Cancer Treatment & Information

Diagnosis of breast cancer usually is comprised of several steps, including examination of the breast, mammography, possibly ultrasonography or MRI, and, finally, biopsy. Biopsy is the only definitive way to diagnose breast cancer.

Examination of the Breast

• A complete breast examination includes visual inspection and careful palpation (feeling) of the breasts, the armpits, and the areas around your collarbone.
• During that exam, your health-care provider may palpate a lump or just feel a thickening.

Mammography

• Mammograms are x-rays of the breast that may help define the nature of a lump. Mammograms are also recommended for screening to find early cancer.
• Usually, it is possible to tell from the mammogram whether a lump in the breast is breast cancer, but no test is 100% reliable. Mammograms are thought to miss as many as 10-15% of breast cancers.
• A false-positive mammogram is one that suggests malignancy (cancer) when no malignancy is found on biopsy.
• A false-negative mammogram is one that appears normal when in fact cancer is present.
• A mammogram alone is often not enough to evaluate a lump. Your health-care provider will probably request additional tests.
• All breast lumps need to be clearly defined as benign or should be biopsied.

Ultrasound

• Ultrasound of the breast is often done to evaluate a breast lump.
• Ultrasound waves create a “picture” of the inside of the breast.
• It can demonstrate whether a mass is filled with fluid (cystic) or solid. Cancers are usually solid, while many cysts are benign.
• Ultrasound might also be used to guide a biopsy or the removal of fluid.

MRI

• MRI may provide additional information and may clarify findings which have been seen on mammography or ultrasound.
• MRI is not routine for screening for cancer but may be recommended in special situations.

Biopsy

• The only way to diagnose breast cancer with certainty is to biopsy the tissue in question. Biopsy means to take a very small piece of tissue from the body for examination and testing by a pathologist to determine if cancer is present. A number of biopsy techniques are available.
• Fine-needle aspiration consists of placing a needle into the breast and sucking out some cells to be examined by a pathologist. This technique is used most commonly when a fluid-filled mass is identified and cancer is not likely.
• Core-needle biopsy is performed with a special needle that takes a small piece of tissue for examination. Usually the needle is directed into the suspicious area with ultrasound or mammogram guidance. This technique is being used more and more because it is less invasive than surgical biopsy. It obtains only a sample of tissue rather than removing an entire lump. Occasionally, if the mass is easily felt, cells may be removed with a needle without additional guidance.
• Surgical biopsy is done by making an incision in the breast and removing the piece of tissue. Certain techniques allow removal of the entire lump.
• Regardless of how the biopsy is taken, the tissue will be reviewed by a pathologist. These are physicians who are specially trained in diagnosing diseases by looking at cells and tissues under a microscope.
• If a cancer is diagnosed on biopsy, the tissue will be tested for hormone receptors. Receptors are sites on the surface of tumor cells that bind to estrogen or progesterone. In general, the more receptors, the more sensitive the tumor will be to hormone therapy. There are also other tests (for example, measurement of HER-2/neu receptors) that may be performed to help characterize a tumor and determine the type of treatment that will be most effective for a given tumor.

What are the symptoms of Breast Cancer?

Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for a cure.

Most breast lumps aren’t cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other potential signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple, often associated with a breast lump
• Retraction or indentation of your nipple
• A change in the size or contours of your breast
• Any flattening or indentation of the skin over your breast
• Redness or pitting of the skin over your breast, like the skin of an orange

A number of conditions other than breast cancer can cause your breasts to change in size or feel. Breast tissue changes naturally during pregnancy and your menstrual cycle. Other possible causes of noncancerous (benign) breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.

If you find a lump or other change in your breast — even if a recent mammogram was normal — see your doctor for evaluation. If you haven’t yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn’t gone away after a month, have it evaluated promptly.

How is Breast Cancer diagnosed?

If you have a symptom or screening test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.

Breast self-examination

Breast self-examination is an option beginning at age 20. By becoming proficient at breast self-examination and familiar with the usual appearance and feel of your breasts, you may be able to detect early signs of cancer. Learn how your breasts typically look and feel and watch for changes. If you detect a change, promptly bring it to your doctor’s attention. Have your doctor review your examination technique if you’d like input or you have questions.

Clinical breast exam

Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.

During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also check for enlarged lymph nodes in your armpit (axilla).

Mammogram

A mammogram, which uses a series of X-ray images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.

Two types of mammograms include:

• Screening mammograms. Screening mammograms are performed on a regular basis — about once a year — to check your breast tissue for any changes since your last mammogram.
• Diagnostic mammograms. Your doctor may recommend a diagnostic mammogram to evaluate a breast change detected by you or your doctor. During a diagnostic mammogram, the radiologist performing the exam can take additional views to evaluate the area of concern more closely.

