Cancer from A to Z

Many factors may influence the development of breast cancer, including:

• Age. Most cases occur in women 50 or older; it is less common in women 35 or younger. Age is the most influential risk factor.
• Family history. Your risk is higher with a family history (especially mother, sister, daughter) of breast and/or ovarian cancer.
• Hormones / childbirth. Your risk is higher if you had your first period before age 12, began menopause after age 55, never had children or had your first child after age 30. Postmenopausal use of hormonal therapy increases your risk of developing breast cancer.
• Previous biopsy. If you’ve had abnormal breast biopsy results or benign breast diseases requiring biopsies, you may be at increased risk. Other breast diseases such as atypical hyperplasia, lobular or ductal carcinoma in situ are risk factors, too.
• Education / socioeconomic status. Women with a higher socioeconomic status and/or education tend to have fewer children and start childbearing after age 30 – both of which put them at higher risk.
• Weight. Obesity or weight gain after menopause are risk factors.

Genetic alterations. Inherited susceptibility genes BRCA1 and BRCA2 account for about five to 10% of all breast cancer cases.
 
Other risk factors include:

• Oral contraceptive use
• A diet high in saturated fats
• Physical inactivity
• Alcohol (more than one alcoholic drink a day)

 
Screening Tests
Breast cancer screening tests are performed on healthy women with no symptoms on a regular basis. Regular screening exams help catch cancer in its early stages, when it is much more likely to respond to treatment. Typical breast screening exams include:

Clinical breast exam: your physician will visually examine your breasts and manipulate them manually to feel for lumps or other breast changes. Clinical breast exams should be performed every one to three years beginning at age 20, and every year beginning at age 40.

Mammogram: Each breast is placed between two photographic plates and compressed, while an X-ray is taken of the breast tissue. Mammograms should be conducted every year beginning at age 40 and possibly earlier if a woman has certain risk factors such as inherited genetic mutations.

In addition to the screening exams above, women should also practice breast “self-awareness.” Becoming familiar with your breasts makes it much more likely that you will notice changes that may signal cancer or another health condition.

There are several procedures that can be used to diagnose breast cancer. Not every procedure will be done for each patient. The evaluation is based upon the patient’s examination and physician recommendations.

Biopsy: a small sample of the suspicious area of the breast is removed for examination under a microscope. Biopsies can be done in the following ways:

Surgical biopsy: an incision is made in the breast. Surgeons locate the tumor by palpation or with the aid of images from a CT scan, ultrasound or mammogram. In an excisional biopsy, the entire mass is removed. In an incisional biopsy, only a portion of the tumor is removed.

Fine Needle Aspiration (FNA): a thin, hollow needle is inserted into the breast to the tumor, and fluid and cells are removed from the tumor. While this test can help to determine if there is cancer present, it cannot determine if the cancer is invasive and additional biopsies may be needed if cancer is actually present.

Core biopsy: a thicker needle is used to remove one or more small cylinder-shaped tissue samples from the tumor.

Diagnostic mammogram: this procedure is similar to the mammogram used for screening, but provides more detailed images of the breast tissue.  

Magnetic Resonance Imaging (MRI): images of the breast are created with powerful magnets that interact with a computer.

Ultrasound: a special wand placed against the skin transmits sound waves, which bounce off breast tissue and are used create an image on a monitor. 

Sentinel lymph node biopsy: lymph nodes are olive-sized glands which are part of a system that circulates lymph fluid throughout the body. The lymphatic system can also carry cancer cells from the tumor site to other areas of the body. In breast cancer patients, the first nodes to be affected are under the arm.

In a sentinel lymph node biopsy, a radioactive tracer is injected into the area before surgery. Then, the surgeon injects a blue dye near the tumorsite, which shows up in cancerous lymph nodes. The node with the highest amount of tracer or blue dye is the “sentinel” node.  The surgeon removes all nodes with blue dye. This procedure can spare healthy lymph nodes, which results in fewer side-effects such as lymphedema. 

 
Staging
(Source: National Cancer Institute)

The staging system allows doctors to help identify the extent of breast cancer involvement. By knowing the extent of disease, doctors can then determine the best treatment for each patient.

Stage 0 (carcinoma in situ): cancer has not spread from the site of origin.

There are 2 types of breast carcinoma in situ:

Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.

Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.

Stage I: Cancer has formed. The tumor is 2 centimeters or smaller and has not spread outside the breast.

Stage IIA

No tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
The tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
The tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB

The tumor is larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA

No tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
The tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
The tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
The tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Stage IIIB: The tumor may be any size and cancer:

Has spread to the chest wall and/or the skin of the breast; and
May have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Stage IIIC: There may be no sign of cancer in the breast or the tumormay be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:

Has spread to lymph nodes above or below the collarbone; and
May have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Stage IIIC breast cancer is divided into operable and inoperable stages:

In operable stage IIIC, the cancer is found in:

10 or more axillary lymph nodes; or
Lymph nodes below the collarbone; or
Axillary lymph nodes and in lymph nodes near the breastbone
In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone.

Stage IV: The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

Surgery
Surgery is the most common treatment for breast cancer. Surgery to remove one or both breasts is called mastectomy. The entire breast is removed, along with any affected lymph nodes. In about 80% of mastectomies, breast reconstruction or implant surgery is performed during the same procedure, after the breast is removed.

Breast-sparing surgery is an attempt to save as much healthy breast tissue as possible. These procedures are best for treating early stage (I & II) tumors. Breast-sparing techniques include:

Lumpectomy: the tumor and a small margin of healthy breast tissue are removed.

Partial mastectomy: the tumor is removed, along with a margin of healthy breast tissue, the lining of the chest muscles, and any affected lymph nodes under the arm.

 
Radiation Therapy
Radiation therapy uses high-energy beams to destroy cancer cells. There are two types of radiation treatment for breast cancer:

External beam radiation: the beams are aimed at the tumor from outside the body. Patients undergo radiation five days a week for a certain number of weeks.

Internal radiation: tiny plastic tubes filled with radioactive material are implanted in the breast at the tumor site and are removed after several days. This procedure requires a hospital stay.

Women who have undergone breast-sparing surgery and/or mastectomymay receive radiation afterwards to kill any lingering cancer cells. Radiation can also be used before surgery to shrink large tumors or to treat tumors in a difficult location.

The following technological means and types of radiation therapy are used with this disease:

• Virtual CT simulation
• Intensity modulated radiartio therapy (IMRT)
• Respiratory Gating

Chemotherapy
Chemotherapy is the use of drugs, either alone or in combination, to kill cancer cells. In breast cancer, chemotherapy is most often used either before or after surgery, or as a primary treatment for cancer that has spread outside the breast at the time of diagnosis.

Hormone Therapy
Hormone therapy is used to prevent female hormones (estrogen, progesterone and estradiol) from fueling the growth of breast tumors in some patients. Hormone therapy can involve taking drugs, either by mouth or through an IV. Tamoxifen is an example of a hormone therapy drug. Surgery to remove the ovaries in women who have not yet reached menopause is another type of hormone therapy.

Biologic Therapy
Biologic therapy is a drug treatment that helps the body’s immune system fight cancer.