissue that filter and clean the lymph. Most lymph nodes that drain the breast are under the arm in what is called the axilla, or armpit.
Collections of cells that are growing abnormally or without control are called tumors. Tumors that do not have the ability to spread throughout the body may be referred to as "benign" and are not thought of as cancerous. Tumors that have the ability to grow into other tissues or spread to distant parts of the body are referred to as "malignant." Malignant tumors within the breast are called "breast cancer". Theoretically, any of the types of tissue in the breast can form a cancer, but cancer cells are most likely to develop from either the ducts or the glands. These tumors may be referred to as "invasive ductal carcinoma" (cancer cells developing from ducts), or "invasive lobular carcinoma" (cancer cells developing from lobes).
Sometimes, precancerous cells may be found within breast tissue, and are referred to as ductal carcinoma in-situ (DCIS) or lobular carcinoma in-situ (LCIS). DCIS and LCIS are diseases in which cancerous cells are present within breast tissue, but are not able to spread or invade other tissues. DCIS represents about 20% of all breast cancers. Because DCIS cells may become capable of invading breast tissue, treatment for DCIS is usually recommended. In contrast, LCIS is considered to be a marker for increased risk for breast cancer, but it does not usually need to be treated unless a true breast cancer is also present.
Breast Cancer in Women
Breast cancer is the second most common malignancy effecting women in America. About 231,840 cases of invasive breast cancer and 60,290 of non-invasive breast cancer were diagnosed in the United States in 2015. The lifetime risk of any particular woman getting breast cancer is about 1 in 8. Men are also at risk for development of breast cancer, although this risk is much lower than it is for women. (See below for more on male breast cancer.)
Being a woman puts you at higher risk of getting breast cancer. Men can develop breast cancer but breast cancer is about 100 times more common in women. Women have more estrogen and progesterone (female hormones), which can promote breast cancer cell growth.
As any woman ages, her risk of breast cancer increases. Risk is also affected by the age when a woman begins menstruating (younger age may increase risk), and her age at her first pregnancy (older age may increase risk). Use of exogenous estrogens, sometimes in the form of hormone replacement treatment (HRT) may increase breast cancer risk.
Caucasian women are slightly more at risk of developing breast cancer than African-American women. However, women diagnosed under the age of 45, are more likely to be Africa-American women. Asian, Hispanic, and Native-American women have the lowest risk of being diagnosed with and dying from breast cancer.
Dense breast tissue is another risk factor for breast cancer. Dense breasts tend to be more glandular and fibrous and this can be seen on a mammogram. Benign breast conditions such as proliferative lesions with or without atypia increase the chance of getting breast cancer.
Family history is very important in determining breast cancer risk. While you would think that a history of cancer in the family would automatically increase risk, it isn't so simple. Some common cancers – like breast and prostate – are seen in many families, but do not necessarily increase risk in that family, particularly if the person was older at the time of diagnosis. Having an elderly grandmother diagnosed with breast cancer does not increase risk much, but a mother diagnosed at 43 does. There is no one size fits all explanation, so it is important to discuss your family history and risk with your healthcare providers.
Known genetic mutations that increase risk of breast cancer are present in some families; these include mutations in the genes BRCA1 and BRCA2. Between 5% to 10% of breast cancers may be related to changes in one of the BRCA genes. Women can inherit these mutations from their parents, or mutations can arise for the first time in any person. Genetic testing for mutations should be considered for any woman with a strong family history of breast cancer, especially breast cancers in family members less than 50 years, or strong family history of prostate or ovarian cancer. If a woman is found to carry either mutation, she has a 50% chance of getting breast cancer before she is 70. Family members may elect to be tested to see if they carry the mutation as well. If a woman does have the mutation, she may choose to undergo more rigorous screening or even undergo preventive (prophylactic) mastectomy to decrease her chances of contracting cancer. The decision to undergo genetic testing is a highly personal one that should be discussed with a genetic counselor who is specially trained to counseling patients regarding the risks and benefits of genetic testing.
Another factor that puts a woman at higher risk of being diagnosed with breast cancer is a history of treatment with radiation to the chest. This risk is highest in women who received chest radiation during adolescence, when the breasts were in development.
If you have had breast cancer in the past, you are 3 to 4 times more likely to develop another breast cancer compared to a woman who has never had the disease - not metastases or spread from the first cancer, but a new cancer altogether. This may occur in the same breast or the other breast. This is why it is so important to keep follow up appointments with your oncology team and continue recommended screening tests.
