Breast Cancer Information

Each year, thousands of women come to Cleveland Clinic seeking help for breast cancer or other breast disorders. Cleveland Clinic is a recognized leader in medicine and research, particularly with respect to breast health, and specializes in the care and education of patients by making sure they get the best cancer information available. Cleveland Clinic specialists are leaders in exploring innovative therapies for breast cancer treatment, including treatment that may reduce the risk of onset or progression of the disease.

What is breast cancer?

Breast cancer is the most common cancer among American women, and the second leading cause of cancer death for American women. Breast cancer can occur in men as well as women, but male breast cancer accounts for only about 1 percent of all breast cancer. While this tumor is feared by many women, the death rate from breast cancer is actually declining in the United States and other Western countries. This decline is likely due to the success of screening programs as well as to improved treatment.

There are several types of breast cancer. Ductal carcinoma in-situ is a breast cancer which can grow within the milk duct, but does not invade into the surrounding tissue and does not spread to distant organs. This type of cancer is a very early stage of breast cancer, and is now often detected on mammograms. "Infiltrating" or "invasive" ductal carcinoma means that the cancer began in the duct and has invaded into the surrounding tissue and may have the ability to spread. The most common type of breast cancer is infiltrating ductal carcinoma. Though every person's cancer is unique, this is the "usual" type of breast cancer.

Lobular carcinoma is the second most common type of breast cancer. This type of breast cancer tends to be more difficult to detect and has distinctive features when examined under the microscope. Lobular cancer has a prognosis that is similar or slightly better than infiltrating ductal carcinoma, and is generally treated in the same way.

Inflammatory breast cancer is considered an aggressive form of breast cancer which usually presents as a rapidly swelling, reddened breast with the skin being "hot" to the touch. There may or may not be a "lump" associated with inflammatory breast cancer. A biopsy of the skin and breast tissue is necessary to make the diagnosis of inflammatory breast cancer. The treatment approach for inflammatory breast cancer is different from the treatment of ductal or lobular cancer.

Paget's disease of the nipple usually appears as a reddened, flaking and scaling of the nipple skin. It may also affect the areola. It may itch, tingle or burn and may develop sores or discharge. Eczema is sometimes confused with Paget's disease. It is important to note that Paget's disease usually only affects one breast. Paget's disease is considered an early form of cancer. However, a majority of people with Paget's disease may also have an underlying breast cancer. Treatment will depend on the specific situation.

In addition to these types of breast cancer, other, less common "special types" of breast cancer include tubular cancer, medullary carcinoma, and mucinous carcinoma (sometimes called "colloid" carcinoma). In general, these types of breast cancer have a prognosis that is better than that of infiltrating ductal carcinoma. Other, rare types of breast cancer include metaplastic breast cancer (in which the cancer cells take on the features of cancers usually found outside of the breast), micropapillary cancer, cystosarcoma phyllodes, sarcoma, and others.

What are the symptoms of breast cancer?

With increasing numbers of breast cancers being diagnosed by screening mammography, breast cancers often are found before they produce any symptoms at all. The most common symptom noted by women who have symptoms is a new lump or mass in the breast. These lumps are usually painless, and can be of widely varying sizes. A new breast lump should be brought to the attention of a doctor. Other symptoms that should be brought to the attention of a health care professional include nipple discharge (especially if it is spontaneous - occurs without squeezing the nipple - and only on one side) and a rash, swelling, or redness on the breast. If a breast cancer is not diagnosed until it has spread, it may produce symptoms related to that organ, such as pain from a breast cancer that has spread to the bone.

How is breast cancer diagnosed?

Breast cancer is usually diagnosed after mammograms detect an abnormality or in the course of evaluating a breast mass. Breast self-examinations, while of unproven benefit, are recommended since many breast cancers are first detected by the patient. The American Cancer Society makes the following screening recommendations for breast cancer:

• Monthly breast self examination starting at age 20.
• Annual breast physical examination by a health care provider starting at age 40.
• Annual screening mammography starting at age 40. The frequency of screening for women between the ages of 40 and 49 may be decreased to every two years if determined appropriate by both the patient and physician.
• Women in high risk categories (with a first-degree relative - a mother, sister, or daughter - with breast cancer; personal history of breast cancer; prior biopsy with atypical ductal hyperplasia or lobular carcinoma in situ) may want to consider starting screening at age 30.

If an abnormality is detected on a mammogram or ultrasound or the patient discovers a lump, a biopsy will be necessary to determine whether the abnormality is cancerous or benign (not cancer). There are several types of biopsies, including fine needle aspiration (for lumps that can be felt), core needle biopsy (which uses a special mammogram machine to locate the abnormality and can take several small samples of tissue) and excisional biopsy (which removes the entire area of concern and is - effectively - a "lumpectomy").

Once diagnosed, the extent of disease ("stage") is usually determined. The "stage" of disease relates to how far and to what organs the cancer has spread. There are four stages into which a breast cancer can fall, with the higher stages indicating more advanced disease. If it is confined to the breast, it is stage I or IIA. If it has spread to regional lymph nodes, most commonly those under the arm, the stage is IIB or III. Tumors that have spread to organs outside of the breast and lymph nodes near the breast are stage IV cancers. Based on the initial stage of the disease determined by simple tests such as mammograms, physical examination, blood tests and chest x-ray, the additional tests done to determine whether the tumor has spread to other organs vary, depending on how likely these tests are to find something

What are the treatment options?

