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Reviewed by the Faculty of Harvard Medical School

Breast Cancer

What Is It?

Breast cancer is a type of uncontrolled growth of abnormal cells that can develop in one of several areas of the breast, including the ducts that carry milk to the nipple, the small sacs that produce milk (lobules) and the nonglandular tissue.

These are the main forms of invasive breast cancer:

  • Invasive ductal carcinoma — This type of breast cancer, which accounts for three-quarters of cases, develops in the milk ducts. It can break through the duct wall and invade the fatty tissue of the breast. It can then spread (metastasize) to other parts of the body through the bloodstream or lymphatic system.
  • Invasive lobular carcinoma — This type of breast cancer accounts for about 15% of cases. It originates in the breast's milk-producing lobules. It can spread to the breast's fatty tissue and other places in the body.
  • Medullary, mucinous and tubular carcinomas — These slow-growing types of breast cancer represent about 8% of all breast cancers.
  • Paget's disease — This is a rare form of breast cancer. It starts in the milk ducts of the nipple and can spread to the dark circle around the nipple (areola). Women who get Paget's disease usually have a history of nipple crusting, scaling, itching or inflammation.
  • Inflammatory carcinoma— This is another rare form of breast cancer. It can seem like an infection, because there is usually no lump or tumor. The skin is red, warm, and looks pitted like an orange peel. Because it spreads quickly, inflammatory carcinoma is the most aggressive and difficult to treat of all breast cancers.

As more women have regular mammograms, doctors are detecting many more noninvasive or precancerous conditions before they become cancer. These conditions include:

  • Ductal carcinoma in situ (DCIS) — This occurs when cancer cells fill the ducts but haven't spread through the walls into fatty tissue. Nearly all women diagnosed at this early stage can be cured. Without treatment, about 25% of DCIS cases will lead to invasive breast cancer within 10 years.
  • Lobular carcinoma in situ (LCIS) — This is less of a threat than DCIS. It develops in the breast's milk-producing lobules. LCIS doesn't require treatment, but it does increase a woman's risk of developing cancer in other areas of both breasts.

A woman's risk of developing breast cancer increases with age; more than three out of four breast cancer cases occur in women over age 50. Other risk factors include:

  • Having close relatives, such as a mother, sister or grandmother, who have had the disease
  • Being of Ashkenazi Jewish descent
  • Having had chest radiation for another cancer, such as Hodgkin disease
  • Having already had the disease or certain other abnormalities of breast tissue
  • Increased exposure to the female hormone estrogen — by having a first menstrual period before age 13, entering menopause after age 51, or using estrogen replacement therapy for more than 5 years.
  • Never having been pregnant, or having a first pregnancy after age 30
  • Being overweight, especially after menopause
  • Drinking alcohol (cancer risk doubles with three or more drinks per day)
  • Having a sedentary lifestyle with little regular exercise.

Although breast cancer is about 100 times more common in women than in men, men can develop the disease.

Symptoms

Symptoms of breast cancer include:

  • A lump or thickening in the breast or under the arm
  • A clear or bloody discharge from the nipple
  • Crusting or scaling of the nipple
  • A nipple that no longer sticks out (inverted)
  • Redness or swelling of the breast
  • Dimpling on the breast skin resembling the texture of an orange
  • A change in the contours of the breast, such as one being higher than the other
  • A sore or ulcer on the skin of the breast that does not heal
Diagnosis

Your doctor will ask whether you have any risk factors for breast cancer, especially whether the disease runs in your family. He or she will then examine your breasts, looking for any signs and symptoms of breast cancer. These include a lump or thickening in your breast, nipple inversion or discharge, swelling or changes in breast contour, redness or dimpling of breast skin, and enlarged lymph nodes under your arm.

If your doctor discovers a lump or your screening mammogram detects an area of abnormal breast tissue, your doctor will recommend additional tests for breast cancer. If you haven't yet had a mammogram, that may be the next step. But in other cases, the next step is an ultrasound or magnetic resonance imaging (MRI).

