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Breast Cancer

breast cancer

Breast tissue is attached to muscle on the chest wall. A tail of breast tissue extends up into the armpit. The breasts contain:

Many lobules which are made up of glandular tissue. They make milk after pregnancy.

Ducts. These are channels which take milk from the lobules to the nipple.

Fatty tissue and supporting connective tissue.

Blood vessels, lymph channels and nerves.

Many women find that their breasts become more lumpy and tender before periods. Breasts also alter their size and shape with increasing age, pregnancy, and with marked weight changes.

What is breast cancer?

Breast cancer is one of the most common cancers. Around one in nine women develop breast cancer at some stage in their life. Most develop in women over the age of 50 but younger women are sometimes affected. Breast cancer can also develop in men, although this is rare. Breast cancer develops from a cancerous cell which develops in the lining of a duct or lobule in one of the breasts.

Invasive or in situ?

Most breast cancers are diagnosed when a tumor has grown from within a duct or lobule into the surrounding breast tissue. These are called invasive breast cancers. Invasive breast cancers are also divided into those where cancer cells have invaded into local blood or lymphatic vessels and those that have not.

Some people are diagnosed when the cancerous cells are still totally within a duct or lobule. These are called carcinoma in situ, as no cancer cells have grown out from their original site. Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. A carcinoma in situ is easier to treat and has a better outlook than an invasive cancer.

Grade of the cancerous cells

  • Grade 1 - the cancer cells tend to be slow-growing and less aggressive.
  • Grade 2 - is a middle grade.
  • Grade 3 - the cancer cells tend to be fast-growing and more aggressive.

Presence of receptors

Some breast cancer cells have receptors, which allow certain types of hormones or proteins to attach to the cancer cell.

  • Hormones. Tests on a sample of breast cancer cells can show if they contain oestrogen receptors. Overall, about 7 in 10 breast cancers are oestrogen receptor positive. Treatment can block the oestrogen in these cancers (see below).
  • HER2. Some breast cancer cells have receptors for a protein known as HER2. Overall about 2 in 10 breast cancers are HER2-positive. Cancers having high levels of these receptors are called HER2-positive.

What causes breast cancer?

A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear.

Risk factors

  • Age. Most cases develop in women over the age of 50.
  • Family history.
  • If you have had a previous breast cancer.
  • Being childless, or if you had your first child after the age of thirty.
  • Not having breast-fed your children.
  • Early age of starting periods.
  • Chest being exposed to radiation.
  • Having a menopause over the age of 55.
  • Taking continuous combined hormone replacement therapy (HRT) for several years (in women over 50 years), leading to a slightly increased risk.
  • Excess alcohol.

Family history and genetic testing

About 1 in 20 cases of breast cancer are caused by a faulty gene which can be inherited. The genes BRCA1 and BRCA2 are the most common faulty genes.

Breast cancer symptoms

  • A breast lump
    • The usual first symptom is a painless lump in the breast. Note: most breast lumps are not cancerous. However, you should always see a doctor if a lump develops, as the breast lump may be cancerous.
  • Changes in the size or shape of a breast.
  • Dimpling or thickening of some of the skin on a part of a breast.
  • The nipple becoming inverted (turning in).
  • Rarely, a discharge occurring from a nipple (which may be bloodstained).
  • A rare type of breast cancer, causing a rash around the nipple, which can look similar to a small patch of eczema.
  • Rarely, pain in a breast.

The first place that breast cancer usually spreads to is the lymph glands (nodes) in the armpit (axilla). If this occurs, you may develop a swelling or lump in an armpit.

How is breast cancer diagnosed?

Initial assessment

If you develop a lump or symptoms which may be breast cancer, a doctor will usually examine your breasts and armpits to look for any lumps or other changes.

  • Mammogram. This is a special X-ray of the breast tissue.
  • Ultrasound scan of the breast.
  • MRI scan of the breast. This is more commonly performed on younger women, who may have denser breast tissue.
  • Biopsy - to confirm the diagnosis

A specialist may take a biopsy with a needle which is inserted into the lump for some cells to be withdrawn. Sometimes the doctor may be guided as to where to insert the needle with the help of a mammogram or ultrasound scan. Sometimes a small operation is needed to obtain a biopsy sample.

