Breast Cancer: The Basics

Christopher Dolinsky, MD and Christine Hill-Kayser, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: May 15, 2013

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What is the breast?

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 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.

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What is breast cancer?

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.

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Am I at risk for breast cancer?

Breast cancer is the most common malignancy effecting women in North America and Europe. Close to 200,000 cases of breast cancer were diagnosed in the United States in 2001. Breast cancer is the second leading cause of cancer death in American women behind lung cancer. The lifetime risk of any particular woman getting breast cancer is about 1 in 8 although the lifetime risk of dying from breast cancer is much lower at 1 in 28. 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.)

The most important risk factor for development of breast cancer is increasing age. 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, but use of oral contraceptives most likely does not increase risk. Family history is very important in determining breast cancer risk. Any woman with a family history of breast cancer will be at increased risk for developing breast cancer herself. Furthermore, known genetic mutations that increase risk of breast cancer are present in some families; these include mutations in the genes BRCA1 and BRCA2. Between 3% 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) mastectomies 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. (Learn more about genetic testing).

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/ 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. For further information about breast cancer risk factors, please see Risk Factors and Breast Cancer.

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Male Breast Cancer

Breast cancer in men accounts for about 1% of all breast cancers and about 0.2% of all cancers in men. There will be about 1,690 new cases of male breast cancer in 2005, compared to 213,000 cases in women. Risk factors for the development of male breast cancer include Klinefelter's syndrome, being of Jewish decent, mumps orchitis, a family history of male or female breast cancer and family cancer syndromes (BRCA1 & 2 gene abnormalities account for 40% of cases).

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.

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How can I prevent breast cancer?

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.

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. In high-risk women, the risk of developing breast cancer can be reduced by about 50% by taking a drug called Tamoxifen for five years. Tamoxifen has some common side effects (like hot flashes and vaginal discharge), which can be quite bothersome, but are not serious, and some serious, but uncommon side effects (like blood clots, pulmonary embolus, stroke, and uterine cancer). Use of Tamoxifen for cancer prevention should be considered carefully by an individual and her doctor, as its use is very individualized. (More information on medication therapy for breast cancer prevention).

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What screening tests are available?

The earlier that a breast cancer is detected, the more likely it is that treatment can 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. Regular screening mammograms can decrease the mortality of breast cancer by 30%. The majority of breast cancers are detected through abnormal mammographic findings. Woman should get a yearly mammogram starting at age 40 (although some groups recommend starting at 50), and women with a genetic mutation that increases their risk or a strong family history may want to begin even earlier. Many centers are now making use of digital mammograms, which may be more sensitive than conventional mammography.

Between the ages of 20 and 39, every woman should have a clinical breast exam every 3 years; and after age 40 every woman should have a clinical breast exam done each year. A clinical breast exam is an exam done by a health professional to feel for lumps and look for changes in the size or shape of the breasts. During the clinical breast exam, you can learn how to do a breast self-exam. Every woman should do a self-breast exam once a month, about a week after her period ends. About 15% of tumors are felt but cannot be seen by regular mammographic screening.

In certain populations of women, MRI screening may be recommended. The American Cancer Society now recommends yearly breast MRI 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 physician, 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.

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What are the signs of breast cancer?

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.

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How is breast cancer diagnosed and staged?

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 doctors 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 doctors 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 doctors will decide which type of biopsy you need depending on your particular breast mass.

Once the tissue is removed, a doctor 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 a receptor known as HER-2. The presence of estrogen and progesterone receptors is important because cancers that have those receptors can be treated with hormonal therapies. HER-2 expression may also help predict outcome. There are also some therapies directed specifically at tumors dependent on the presence of HER-2. See Understanding Your Pathology Report for more information.

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. See Complete Staging of Breast Cancer.

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 doctor 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 doctor may recommend other tests, such as CT scan and bone scan. Each patient is an individual and your doctors will determine what is necessary to adequately stage your cancer.

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What are the treatments for breast 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.

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Treatment for Early/Moderate Stage Breast Cancer

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.

Surgery

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 rind 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 doctors 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, however, 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 and dissection of the lymph nodes under the arm. 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.

Chemotherapy

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. 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. Depending on the type of chemotherapy regimen you receive, you may get medication every 2 to 4 weeks. Most chemotherapies used for breast cancer are given through a vein, so they need to be given in an oncology clinic. Drugs 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 doctors to come up with the best regimen for your lifestyle.

Radiotherapy

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 above, 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. These techniques are only appropriate for certain patients, and your radiation oncologist can discuss the pros and cons of each one with you.

Hormonal Therapy

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 drugs called aromatase inhibitors. These drugs are delivered in pill form for 5 - 10 years after breast cancer surgery. These drugs 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 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.

Biologic Therapy

The pathologist also examines your tumor for the presence of HER-2 overexpression. HER-2 is a receptor that some breast cancers express. A compound called Herceptin (or trastuzumab) is a substance that blocks this receptor and helps stop the breast cancer from growing. Patients with tumors that express HER-2 may benefit from Herceptin, and this should be discussed with a medical oncologist when the treatment plan is decided upon.

Follow-up Testing

Once a patient has been treated for early/moderate stage breast cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits every 3-4 months. The longer you are free of disease, the less often you will have to go for checkups. After 5 years, you could see your doctor once a year. You should have a mammogram of the treated and untreated breasts every year. Because having had breast cancer is a risk factor for getting it again, having mammograms done every year 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 doctor.

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 doctor about participating in clinical trials in your area.

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Treatment for Advanced Breast Cancer

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. We will address the treatment options for advanced breast cancers below.