DES was the first synthetic estrogen and was given to pregnant women from 1938-1971 because it was believed to prevent miscarriages and promote "healthy pregnancies." It was found that not only did the drug not prevent problems associated with pregnancy, it also caused health issues for the women taking it, as well as children born of these pregnancies. Women who took DES have been found to have a "moderately" increased risk of developing breast cancer. Studies have found a 30% increased risk compared to women who did not take DES. Women who were given DES should have annual mammograms and breast exams by a healthcare provider. They should be familiar with their normal breast tissue and report any nipple discharge or changes in their breast tissue or skin (dimpling, swelling, redness, nipple retraction) to their healthcare provider. Women who were given DES during pregnancy should be sure their children know this and report it to their healthcare team. Daughters born to women taking DES (DES daughters) are at increased risk of breast cancer as well and should discuss screening recommendations with their healthcare providers.
Some factors associated with breast cancer risk can be controlled by a woman herself. Use of hormone replacement therapy (HRT), drinking more than 5 alcoholic drinks per week, being overweight, and being inactive may all contribute to breast cancer risk. These are called modifiable risk factors. It is important to remember that even someone without any risk factors can still get breast cancer. Proper screening and early detection are our best weapons in reducing the mortality associated with this disease.
There will be about 2,350 new cases of male breast cancer in 2015. Age is a risk factor in men for the development of breast cancer. The average age of men diagnosed with breast cancer is 68. The risk of breast cancer is also increased in men with a family history of breast cancer. Other risk factors for the development of male breast cancer include Klinefelter's syndrome (a congenital condition in which men are born with a Y chromosome and at least 2 X chromosomes), being of Jewish decent, mumps orchitis (a swelling of the testes caused by the mumps virus), estrogen treatment, obesity, liver disease, radiation exposure and heavy alcohol consumption.
The predominant presenting symptom in men is a mass in the breast. Other signs of male breast cancer include nipple discharge (particularly if bloody), nipple retraction and skin ulceration. Mammograms are difficult to perform, particularly on thin men, so a biopsy should be done on a suspicious lump.
The most important risk factors for the development of breast cancer, such as age and family history, cannot be controlled by an individual person. However, some risk factors may be in a woman's control. These include things like avoiding long-term hormone replacement therapy use, having children before age 30, breastfeeding, avoiding weight gain through exercise and proper diet, and limiting alcohol consumption to 1 drink a day or less. Men can control some risk factors like obesity and limiting alcohol intake. However, other risk factors can’t be avoided like Klinefelter’s syndrome and being of Jewish decent.
Women at very high risk due to family history may benefit from chemoprevention, which means taking a medication or supplement to prevent the development of a cancer. Some women at high risk for developing breast cancer may be offered a form of chemoprevention to reduce their risk of breast cancer. A category of medications called selective estrogen receptor modulators (SERMs) work by blocking the effect of estrogen on certain tissues in the body, including breast tissue. In doing so, they can reduce the risk of developing breast cancer. The two most studied SERMs are tamoxifen and raloxifene. These medications do have their own risks, so whether or not to take them as chemoprevention is a discussion each woman should have with her healthcare provider.
The earlier that a breast cancer is detected, the more likely it is be curable. For this reason, we screen for breast cancer using mammograms, clinical breast exams, and breast self-exams. Screening mammograms are simply x-rays of the breasts. Each breast is placed between two plates for a few seconds while the x-rays are taken. If something appears abnormal, or better views are needed, magnified views or specially angled films are taken during the mammogram. Mammograms often detect tumors before they can be felt and they can also identify tiny specks of calcium that could be an early sign of cancer. The majority of breast cancers are detected through abnormal mammographic findings. Currently there is much discussion as to when and how often a woman should have a mammogram. Current recommendations from the American Cancer Society say:
- Women ages 40-44 should have the choice to start screening mammograms after discussing the risks and benefits with their provider.
- Women ages 45 to 54 should get a mammogram every year.
- Women ages 55 and older should get a mammogram every 2 years, with the choice to continue getting them every year.
- Continue screening as long as the woman is in good health and expected to live 10 years or more.
If you have a family history of breast cancer or a personal health history that increases your risk (radiation exposure, genetic mutation, etc), speak with your provider about starting mammograms earlier, depending on your personal and/or family history. Many centers are now making use of digital mammograms, which appear to be more sensitive than conventional mammography.
Guidelines for clinical breast exam (completed by your healthcare provider) have recently changed. This exam is no longer recommended; as there is no clinical evidence to support that it will detect cancer early. Women should still be familiar with their normal breast tissue and report any changes in appearance, size, or feel of the tissue or nipples, or any nipple discharge to their health care provider.