The biopsy sample can confirm or rule out breast cancer. Also the cells from a tumour can be assessed and tested to determine their grade and receptor status (see above).

Assessing the extent and spread

If you are confirmed to have breast cancer, further tests may be needed likeblood tests, an ultrasound scan of the liver, chest X-ray, a bone scan or other types of scan. This assessment is called staging of the cancer.

What is the treatment for breast cancer?

Treatment options which may be considered include surgery, chemotherapy, radiotherapy and hormone treatment. Often a combination of two or more of these treatments is used. The treatments used depend on:

The cancer itself - its size and stage , the grade of the cancer cells, and whether it is hormone responsive or contains HER2 receptors;
AND
The woman with the cancer - your age, whether or not you have had your menopause, your general health and personal preferences for treatment.

Treatment aims to cure the cancer in many cases. In particular, the earlier the stage of the cancer, the better the chance of a cure. Because of routine mammography, many women are diagnosed with breast cancer in the early stages and have a good chance of a cure. Doctors tend to use the word remission rather than the word cured.

Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so it progresses less rapidly.

Treatment may aim to ease symptoms in some cases. Even if a cure is not possible, treatments may be used to reduce the size of a tumour, which may ease symptoms such as pain.

Surgery

Breast-conserving surgery. This is often an option if the tumour is not too big. A lumpectomy (or wide local excision) is one type of operation where just the tumour and some surrounding breast tissue are removed. It is usual to have radiotherapy following this operation.

Removal of the affected breast (mastectomy). This may be necessary if there is a large tumour or a tumour in the middle of the breast. It is often possible to have breast reconstructive surgery to create a new breast following a mastectomy. This can often be done at the same time as the mastectomy.

Radiotherapy

Radiotherapy is a treatment which uses high-energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. For breast cancer, radiotherapy is mainly used in addition to surgery. For example, if you have breast-conserving surgery it is usual to have radiotherapy to the affected breast after the operation.

Hormone treatments

Some types of breast cancer are affected by the female hormones oestrogen and progesterone. Treatments which reduce the level of these hormones, or prevent them from working, are commonly used in people with breast cancer. Hormone treatment works best in women with hormone-responsive breast cancer, but they sometimes work in cancers classed as non-hormone-responsive.

Hormone treatments include:

  • Oestrogen blockers. Tamoxifen has been available for many years and is still widely used. It works by blocking the oestrogen from working on cells. It is usually taken for five years.
  • Aromatase inhibitors. These are medicines which work by blocking the production of oestrogen in body tissues. These medicines include anastrozole, letrozole and exemestane.
  • Gonadotrophin-releasing hormone (GnRH) analogues. These medicines work by greatly reducing the amount of oestrogen that you make in the ovaries. The commonly used one is goserelin. They are usually given by injection and may be used for women who have not yet reached the menopause.

An alternative which may be considered for women before the menopause is to remove the ovaries (or to destroy them with radiotherapy). This stops oestrogen from being made.

Chemotherapy

Chemotherapy is a treatment of cancer by using anti-cancer medicines which kill cancer cells, or stop them from multiplying. When chemotherapy is used in addition to surgery it is known as adjuvant chemotherapy. Chemotherapy is sometimes given before surgery to shrink a tumour so that surgery may have a better chance of success and also a smaller operation may be performed. This is known as neoadjuvant chemotherapy.

Trastuzumab (Herceptin®)

Trastuzumab (also known as Herceptin®) is a treatment that may be given to women who have a large number of HER2 receptors in their cancer. It is a type of medicine called a monoclonal antibody. It works by attaching to HER2 receptors on the surface of breast cancer cells, thereby stopping the cancer cells from dividing and growing.

What is the outlook?

The outlook has greatly improved in recent years. Deaths from breast cancer are now at the lowest ever in 40 years. This is mainly due to the improvements in the treatment of breast cancer. The outlook is best in those who are diagnosed when the cancer is still small, and has not spread. More breast cancers are also now being diagnosed and treated at an early stage. In general, the more advanced the cancer then the less chance that treatment will be curative.

Screening for breast cancer

Women aged between 50 and 70 are suggested having a routine mammography every three years. Mammography is a special X-ray test and aims to detect breast cancer at an early stage when treatment is most likely to be curative. Genetic testing and mammography screening (and preventive treatments in some cases) may also be offered to younger women with a strong family history of breast cancer.


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