Ultrasound can confirm whether the lump is a solid tumor or a fluid-filled, noncancerous cyst. It can also be used to assess any abnormal areas found on a mammogram. Although it is not routinely performed, MRI is used to assess abnormalities on a mammogram, get a more accurate estimate of a cancer's size, and check for other cancers. MRI can also be used for screening in women at high risk of breast cancer.

If the lump is solid, your doctor probably will recommend a breast biopsy. During a biopsy, a small amount of breast tissue is removed and analyzed in a laboratory. Sometimes, your doctor will recommend a biopsy without doing an ultrasound or MRI first.

A breast biopsy can be done in different ways. These include:

  • Fine-needle aspiration, which uses a thin needle to withdraw bits of tissue from the tumor
  • Large core needle biopsy, which allows larger pieces of tissue to be removed
  • Stereotactic needle biopsy, a type of large core needle biopsy, which uses special imaging equipment to pinpoint the tissue to be removed
  • Surgical biopsy, which involves removing all or part of the breast lump

The type of biopsy your doctor chooses will depend on the location of the lump, its size and other factors.

A specialist called a pathologist will examine the tissue under a microscope to determine whether the tissue contains cancer cells. If it does, the pathologist can determine the type of breast cancer. The pathologist will also assign a grade to the cancer. The grade indicates how closely the cancer cells resemble normal cells. A lower grade means that the cancer is slower-growing and less likely to spread; a higher grade means that the cancer is aggressive and likely to spread. The grade is one factor doctors consider when planning treatment. The pathologist may also determine how rapidly the cancer cells are dividing.

Depending on the type of biopsy and whether neighboring lymph nodes were removed, the biopsy report may include additional information. For example, the report may clarify how much the cancer has spread.

Another important step is to determine whether the cancer cells are "hormone-receptor positive" for estrogen and progesterone. Receptors allow specific substances, such as hormones, to latch on to the cell. Normal breast cells have both estrogen and progesterone receptors; cancer cells may have neither receptor, just one, or both. Women who have hormone-receptor positive cancers generally have a better prognosis. That's because they are more likely to respond to hormone therapy.

The biopsy sample should also be tested for a growth-promoting protein called HER2. The HER2 gene tells the cell to make the HER2 protein. Cancers with multiple copies of the HER2 gene produce too much HER2. These cancers, called HER2-positive, tend to grow and spread quickly.

This kind of information helps to guide treatment decisions. For example, women with HER2-positive cancers are likely to benefit from drugs that target the HER2 protein.

You may need to have additional tests to determine whether the cancer has spread. These include:

  • Bone scans
  • CT (computed tomography) scans
  • PET scans. PET scans look for metabolically active tissue. They are most useful to look for cancer that may have spread to other parts of the body.
Expected Duration

Breast cancer will continue to grow and spread until it is treated.

Prevention

Although there are no guarantees, you can take some steps to help prevent breast cancer:
  • Maintain a healthy weight.
  • Exercise regularly.
  • Limit your use of alcohol. (Experts recommend no more than one drink per day for women and two drinks per day for men.) If you do drink, you may decrease your breast cancer risk by taking a folate supplement.
  • Have a breast exam 3 years if you are under age 40 and every year if you are over 40.
  • Have a mammogram every year starting at age 40. (Some experts believe mammography should start at age 50. Ask your doctor what makes sense for you.) Mammograms can detect breast cancer two to five years before a tumor becomes large enough to be felt. Women who believe they may be at high risk of hereditary breast cancer should talk to a genetic counselor before testing.

Some women inherit mutations in certain genes – BRCA1 and BRCA2. These genetic mutations put them at very high risk of developing breast and ovarian cancer. These women require more frequent screening, usually with MRI. Some women opt to have their breasts and ovaries removed; this is the best way to prevent breast and ovarian cancers.