Yet mammograms aren’t perfect. A certain percentage of breast cancers — sometimes even lumps you can feel — don’t show up on X-rays (false-negative result). The rate is higher for women in their 40s. That’s because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.

At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, to fear and anxiety, and to increased health care costs. The skill and experience of the radiologist reading the mammogram also have a significant effect on the accuracy of the test results. In spite of these drawbacks, however, most experts agree mammography is the most reliable screening test for most women.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test may help reduce breast tenderness.

Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test less uncomfortable. The pad doesn’t interfere with the image quality of the mammogram. If possible, try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover. Most important, don’t let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings.

Other tests

Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies highly suspicious areas on the mammogram, allowing the radiologist to focus on specific spots, but many of these areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer detection rate.

Digital mammography. In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, digital images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere. Digital mammography has been found to be most helpful in evaluating dense breast tissue in women in their 40s.

Magnetic resonance imaging (MRI). This technique uses a magnet and radio waves to take pictures of the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. MRI doesn’t take the place of mammograms, but rather is performed as an additional (adjunct) study of the breast.

MRI isn’t recommended for routine screening on women at average risk because it has a high rate of false-positive results, leading to unnecessary anxiety and biopsies. It’s also expensive, not readily available and requires interpretation by an experienced radiologist. However, the American Cancer Society now recommends annual screening MRI for women with a lifetime breast cancer risk of 20 percent or higher, women who received chest radiation between ages 10 and 30, and women with a strong family history of breast and ovarian cancers.

Recent recommendations propose that women with newly diagnosed breast cancer in one breast have a one-time MRI done. MRI can detect breast tumors in the opposite (contralateral) breast missed by mammograms. The test can also detect additional lesions in the affected breast. However, whether finding early tumors in this situation improves treatment outcomes — and deaths from breast cancer — is still unknown.

Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to produce images of structures deep within the body. Because it doesn’t use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn’t used for routine screening because it has a high rate of false-positive results — finding problems where none exist.

Experimental procedures

Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in your breast — the site where most cancers originate — and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes may show up long before tumors can be detected on a mammogram. But because ductal lavage is a new and invasive procedure, many unknowns remain, including the rate of false-negative results, the exact location in the breast of abnormal cells and whether those cells will necessarily lead to cancer. Clinical trials are being conducted to help find the answers to these questions. In the meantime, ductal lavage isn’t recommended as a screening tool.

Molecular breast imaging (MBI). This experimental technique tracks the movement of a radioactive isotope injected into the bloodstream and taken up by breast tissue, particularly tumors. In preliminary studies, MBI found small tumors that both mammography and ultrasound missed. It’s not yet clear how any abnormal findings from MBI could be biopsied, but this is an area of study. Besides requiring some radiation, this imaging method also involves slight compression of the breast. This imaging technique is being studied in women with dense breast tissue and women at high risk of breast cancer. Depending on study results, MBI would most likely become an adjunct to — but not a replacement for — mammography.

Diagnostic procedures

Unlike screening tests, diagnostic procedures help to further characterize breast abnormalities found by some other means, such as by feeling a breast lump or seeing a spot on a mammogram or MRI. These tests help your doctor determine the need for a biopsy and also may be used to help guide a biopsy.

Ultrasound

Ultrasound uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren’t cancerous, although your doctor may recommend draining the cyst. If the cyst appears very typical and disappears completely with removal of the fluid, then observation is the only follow-up necessary. If the cyst appears complex, doesn’t disappear completely when the fluid is drained or contains bloody fluid, a biopsy is necessary to determine whether cancer is present.

Biopsy

A biopsy — a small sample of tissue removed for analysis in the laboratory — is the only test that can tell if cancer is present. Biopsies can provide important information about an unusual breast change and help determine whether surgery is needed and if so, the type of surgery required. Types of biopsies include:

Fine-needle aspiration biopsy. Your doctor uses a thin, hollow needle to withdraw tissue from the lump. He or she then sends the tissue to a lab for microscopic analysis. The procedure takes about 30 minutes and is similar to drawing blood. A similar procedure — fine-needle aspiration — is typically performed to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.

Core needle biopsy. A radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken then sent to a pathologist to be analyzed for malignant cells. The advantage of a core needle biopsy is that it removes more tissue for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle. 

Stereotactic biopsy. This technique is used to sample and evaluate an area of concern, such as microcalcification, that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.

Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can’t be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy and is a way to guide the surgeon to the area to be removed and tested.

Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is large, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests

Malignant cells removed in a biopsy can be tested for the presence of hormone receptors. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these sites.

Staging tests

Staging tests determine the size and location of your cancer and whether it has spread. They also help with treatment planning. Cancer is staged using the numbers 0 through IV. Stage 0 cancers are also called noninvasive, or in situ (in one place), cancers. Although they don’t have the ability to invade normal breast tissue or spread to other parts of your body, it’s important to have them removed because they eventually can become invasive cancers.