In certain populations of women, MRI screening in addition to mammogram may be recommended. The American Cancer Society now recommends yearly breast MRI and mammogram for breast cancer screening for women who carry a known BRCA 1 or 2 mutation, those with a very strong family history of breast or ovarian cancer, and those who have had prior radiation treatment to the chest (for example, radiation as part of treatment for Hodgkin's Lymphoma). Other populations of women who may benefit from MRI screening are those who have already had breast cancer, those with known lobular carcinoma in-situ (LCIS), and those with very dense breast, which may be difficult to visualize on mammograms. Decisions regarding how to screen for breast cancer (with mammograms, MRI, or both) should be made between an individual and her healthcare provider, based on her individual breast cancer risk profile.
Other screening modalities that are currently being studied include, ductal lavage, ultrasound, optical tomography, and PET scan.
Unfortunately, the early stages of breast cancer may not have any symptoms. This is why it is important to follow screening recommendations. As a tumor grows in size, it can produce a variety of symptoms including:
- Lump or thickening in the breast or underarm
- Change in size or shape of the breast
- Nipple discharge or nipple turning inward
- Redness or scaling of the skin or nipple
- Ridges or pitting of the breast skin
These symptoms do not always signify the presence of breast cancer, but they should always be evaluated immediately by a healthcare professional.
Once a patient has symptoms suggestive of a breast cancer or an abnormal screening mammogram, she will usually be referred for a diagnostic mammogram. A diagnostic mammogram is another set of x-rays with additional angles and close-up views. Often, an ultrasound will be performed during the same session. An ultrasound uses high-frequency sound waves to outline the suspicious areas of the breast. It is painless and can often distinguish between benign and malignant lesions.
Depending on the results of the mammograms and/or ultrasounds, your providers may recommend that you get a biopsy. A biopsy is the only way to know for sure if you have cancer, because it allows your providers to get cells that can be examined under a microscope. There are different types of biopsies; they differ with regard to how much tissue is removed. Some biopsies use a very fine needle, while others use thicker needles or even require a small surgical procedure to remove more tissue. Your team of providers will decide which type of biopsy you need depending on your particular breast mass.
Once the tissue is removed, a provider known as a pathologist will review the specimen. The pathologist can tell if is the cells are cancerous or not, If the tumor does represent cancer, the pathologist will characterize it by what type of tissue it arose from, how abnormal it looks (known as the grade), whether or not it is invading surrounding tissues, and whether or not the entire lump was removed during surgery. The pathologist will also test the cancer cells for the presence of estrogen and progesterone receptors as well as HER-2 Neu receptor. The presence of estrogen and progesterone receptors are important because cancers that have these receptors can be treated with hormonal therapies. HER-2 expression may help predict prognosis and allow for treatment with therapies directed specifically at HER-2. See Understanding Your Pathology Report for more information.
How is breast cancer staged?
In order to guide treatment and offer some insight into prognosis, breast cancer is staged into five different groups. This staging is done in a limited fashion before surgery taking into account the size of the tumor on mammogram and any evidence of spread to other organs that is picked up with other imaging modalities; and it is done definitively after a surgical procedure that removes lymph nodes and allows a pathologist to examine them for signs of cancer. The staging system is very complex. A simplified version is described below, and the entire staging system is outlined at the end of this article.
- Stage 0: (called carcinoma in situ)
- Lobular carcinoma in situ (LCIS) refers to abnormal cells lining a gland in the breast. This is a risk factor for the future development of cancer, but this is not felt to represent a cancer itself.
- Ductal carcinoma in situ (DCIS) refers to abnormal cells lining a duct. Women with DCIS have an increased risk of getting invasive breast cancer in that breast. Treatment options are similar to patients with Stage I breast cancers.
- Stage I: early stage breast cancer where the tumor is less that 2 cm, and hasn't spread beyond the breast.
- Stage II: early stage breast cancer in which the tumor is either less than 2 cm across and has spread to the lymph nodes under the arm; or the tumor is between 2 and 5 cm (with or without spread to the lymph nodes under the arm); or the tumor is greater than 5 cm and hasn't spread outside the breast.
- Stage III: locally advanced breast cancer in which the tumor is greater than 5 cm across and has spread to the lymph nodes under the arm; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.
- Stage IV: metastatic breast cancer in which the cancer has spread outside the breast to other organs in the body.
Depending on the stage of your cancer, your provider may want additional tests to determine whether the cancer has spread to any organs outside of the breast and surrounding lymph nodes. Nearly all women with a breast cancer diagnosis will need a chest x-ray and basic blood work. If you have a stage III cancer, your provider may recommend other tests, such as CT scan and bone scan. Each case is unique and your providers will determine what is necessary to adequately stage your cancer.