Treatment

Treatment for breast cancer usually begins with a decision about the type of surgery. A mastectomy removes the entire breast. A lumpectomy removes only the cancerous tumor and a small amount of healthy tissue around it.

After surgery, your doctor may recommend radiation therapy, chemotherapy, hormonal therapy, targeted therapy or a combination of therapies. Additional therapies decrease the risk of cancer returning or speading.

Radiation therapy usually is recommended after a lumpectomy to destroy any cancer cells left behind and to prevent the cancer from returning. Without radiation therapy, the odds of the cancer returning increase by about 25%.

The need for chemotherapy depends on how much the cancer has spread. In some cases, chemotherapy is recommended before surgery to shrink a large tumor so that it can be removed more easily. Chemotherapy is usually necessary if cancer returns.

Hormone therapy usually is recommended if the cancer is estrogen-receptor positive. The drug most often used in these cases is tamoxifen. It locks estrogen out of breast cancer cells that are estrogen-receptor positive. (Estrogen can help cancer cells grow.) This may reduce the chances that the cancer will return by up to 30%.

Aromatase inhibitors are another form of hormone therapy. These drugs decrease the amount of estrogen in the body by blocking estrogen production in all other tissues except the ovaries. Aromatase inhibitors are most useful in menopausal women, because the ovaries stop making estrogen after menopause.

Drugs that target specific genetic changes to attack cancer cells are called targeted therapies. For example, if you breast cancer is HER2-positive, your doctor may offer you trastuzumab (Herceptin). This drug is a manmade version of an immune system protein. It attaches itself to the HER2 receptor, slowing the growth of cancer. It may also stimulate your immune system to mount a stronger attack.

Treatment for DCIS is a lumpectomy usually followed by radiation. (In some women, a lumpectomy without radiation may be effective.) However, a mastectomy may be done. For example, it may be recommended if DCIS occurs in more than one location or if the tumor cells look especially worrisome on biopsy. Lymph nodes might also be removed as part of the mastectomy.

LCIS doesn't lead to cancer so no treatment is required. However, women with this condition are more likely to develop cancer in other areas of their breasts, so they should have regular mammograms and breast exams by a doctor. To decrease breast cancer risk, some women use hormonal therapy, such as tamoxifen.

Based on your genetic markers, your doctor can choose the drugs that are most likely to attack your cancer. He or she may look to genetic markers to determine the chances that your breast cancer will spread to another site.

When To Call A Professional

Call your doctor immediately if you find a lump or abnormal thickening in your breast. Call your doctor if you notice a new inverted nipple, fluid dripping from a nipple, a swelling in a breast or a change in its contour, or redness or dimpling of breast skin.

Prognosis

Early diagnosis significantly improves the outlook for women with breast cancer. If the tumor is small and confined to the breast, more than 90% of women survive for at least 5 years or longer. However, if the disease spreads throughout the body before diagnosis, the 5-year survival rate drops to less than 20%.

Cancer in one breast puts you at higher than average risk of developing cancer in the other breast. This is true even if you are still being treated with an estrogen blocker. Be sure to have regular checkups and mammograms.

Additional Info

National Cancer Institute (NCI)
U.S. National Institutes of Health
Public Inquiries Office
6116 Executive Blvd.
Room 3036A
Bethesda, MD 20892-2580
Toll-Free: 1-800-422-6237
TTY: 1-800-332-8615
www.nci.nih.gov/

American Cancer Society (ACS)
1599 Clifton Road, NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
www.cancer.org

Aetna Members: If you are a female member of an HMO-based plan and would like more information about breast cancer and breast cancer prevention, please call (888) 322 8742.

Miembros de Aetna: Si tiene un plan HMO y desea más información sobre el cáncer de seno y la prevención del cáncer de seno, por favor llame al 1-888-322-8742.

Last updated November 18, 2011




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