The treatment of breast cancer is individualized for each patient, depending on many factors, including the stage of the disease, the particular organs involved, the symptoms produced by the cancer, the microscopic characteristics of the tumor, and the overall health of the patient.

Breast Cancer Stages I, II and III

Most patients are diagnosed before the cancer has spread distantly, so that the initial treatment plan is designed with the intention of both removing the breast tumor and preventing the cancer from coming back. The reason breast cancers come back after surgery is that microscopic tumor cells have spread undetected to other organs even before the tumor has been detected and the main tumor has been surgically removed. Therefore, the treatment of breast cancer is usually a "multi-modality" treatment. In other words, many types of treatment may be used on the same cancer in order to produce the best result. The roles of these different treatments are discussed below:

Surgery

Most tumors are detected before they have spread to other organs, in which case surgery is the principal treatment. Removal of the entire breast (mastectomy) is sometimes required to adequately treat the tumor, especially if it is large or if there are several tumors. Often, however, only the tumor and a little bit of normal tissue around it need to be removed. This is called a partial mastectomy, "lumpectomy," or breast-conserving operation. Because treatment decisions are often based on whether the lymph nodes under the arm contain cancer, these lymph nodes need to be tested. This can be done by removing many nodes and looking at them under the microscope. More recently, it has been found that the first node that the cancer is likely to travel to can be identified. That lymph node (or group of nodes) is called the "sentinel" node. If the sentinel node has no cancer in it, no other nodes need to be removed. If that lymph node does have cancer in it, though, additional lymph nodes need to be removed.

In women who have the entire breast removed, additional surgery can be done to replace the missing tissue so create a more normal appearance. This additional plastic "reconstructive" surgery can involve an artificial implant or the use of normal tissue to replace the missing breast.

Radiation therapy

If a partial mastectomy or "lumpectomy" is performed, radiation may be used to treat the remaining breast tissue. This treatment has been shown to reduce the chance of the cancer coming back in the breast. Radiation is also sometimes used after mastectomy if the tumor is especially large or if many lymph nodes under the arm contain cancer.

Hormonal therapy

If the tumor tests positive for the estrogen receptor or progesterone receptor (meaning it is sensitive to one of these hormones), the tumor may respond to hormone-based treatments. Therefore, most patients with estrogen- or progesterone-receptor positive tumors will also receive treatment with hormonal manipulation. These treatments are designed to starve microscopic tumor cells of the estrogen that feeds their growth. One such hormonal medicine is tamoxifen, which is an estrogen-blocker that works in both pre-menopausal and post-menopausal women. Sometimes, pre-menopausal women are treated with shots to stop their ovaries from making estrogen or by having their ovaries removed. In post-menopausal women, a type of medicine called an aromatase-inhibitor is sometimes used. These medicines, which go by names such as Arimidex (anastrozole), Aromasin (exemestane) and Femara (letrozole), reduce the estrogen levels of women who have gone through menopause. Breast cancers that have negative estrogen and progesterone receptors do not benefit from hormone therapy.

Chemotherapy

Chemotherapy is sometimes given after surgery in an attempt to kill microscopic cancer cells that may be lurking in the body even though we can't find them with X-rays or scans. Chemotherapy is useful for patients whose tumors test negative for the estrogen- and progesterone-receptors. It has been shown to improve the odds of many patients who receive hormonal treatments as well. There are many different medicines considered to be chemotherapy drugs, and there are a number of combinations of these drugs that have been found to be useful. The particular chemotherapy medicines chosen depend upon the tumor characteristics, the risk of the cancer coming back or spreading, the side effects of the medicines, and the overall health of the patient.

Trastuzumab (also known by its brand name, Herceptin)

HER2/neu is a protein molecule on the surface of approximately 20 percent of breast cancers that causes those cancers to grow rapidly. Trastuzumab is an intravenous (given through a vein) medicine that attacks this her2/neu molecule, and causes these breast cancer cells to die. Trastuzumab is only useful if special tests indicate that the tumor is positive for the HER2/neu molecule, but patients with such tumors seem to fare much better if they receive the medicine trastuzumab.

Breast Cancer Stage IV

Cancers that have spread to other organs are generally treated with hormone-based treatments such as tamoxifen or a newer type of medicine called an aromatase-inhibitor, chemotherapy, or trastuzumab (often known by its brand name, Herceptin). Such treatments are worthwhile, but cancer that has spread to distant organs is almost never "cured." When a patient has breast cancer that has spread to other organs, radiation is also sometimes given to treat specific problems, such as a painful bone tumor. Even though advanced breast cancer cannot be cured, many patients will live for years with the disease with reasonably good quality of life.

Get the Cancer Information you need

Breast Cancer is a serious problem that threatens many women. Contact the Cleveland Clinic today to schedule an appointment for a screening, and to get the cancer information necessary to detect it early and increase your chance of survival.