Treatments for breast cancer vary based on many individual factors, including cancer stage, the age and overall health of the patient, and individual pathologic findings. Treatments for early-stage and advanced breast cancer are discussed separately in the upcoming sections of this article.
Generally speaking, early/moderate-stage breast cancer refers to breast cancer that is stage 0-II. These cancers are less than 5 centimeters, can be removed surgically, and have not spread beyond the breast and regional lymph nodes.
Almost all women with early/moderate-stage breast cancer will have some type of surgery in the course of their treatment. The purpose of surgery in this setting is to remove as much of the cancer as possible, and there are many different ways that the surgery can be carried out. Some women will be candidates for what is called breast-conserving surgery (BCS). BCS may refer to a lumpectomy, during which the tumor and a portion of normal tissue are removed, or a segmental/partial mastectomy, during which a larger piece of tissue, but not the whole breast, is removed. Many patients will also have surgical procedures to remove lymph nodes from the axilla (armpit). Any patient who has an invasive breast cancer (any stage except stage 0) should have surgery to the axillary region. This may be a sentinel lymph node biopsy, when 1-2 lymph nodes are removed, an axillary dissection, when many more nodes are removed, or both. The pathologist will review both the breast tissue removed during BCS and the lymph node tissue that is removed. S/he will communicate with your surgeon and other providers regarding the type of cancer cells that are seen, as well as the size of the cancer, and the number of lymph nodes that have cancer in them. These factors will help to determine what further treatment may be needed.
In most cases, a woman who undergoes breast-conserving surgery will require radiation treatment to the remaining breast tissue. The reason for this is that radiation decreases the risk of the cancer recurring (coming back) in the breast tissue. Very large studies have shown that breast conserving surgery and radiation are as effective as mastectomy (removal of the entire breast) for patients with early/moderate stage breast cancer. Many patients prefer BCS and radiation to mastectomy because BCS allows the patient to keep her breast; however, some women with early stage breast cancer prefer mastectomy, and this is certainly another treatment option. Modified radical mastectomy refers to removal of the entire breast, as well as the dissection of the lymph nodes under the arm. Many women who have modified radical mastectomies choose to undergo breast reconstruction. A patient who desires reconstruction should try to meet with a plastic surgeon before her mastectomy to discuss reconstruction options. Learn more about breast reconstruction.
Even when tumors are removed by surgery, microscopic cancer cells can spread to distant sites in the body. In order to decrease a patient's risk of the cancer returning (called recurrence), many breast cancer patients are offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body to eliminate cancer cells that have broken off from the breast tumor and spread. Many factors go into determining whether an individual patient should have chemotherapy. Generally, patients with higher stage disease need chemotherapy; however, chemotherapy can be beneficial even for patients with early-stage disease. Individual factors such as age, overall health, and biologic properties of a woman's breast tumor may go into decisions regarding whether or not she should have chemotherapy. In some cases, the genetic make up of the tumor may be used to determine the potential benefit of chemotherapy. Available genetic tests include OncoType Dx and MammaPrint.
There are many different chemotherapy drugs, and they are usually given in combinations for 3 to 6 months after surgery for early/moderate stage breast cancer. Most chemotherapies used for breast cancer are given through a vein, so they need to be given in an oncology clinic. Medications that are commonly used in early/moderate stage breast cancer treatment include adriamycin (doxorubicin), cyclophosphamide, cisplatin, and taxanes (taxol and taxotere). There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your providers to come up with the best regimen for your lifestyle.
Many patients with early/moderate stage breast cancer require radiation therapy. Radiation therapy refers to use of high energy x-rays to kill cancer cells. As discussed previously, radiation therapy is recommended for nearly all early-stage breast cancer patients who have breast-conserving surgery. Radiation is important in reducing the risk of local recurrence. Your radiation oncologist can answer questions about the utility, process, and side effects of radiation therapy in your particular case.
Patients having radiation usually need to come to a radiation therapy treatment center 5 days a week for up to 6 weeks to receive treatment. The treatment takes just a few minutes, and it is painless. Most patients having radiation for early/moderate stage breast cancer receive treatment to the whole breast for 4-5 weeks; the final 1-2 weeks of treatment usually involve a "boost" of radiation that is only delivered to the area in the breast where the tumor was. Some other regimens exist for delivering radiation for early/moderate-stage breast cancers. One approach includes giving more radiation per day to the whole breast so that the treatment takes only 4 weeks. Other approaches reduce the treatment time to 1 week (brachytherapy or Mammosite). Another technique may include radiation to the regional lymph nodes which is thought to reduce recurrence. These techniques are only appropriate for certain patients. Your radiation oncologist will discuss the most appropriate course of treatment for your individual case.
