What is the cancer process?

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

• Benign tumors are not cancer:
  
• Benign tumors are rarely life-threatening.
  
• Generally, benign tumors can be removed. They usually do not grow back.
  
• Cells from benign tumors do not invade the tissues around them.
  
• Cells from benign tumors do not spread to other parts of the body.
  

• Malignant tumors are cancer:
  
• Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
  
• Malignant tumors often can be removed. But sometimes they grow back.
  
• Cells from malignant tumors can invade and damage nearby tissues and organs.
  
• Cells from malignant tumors can spread (metastasize) to other parts of the body. Cancer cells spread by breaking away from the original (primary) tumor and entering the bloodstream or lymphatic system. The cells invade other organs and form new tumors that damage these organs. The spread of cancer is called metastasis.
  

When breast cancer cells spread, the cancer cells are often found in lymph nodes near the breast. Also, breast cancer can spread to almost any other part of the body. The most common are the bones, liver, lungs, and brain. The new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer. For that reason, it is treated as breast cancer, not bone cancer. Doctors call the new tumor "distant" or metastatic disease.

What are risk factors for breast cancer?

No one knows the exact causes of breast cancer. Doctors often cannot explain why one woman develops breast cancer and another does not. They do know that bumping, bruising, or touching the breast does not cause cancer. And breast cancer is not contagious. You cannot "catch" it from another person.

Research has shown that women with certain risk factors are more likely than others to develop breast cancer. A risk factor is something that may increase the chance of developing a disease.

Studies have found the following risk factors for breast cancer:

• Age: The chance of getting breast cancer goes up as a woman gets older. Most cases of breast cancer occur in women over 60. This disease is not common before menopause.

• Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting cancer in her other breast.

• Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is higher if her family member got breast cancer before age 40. Having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk.

• Certain breast changes: Some women have cells in the breast that look abnormal under a microscope. Having certain types of abnormal cells (atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.

• Gene changes: Changes in certain genes increase the risk of breast cancer. These genes include BRCA1,BRCA2, and others. Tests can sometimes show the presence of specific gene changes in families with many women who have had breast cancer. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes.

• Reproductive and menstrual history:
  
  • The older a woman is when she has her first child, the greater her chance of breast cancer.
    
  • Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.
    
  • Women who went through menopause after age 55 are at an increased risk of breast cancer.
    
  • Women who never had children are at an increased risk of breast cancer.
    
  • Women who take menopausal hormone therapy with estrogen plus progestin after menopause also appear to have an increased risk of breast cancer.
    
  • Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.
    
    

• Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.

• Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma. Studies show that the younger a woman was when she received radiation treatment, the higher her risk of breast cancer later in life.

• Breast density: Breast tissue may be dense or fatty. Older women whose mammograms (breast x-rays) show more dense tissue are at increased risk of breast cancer.

• Taking DES (diethylstilbestrol): DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.) Women who took DES during pregnancy may have a slightly increased risk of breast cancer. The possible effects on their daughters are under study.

• Being overweight or obese after menopause: The chance of getting breast cancer after menopause is higher in women who are overweight or obese.

• Lack of physical activity: Women who are physically inactive throughout life may have an increased risk of breast cancer. Being active may help reduce risk by preventing weight gain and obesity.

• Drinking alcohol: Studies suggest that the more alcohal a woman drinks, the greater her risk of breast cancer.
  

Other possible risk factors are under study. Researchers are studying the effect of diet, physical activity, and genetics on breast cancer risk. They are also studying whether certain substances in the environment can increase the risk of breast cancer.

Many risk factors can be avoided. Others, such as family history, cannot be avoided. Women can help protect themselves by staying away from known risk factors whenever possible.

But it is also important to keep in mind that most women who have known risk factors do not get breast cancer. Also, most women with breast cancer do not have a family history of the disease. In fact, except for growing older, most women with breast cancer have no clear risk factors.

If you think you may be at risk, you should discuss this concern with your doctor. Your doctor may be able to suggest ways to reduce your risk and can plan a schedule for checkups.

What are the symptoms of breast cancer?

Common symptoms of breast cancer include:

• A change in how the breast or nipple feels
  
  • A lump or thickening in or near the breast or in the underarm area
    
  • Nipple tenderness
  
  
• A change in how the breast or nipple looks Nipple tenderness
  
  • A change in the size or shape of the breast
    
  • A nipple turned inward into the breast
    
  • The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
  
  
• Nipple discharges (fluid)
  

Early breast cancer usually does not cause pain. Still, a woman should see her health care provider about breast pain or any other symptom that does not go away. Most often, these symptoms are not due to cancer. Other health problems may also cause them. Any woman with these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

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.

Clinical breast exam

Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic mammogram

Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasound

An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.

Magnetic resonance imaging

Magnetic resonance imaging(MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.

Biopsy

Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.

Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.

Doctors can remove tissue from the breast in different ways:

• Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.
  
• Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
  
• Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
  
• An incisional biopsy takes a sample of a lump or abnormal area.
  
• An excisional biopsy takes the entire lump or area.
  

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

If you are diagnosed with cancer, your doctor may order special lab tests on the breast tissue that was removed. These tests help your doctor learn more about the cancer and plan treatment:

• Hormone receptor test: This test shows whether the tissue has certain hormone receptors. Tissue with these receptors needs hormones (estrogen or progesterone) to grow.
  
• HER2 test: This test shows whether the tissue has a protein called human epidermal growth factor receptor-2 (HER2) or the HER2/neu gene. Having too much protein or too many copies of the gene in the tissue may increase the chance that the breast cancer will come back after treatment.
  
  

What about follow-up care?

Follow-up care after treatment for breast cancer is important. Recovery is different for each woman. Your recovery depends on your treatment, whether the disease has spread, and other factors.

Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Your doctor will monitor your recovery and check for recurrence of the cancer.

You should report any changes in the treated area or in your other breast to the doctor right away. Tell your doctor about any health problems, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. Also talk to your doctor about headaches, dizziness, shortness of breath, coughing or horseness, backaches, or digestive problems that seem unusual or that don't go away. Such problems may arise months or years after treatment. They may suggest that the cancer has returned, but they can also be symptoms of other health problems. It is important to share your concerns with your doctor so problems can be diagnosed and treated as soon as possible.

Follow-up exams usually include the breasts, chest, neck, and underarm areas. Since you are at risk of getting cancer again, you should have mammograms of your preserved breast and your other breast. You probably will not need a mammogram of a reconstructed breast or if you had a mastectomy without reconstruction. Your doctor may order other imaging procedures or lab tests.

Breast Cancer At A Glance

• One in every eight women in the United States develops breast cancer.
  
• The causes of breast cancer are not yet fully known although a number of risk factors have been identified.
  
• Breast cancer is diagnosed with self- and physician- examination of the breasts, mammography, ultrasound testing, and biopsy.
  
• There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues.
  
• Treatment of breast cancer depends on the type and location of the breast cancer, as well as the age and health of the patient.
  
• The American Cancer Society recommends that a woman should have a baseline mammogram between the ages of 35 and 40 years. Between 40 and 50 years of age mammograms are recommended every other year. After age 50 years, yearly mammograms are recommended.