Surgery

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, or 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.

Advanced breast cancer treatment is by no means a one-size-fits-all recipe. 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 doctor may recommend that the combination of medications be changed. Your doctor may also give you a chemotherapy break if you have severe side effects from the drugs.

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 drugs 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 doctors to come up with the best regimen for your lifestyle.

Chemotherapy

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), Doxil®, cyclophosphamide, cisplatin, taxanes (taxol and taxotere), capecitabine, fluorouracil, vinorelbine, eribulin, carboplatin, epirubicin, ixabepilone.

Targeted Therapy

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 agents 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.

Hormonal Therapy

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 drugs called aromatase inhibitors (anastrozole, letrozole, exemestane).

These drugs can be given for 5 - 10 years after an early stage breast cancer diagnosis or can be used as a treatment for metastatic cancers. These drugs 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

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 breast conserving surgery or 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 larger amounts per day so that treatments are required for only 1-3 weeks.

Progress continues to improve outcomes and quality of life for women with advanced and metastatic breast cancer. New advances are made everyday to further understand the best ways to treat and manage advanced stage breast cancer. Your healthcare team will help you decide what options are best for you. Many women are living full and active lives doing what they enjoy, due in part to the advances made in breast cancer research. There are several resources and sources of support available to give hope and information to those with advanced breast cancer.

Appendix: Complete Breast Cancer Staging

Stage Information for Breast Cancer (Adapted from American Joint Commission 7th Edition)

Primary Tumor or T stage

Tis

Carcinoma in situ. This may refer to ductal carcinoma in situ, lobular carcinoma in situ, or Paget disease of the nipple.

T1

Tumor 2 cm or less. T1 disease is broken down further as below:

T1mi

Tumor 1 mm or less

T1a

Tumor 1-5 mm

T1b

Tumor 6-10 mm

T1c

Tumor greater than 1 cm and up to 2 cm

T2

Tumor 2-5 cm

T3

Tumor more than 5 cm

T4

Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules).

Lymph node (or N) stage clinical: This designation is provided without information obtained from surgery

N0

No regional lymph node metastases.

N1

Metastases to movable level I, II axillary lymph node(s) on the same side as the breast cancer.

N2

Metastases in level I, II axillary lymph nodes that are clinically fixed or matted on the same side as the breast cancer (N2a)

OR

Metastases in internal mammary nodes (those near the breast bone) in the absence of clinically evident axillary lymph node metastases (N2b)

N3

Metastases in infraclavicular (those under the collar bone) lymph node(s) (N3a)

OR

Metastases in internal mammary lymph node(s) (near the breast bone) with clinically evident level I, II axillary lymph node metastases. (N3b)

OR

Metastases in ipsilateral supraclavicular lymph node(s) (those above the collar bone) (N3c)

Lymph node (or N) stage pathologic: This designation can only be given once lymph nodes are removed by the surgeon.

pN0

No regional lymph node metastasis.

 

pN0(i–)

No regional lymph node metastases histologically, negative immunohistochemistry (a special way of staining slides under the microscope).

pN0(i+)

Malignant cells in regional lymph node(s) in a region 2mm or smaller (detected by special stains).

pN0(mol–)

No regional lymph node metastases histologically, negative molecular findings (RT-PCR).

pN0(mol+)

Positive molecular findings through a test called PCR, but no abnormal cells visible under the microscope..

pN1

Micrometastases (pN1mi, cancer cells in a region greater than 0.2mm but less than 2mm).

OR

Metastases in 1–3 axillary lymph nodes (pN1a).

AND/OR

Metastases in internal mammary nodes (near the breast bone) that were only visible when the lymph node was examined under the microscope (pN1b if there are no cancer cells in the axillary lymph notes, pN1c if there are cancer cells both in the axillary nodes and the nodes near the breast bone)

pN2

Metastases in 4–9 axillary lymph nodes (pN2a).

OR

Metastases in lymph nodes near the breast bone that could be seen BEFORE surgery, without metastases in the axillary lymph nodes (pN2b).

pN3

Metastases in >10 axillary lymph nodes (pN3a).

OR

Metastases in infraclavicular (under the collar bone) lymph nodes (pN3b).

OR

Metastases in lymph nodes near the breast bone that could be seen BEFORE surgery, with metastases in the axillary lymph nodes (pN3b).

OR

Metastases in >3 axillary lymph nodes and in lymph nodes near the breast bone that had cancer cells only visible under the microscope (pN3b).

OR

Metastases in lymph nodes above the collar bone on the same side as the involved breast (pN3c).

Distant Metastases or M stage

 

M0

No evidence of distant metastases.

cM0(i+)

No evidence of distant metastases on imaging studies,, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other lymph node tissue outside of the armpit, collar bone, or breast bone regions tthat are ?0.2 mm in a patient without symptoms or signs of metastases.

M1

Distant detectable metastases

After a T stage, N stage, and M stage has been defined, these factors are put together to determine the overall cancer stage:

Stage

T

N

M

0

Tis

N0

M0

IA

T1

N0

M0

IB

T0

N1mi

M0

 

T1

N1mi

M0

IIA

T0

N1

M0

 

T1

N1

M0

 

T2

N0

M0

IIB

T2

N1

M0

 

T3

N0

M0

IIIA

T0

N2

M0

 

T1

N2

M0

 

T2

N2

M0

 

T3

N1

M0

 

T3

N2

M0

IIIB

T4

N0

M0

 

T4

N1

M0

 

T4

N2

M0

IIIC

Any T

N3

M0

IV

Any T

Any N

M1

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