When the pathologist examines a tumor specimen, he or she may determine that the tumor is expressing estrogen and/ or progesterone receptors. Patients whose tumors express estrogen receptors are candidates for therapy with estrogen blocking drugs. Estrogen-blocking drugs include tamoxifen and a family of medications called aromatase inhibitors. These medications are delivered in pill form for 5 - 10 years after breast cancer surgery. They have been shown to drastically reduce your risk of recurrence if your tumor expresses estrogen receptors. They may be accompanied by side effects, however. When taking tamoxifen, patients may experience weight gain, hot flashes, vaginal dryness, and discharge. Taking tamoxifen may also increase risk of serious medical issues, such as blood clots, stroke, and uterine cancer. Patients taking aromatase inhibitors may experience bone or joint pain, and are at increased risk for thinning of the bones (osteopenia or osteoporosis). Patients taking aromatase inhibitors should have yearly bone density testing, and may require treatment for bone thinning.
The pathologist also examines your tumor for the presence of HER-2 overexpression. HER-2 is a receptor that is over-expressed in about 25% of breast cancers. These are referred to as HER2 positive breast cancers. These tumors may grown faster and are more likely to spread, but there are also medications designed specifically to target the HER2 protein, giving these tumors an extra treatment option. The most common treatment for HER2 positive cancers is trastuzumab (Herceptin®), which may be given to treat the cancer or prevent it from recurring. In addition, lapatinib (Tykerb®) and pertuzumab (Perjeta®) also treat HER2 positive cancers.
Advanced breast cancer is a term that is generally used to refer to breast cancers that are stage III or IV at the time of diagnosis, or breast cancers that were stage 0-II at diagnosis and have recurred (come back) in other parts of the body.
There are many reasons that patients with advanced breast cancer may need to undergo surgery. Locally advanced (stage III) breast cancers are usually treated with a modified radical mastectomy. This refers to removal of the entire breast, as well as and dissection of the lymph nodes under the arm. Occasionally, if a woman with stage III breast cancer has a strong desire to preserve her breast, she can receive chemotherapy to shrink the tumor, followed by breast conserving surgery (removal of only the tumor and a small amount of breast tissue and not the whole breast). This is a decision that can only be made with advice from your surgical team. Your surgeon can discuss your options and the pros and cons of these surgical procedures. Many women who have modified radical mastectomies choose to undergo a reconstruction. A patient who desires reconstruction should try to meet with a plastic surgeon before her mastectomy to discuss reconstruction options. Learn more about breast reconstruction.
Some women who are diagnosed with stage IV cancer, or women with early stage cancer that has become metastatic, may also require modified radical mastectomy. At other times, women with stage IV disease may only undergo breast biopsy without a larger surgery. This may be done because the treatment team feels that drug therapy is required to deal with all of the disease that is present, and that surgery to remove the breast tumor will not be beneficial for the patient and will further delay chemotherapy. In some cases, a patient with stage IV disease may be able to have surgery to remove tumors that have spread to other sites, (i.e. brain, spinal cord and lungs) in order to relieve symptoms or control further spread of the cancer.
Chemotherapy & Biologic Therapy
The term "advanced breast cancer" means that the cancer cells have spread beyond the original tumor into lymph nodes, tissue surrounding the tumor or other areas of the body. In some cases, the cancer cells cannot be seen on radiology scans, but we suspect they may be traveling through the blood and lymphatic systems. In stage IV (metastatic) disease, these cells typically form tumors that can be seen on radiology scans and/or cause problems or symptoms for the patient. For this reason, the treatment for patients with advanced breast cancer must be "systemic" – meaning it can travel throughout the body. Systemic treatments include chemotherapy, hormone therapy and biologic therapies, including those targeting HER2 receptors. Surgery and radiation are local treatments, as they can only treat a specific area.
Treatment of advanced breast cancer varies from patient to patient. It requires discussion between patient and oncologist and consideration of many factors, including hormone receptor and HER2 status, prior treatments, the patient's other health conditions, goals of treatment, and balancing quality of life with treatment side effects. Your oncologist may prescribe one chemotherapy agent, or a combination of agents. Sometimes a certain combination of medications will be given for several cycles. If they appear not to work or to stop working, your provider may recommend that the combination of medications be changed. Your provider may also give you a chemotherapy break if you have severe side effects from the medications.