Stage I to IV cancers are invasive tumors that have the ability to invade normal breast tissue or spread to other areas. A stage I cancer is small and well localized and has a high cure rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it’s not possible to cure cancer at this stage, it may still respond well to various treatments, which could effectively shrink and control the cancer for an extended period of time.

Genetic tests

If you have a strong family history of breast cancer or other cancers, blood tests may help identify defective BRCA or other genes that are being passed through the family. These tests are often inconclusive and should only be done in select cases after a thorough evaluation with a genetic counselor. Unless you are at high risk of hereditary breast or ovarian cancers, genetic testing usually isn’t recommended.

In general, testing is beneficial only if the results will help you make a decision about how you might best reduce your breast or other cancer risk. Options range from lifestyle changes and closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy and removal of your ovaries (oophorectomy).

What Is Breast Cancer? 

Each month, a woman’s breasts go through temporary changes associated with menstruation, and a lump may form.  While the vast majaority of these growths are not cancerous, any lump should be examined immediately.  Lumps are most common in the lobules — small sacs that produce milk — or the ducts that carry milk to the nipple.  But they occasionally start in other tissue.  The two main categories of breast cancer are lobular and ductal carcinomas.

Breast cancer usually begins with the formation of a small, confined tumor. Some tumors are benign, meaning they do not invade other tissue; others are malignant, or cancerous. Malignant tumors have the potential to metastasize, or spread. Once such a tumor grows to a certain size, it is more likely to shed cells that spread to other parts of the body through the bloodstream and lymphatic system. Different types of breast cancer grow and spread at different rates; some take years to spread beyond the breast, while others move quickly.

Men can get breast cancer, too, but they account for less than one-half of one percent of all cases.  Among women, breast cancer is the most common cancer and the second leading cause of cancer deaths — behind lung cancer. If eight women were to live to be at least 85, one of them would be expected to develop the disease at some point during her life.  Two-thirds of women with breast cancer are over 50, and most of the rest are between 39 and 49.

Fortunately, breast cancer is very treatable if detected early. Localized tumors can usually be treated successfully before the cancer spreads; and in nine in 10 cases, the woman will live at least another five years.  Experts usually consider a five-year survival to be a cure. Once the cancer begins to spread, getting rid of it completely is more difficult, although treatment can often control the disease for years.  Improved screening procedures and treatment options mean that at least seven out of 10 women with breast cancer will survive more than five years after initial diagnosis, and half will survive more than 10 years.

What Causes Breast Cancer?

Although the precise causes of breast cancer are unclear, we know what the main risk factors are. Still, most women considered at high risk for breast cancer do not get it, while many who do have no known risk factors.  Among the most significant factors are advancing age and a family history of breast cancer.  Risk increases slightly for a woman who has had a benign breast lump and increases significantly for a woman who has previously had cancer of the breast or the ovaries.

A woman whose mother, sister, or daughter has had breast cancer is two to three times more likely to develop the disease, particularly if more than one first-degree relative has been affected.  Researchers have now identified two genes responsible for some instances of familial breast cancer — called BRCA1 and BRCA2.  About one woman in 200 carries it.  Having the gene predisposes a woman to breast cancer but does not ensure that she will get it.

Generally, women over 50 are more likely to get breast cancer than younger women, and African-American women are more likely than Caucasions to get breast cancer before menopause. A link between breast cancer and hormones is gradually becoming clearer. Researchers think that the greater a woman’s exposure to the hormone estrogen, the more susceptible she is to breast cancer. Estrogen tells cells to divide; the more the cells divide, the more likely they are to be abnormal in some way, possibly becoming cancerous.

A woman’s exposure to estrogen and progesterone rises and falls during her lifetime, influenced by the age she starts and stops menstruating, the average length of her menstrual cycle, and her age at first childbirth.  A woman’s risk for breast cancer is increased if she starts menstruating before age 12, has her first child after 30, stops menstruating after 55, or has a menstrual cycle shorter or longer than the average 26-29 days.  Current information indicates that the hormones in birth control pills probably do not increase the risk.  Some studies suggest that taking hormone replacement therapy after menopause may increase risk, especially when taken for more than 5 years.  The jury is still somewhat out on this matter though.  Heavy doses of radiation therapy may also be a factor, but low-dose mammograms pose almost no risk.

The link between diet and breast cancer is debated. Obesity is a noteworthy risk factor, and drinking alcohol regularly — more than a couple of drinks a day — may promote the disease. Many studies have shown that women whose diets are high in fat are more likely to get the disease. Researchers suspect that if a woman lowers her daily calories from fat — to less than 20%-30% — her diet may help protect her from developing breast cancer.