Some patients with advanced breast cancers receive a certain, planned number of cycles of therapy. At the end of this number of cycles, the treatment is stopped. Some patients may have aggressive breast surgery (either breast conserving surgery or modified radical mastectomy) either before or after chemotherapy. Other patients require chemotherapy for the rest of their lives. For these patients, breast cancer may become a chronic illness that never goes away; however, it can often be controlled for many, many years with medications that do not make the patient very sick. For these patients, one goal of treatment is for effective chemotherapy to be given while the patient maintains a good quality of life. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your providers to come up with the best regimen for your lifestyle.
The treatments used in advanced breast cancer include chemotherapy, hormone therapy and biologic therapies. There are many different chemotherapy medications, which can be given alone or in various combinations. Many chemotherapy medicines used for breast cancer are given through a vein, so they need to be given in an oncology clinic, although some can be given by mouth, in the form of a pill.
Some of the standard chemotherapy agents that are used in the treatment of breast cancer include: adriamycin (doxorubicin), cyclophosphamide, cisplatin, taxanes (taxol and taxotere), capecitabine, fluorouracil, vinorelbine, eribulin, carboplatin, epirubicin, and ixabepilone.
Targeted therapies work more specifically than standard chemotherapy by targeting something specific to the cancer cells, often inhibiting some function that is necessary for cell division.
When the tumor is first examined by the pathologist, testing will be done to look for the presence of HER2 overexpression. HER2 is a receptor that is present on the surface of some breast cancer cells. Several targeted therapies work by blocking this receptor, including Herceptin (trastuzumab®), lapatinib (Tykerb®) and pertuzumab (Perjeta®). Patients with tumors that express HER2 may benefit from one of these treatments, or a combination of them, as they target different areas of HER2 cells.
The HER2 receptor may also be targeted by a drug called trastuzumab ematansine (Kadcyla™). This targeted therapy has a chemotherapy agent attached to it and is able to attach to the HER2 receptors and deliver the chemotherapy directly to the cancer cell. The HER2 receptor is the most common target utilized by targeted therapies to treat breast cancer. However, other targets are being studied. One receptor, the "mammalian target of rapamycin" (also called mTor), is the target of a new class of agents, called mTor inhibitors, including everolimus and temsirolimus.
When the pathologist examines a tumor specimen, he or she may determine that the tumor is expressing estrogen and/ or progesterone receptors. Patients whose tumors express estrogen receptors are candidates for therapy with estrogen blocking medications. Estrogen-blocking drugs include tamoxifen and a family of medications called aromatase inhibitors (anastrozole, letrozole, exemestane).
These can be given for 5 - 10 years after an early stage breast cancer diagnosis or can be used as a treatment for metastatic cancers. They can be very effective at preventing new growth of breast cancer; however, they may be accompanied by side effects. When taking tamoxifen, patients may experience weight gain, hot flashes and vaginal discharge. Taking tamoxifen may also increase risk of serious medical issues, such as blood clots, stroke, and uterine cancer. Patients taking aromatase inhibitors may experience bone or joint pain, and are at increased risk for thinning of the bones (osteopenia or osteoporosis). Patients taking aromatase inhibitors should have yearly bone density testing, and may require treatment for bone thinning.
Radiation therapy is the use of high-energy x-rays to kill cancer cells. There are many ways that radiation therapy may be used for patients with advanced breast cancer. Some patients require radiation therapy to the breast or the chest wall after modified radical mastectomy. Many patients having this treatment will also require radiation to the axilla (armpit) or supraclavicular (lower neck) regions. This radiation can be given at the same time as radiation to the breast or chest wall, and is given with the goal of killing any cancer cells that may be in the patient's lymph nodes. Generally, this radiation will require the patient to come for radiation treatments 5 days a week for 5-6 weeks. The radiation treatments themselves are painless, but skin irritation and fatigue can develop as the radiation course goes on.
Radiation therapy may also be used for advanced breast cancer patients who develop tumors that are causing symptoms or problems in other parts of the body, including the brain, spinal cord, arms and legs, liver, or lungs. Often, but not always, this radiation can be given in shorter courses of 1-3 weeks.
Clinical trials are extremely important in furthering our knowledge of this disease. It is though clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your healthcare provider about participating in clinical trials in your area.
Once a patient has been treated for breast cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits every 3-6 months. The longer you are free of disease, the less often you will have to go for checkups. After 5 years, you may only see your provider once a year. For those treated with breast-conserving surgery you will be instructed to have a mammogram about 6 months after the completion of treatment and then at least once a year going forward. Women treated with a single mastectomy should have yearly mammograms of the remaining breast. Because having had breast cancer is a risk factor for getting it again, having mammograms is extremely important.
If you are taking tamoxifen, it is important that you get a pelvic exam each year and report any abnormal vaginal bleeding to your provider. Tamoxifen can increase your risk of uterine cancer and vaginal bleeding can be a symptom of uterine cancer. If you are taking an aromatase inhibitor your bone health will be closely monitored.
If you are having symptoms of recurrence your provider will instruct you to have other tests done such as: blood tests, including tumor marker studies and liver function tests, CT scans, bone scan, MRI, biopsy and x-rays. It is important to speak with your provider regarding any new symptoms or side effects you are having to determine if these symptoms could be related to recurrence, long-term side effects of treatment, or another unrelated health issue.
There are a number of long-term side effects and issues related to treatment for breast cancer. Here are some of the more common side effects and issues that you may have to manage after treatment for breast cancer:
- Lymphedema is the buildup of fluid in the arm in which you had lymph nodes removed. Lymphedema causes swelling, tightness and sometimes pain in the affected arm. Your provider can refer you to a physical therapist who specializes in working with lymphedema. You should be educated about reducing your risk of developing lymphedema.
- Body image issues are common in those treated with surgery. The removal of part or even the whole breast may leave a woman feeling as though she is disfigured. Speak with your provider regarding the options you have including speaking with a therapist who specializes in body image issues, a reconstructive surgeon and someone who provides and fits specialty bras and inserts.
- Sexuality can be impacted and is related to the body image issues a woman might face. A woman may be left with scars from surgery, lack of sensation in the breast(s) and may even be affected by chronic chest pain. Speak with your provider and partner to determine ways to manage sexuality issues.
- Fertility is a topic that should be discussed prior to starting treatment since some treatments may affect a woman’s ability to have a baby. If after treatment a woman would like to conceive, you may wish to see an oncofertility specialist to evaluate your fertility.
Fear of recurrence, financial impact of cancer treatment, employment issues, and coping strategies are common emotional and practical issues experienced by breast cancer survivors. Your healthcare team can identify resources for support and management of these practical and emotional challenges faced during and after cancer.
Cancer survivorship is a relatively new focus of oncology care. With some 15 million cancer survivors in the US alone, there is a need to help patients transition from active treatment to survivorship. What happens next, how do you get back to normal, what should you know and do to live healthy going forward? A survivorship care plan can be a first step in educating yourself about navigating life after cancer and helping you communicate knowledgeably with your healthcare providers. Create a survivorship care plan today on OncoLink.
After Breast Cancer Diagnosis
Provides free, personalized information and one-to-one support to people affected by breast cancer – patients, families and friends.
A nonprofit organization dedicated to providing the most reliable, complete, and up-to-date information about breast cancer.
Facing Our Risk of Cancer Empowered is a nonprofit organization for women who are at high risk of getting breast or ovarian cancers due to their family history and genetic status.
Linda Creed Breast Cancer Foundation
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Living Beyond Breast Cancer
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Pregnant with Cancer
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Sister's Network, Inc.
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Susan G. Komen Breast Cancer Foundation
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Young Survival Coalition
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Mothers Supporting Daughters with Breast Cancer (MSDBC)
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A national not-for-profit organization supporting young women and their families, of all Jewish backgrounds, facing breast cancer. Our mission is to offer a community of support to women diagnosed with breast cancer or at increased genetic risk, by fostering culturally-relevant individualized connections with networks of peers, health professionals, and related resources.
Stage Information for Breast Cancer (American Joint Commission Version 1.2016)
Primary Tumor (T)
|TX||Primary tumor cannot be assessed|
|T0||No evidence of primary tumor|
|Tis||Carcinoma in situ|
|Tis (DCIS)||Ductal carcinoma in situ|
|Tis (LCIS)||Lobular carcinoma in situ|
|T1||Tumor less than or equal to 20mm or less in greatest dimension|
|T1mi||Tumor less than or equal to 1mm in greatest dimension|
|T1a||Tumor greater than 1mm but less than or equal to 5mm in greatest dimension|
|T1b||Tumor greater than 5mm but less than or equal to 10mm in greatest dimension|
|T1c||Tumor greater than 10mm but less than or equal to 20mm in greatest dimension|
|T2||Tumor greater than 20mm but less than or equal to 50mm in greatest dimension|
|T3||Tumor greater than 50mm in greatest dimension|
|T4||Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules).|
|T4a||Extension to the chest wall, not including only pectoralis muscles adherence/invasion|
|T4b||Ulcerations and/or ipsilateral satellite nodules and/or edema (including peau d’orange) of the skin, which do not meet the criteria for inflammatory carcinoma|
|T4c||Both T4a and T4b|
Lymph node (N)
|NX||Regional lymph nodes cannot be assessed.|
|N0||No regional lymph node metastasis|
|N1||Metastases to movable ipsilateral level I, II axillary lymph node(s)|
|N2||Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matter.|
|N2a||Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another or to other structures.|
|Metastases only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident I, II axillary lymph node metastases|
|N3||Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph nose involvement; or in clinically detected ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement|
|N3a||Metastasis in ipsilateral infraclavicular lymph node(s)|
|N3b||Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)|
|Metastasis in ipsilateral supraclavicular lymph node(s)|
Lymph node (N)
|pNX||Regional lymph nodes cannot be assessed|
|pN0||No regional lymph node metastasis histologically|
|pN0(i-)||No regional lymph nose mets histologically, negative IHC|
|pNO(I+)||Malignant cells in regional lymph nodes no greater than 0.2mm|
|pNO(mol-)||No regional lymph node mets histologically, negative molecular findings|
|pNO(mol+)||Positive molecular findings, but not regional node mets detected by
|pN1||Micrometastases; or metastases in 1-3 axillary lymph nodes|
|pN1mi||Micrometastases greater than 0.2mm but not larger than 2.0mm|
|pN1a||Mets in 1-3 axillary lymph nodes|
|pN1b||Mets in internal mammary nodes|
|pN1c||Mets in 1-3 axillary lymph nodes and in internal mammary lymph nodes|
|pN2||Mets in 4-9 axillary lymph nodes or in clinically detected internal mammary lymph nodes in absence of axillary node mets|
|pN2a||Mets is 4-9 axillary nodes with at least one tumor greater than 2mm|
|pN2b||Mets in clinically detected internal mammary lymph nodes in the absence of axillary lymh node metastases|
|Metastases in ten or more axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or in clinically detected ipsilateral internal mammary lymph nodes in the presence of one or more positive level I, II axillary lymph nodes; or in more than three axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected; or in ipsilateral supraclavicular lymph nodes|
|pN3a||Metastases in ten or more axillary lymph nodes (at least one tumor deposit greater than 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes|
|pN3b||Metastases in clinically detected ipsilateral internal mammary lymph nodes in the presence of one or more positive axillary lymph nodes; or in more than three axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected|
|Metastasis in ipsilateral supraclavicular lymph nodes|
Distant Metastases (M)
|M0||No evidence on distant metastases|
|cM0(I+)||No clinical or radiographic evidence of distant mets, but microscopically detected cancer cells in blood, bone marrow, or other nonregional nodal tissue that are not larger than 0.2mm|
|M1||Detectable mets larger than 0.2mm|
After a T stage, N stage, and M stage has been defined, these factors are put together to determine the overall cancer stage:
|Stage IIIC||Any T||N3||M0|
|Stage IV||Any T||Any N||M1|
Invasive breast cancer is graded:
GX: Grade cannot be assessed
G1: Low combined histologic grade
G2: Intermediate combines histologic grade
G3: High combined histologic grade
Abeloff, M., Armitage, J., Niederhuber, J., Kastan, M. & McKenna, G. (Eds.): Clinical Oncology (2008). Elsevier, Philadelphia, PA.
American Cancer Society. 2015. Found at: http://www.cancer.org/cancer/breastcancer/index
Anders CK, Zagar T & Carey LA. The management of early-stage and metastatic triple-negative breast cancer: a review. Hematology/Oncology Clinics of North America. 27(4):737-749. 2013.
Centers for Disease Control. Breast Cancer: What screening tests are there? 28 August 2014. Found at: http://www.cdc.gov/cancer/breast/basic_info/screening.htm
Goldhirsch A, Winer EP, Coates AS, Gelber RD, Piccart-Gebhart M, Thurlimann B & Senn H. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Annals of Oncology. 24(9):2206-2223.
Manguso N, Gangi A & Giuliano AE. Neoadjuvant Chemotherapy and surgical management of the axilla in breast cancer: a review of current data. Oncology. 29(10):733-738. Oct 2015.
National Comprehensive Cancer Network. NCCN Guidelines Version 1.2016 Breast Cancer.
Whelan TJ et al. Regional Nodal Irradiation in Early-Stage Breast Cancer. The New England Journal of Medicine. 373:307-316. 2015.