Breast Cancer, Symptoms and Causes
The North Shore-LIJ Cancer Institute is a leader in breast cancer diagnosis, treatment and research, providing the most current and most promising treatments, including those available only through clinical research trials. Our dedicated team of specialists, including medical oncologists, surgical oncologists, radiation oncologists, plastic and reconstructive surgeons, nurses, nutritionists and genetic counselors, provide comprehensive and compassionate care to treat, educate and support breast cancer patients.
Treatment options for breast cancers at North Shore-LIJ Cancer Institute include the latest in diagnostic, chemotherapeutic and biologic therapies and access to up-to-date clinical trials clinical trials and innovative treatments, including:
- Advanced imaging for breast cancer detection:
- Digital mammography
- Stereotactic needle biopsy
- Breast magnetic resonance (MRI)
- Positron emission tomography (PET)
- Breast conserving surgery and treatment
- Sentinel lymph node biopsy
- Innovative reconstruction techniques
- Chemotherapy (intravenous and oral)
- Hormone therapy
Patients have the opportunity to participate in clinical trials relevant to their particular condition, if they so desire, and they are monitored by our research nurses and managers, in addition to their doctors, effectively adding an extra layer of support to the care we provide.
Breast Cancer: An Overview
What Are the Different Types of Breast Cancer?
There are several types of breast cancer, including:
- The most common type which begins in the lining of the ducts and is called ductal carcinoma.
- Another common type, called lobular carcinoma, occurs in the lobules (milk-producing glands).
- Paget's disease, a rare form of breast cancer that begins in the glands in or under the skin. It is often characterized by inflamed, red patches on the skin. Paget's disease often originates from breast duct cancer, and is associated with an eczema-like rash usually appearing around the nipple. When breast cancer metastasizes, or spreads outside the breast, cancer cells are often found in the lymph nodes under the arm. If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body.
Cancer that spreads is the same disease and has the same name as the original or primary cancer. When breast cancer spreads, it is called metastatic breast cancer, even though the secondary tumor is in another organ. This may also be called "distant" disease.
What Are the Signs and Symptoms of Breast Cancer?
The following are the most common symptoms of breast cancer. However, each individual may experience symptoms differently. Early breast cancer usually does not cause pain and may cause no symptoms. Some breast cancers never cause symptoms or other indications of a problem. As the cancer grows, however, it can cause changes that women and men should watch for, such as:
- A lump or thickening (a mass, swelling, skin irritation or distortion) in or near the breast or in the underarm area
- A change in the size or shape of the breast
- A change in the color or feel of the skin of the breast, areola or nipple (dimpled, puckered or scaly)
- Nipple discharge, erosion, inversion or tenderness
A woman (or man) should consult a physician when any of these changes are noticed.
How Is Breast Cancer Diagnosed?
It is important to remember that a lump or other changes in the breast, or an abnormal area on a mammogram, may be caused by cancer or by other, less serious problems.
Breast Cancer Exam
To determine the cause of any signs or symptoms, your physician will perform a careful physical exam that includes a personal and family medical history as well as determining current overall health status. In addition, an examination may include the following:
- Palpation – carefully feeling the lump and the tissue around it – its size, its texture, and whether it moves easily. Benign lumps often feel different from cancerous ones.
- Nipple Discharge Examination – Fluid may be collected from spontaneous nipple discharge and then sent to the lab to look for cancer cells. Most nipple secretions are not cancer, as an injury, infection, or benign tumor may cause discharge.
Breast Cancer Imaging
For women who are at high risk for breast cancer, a procedure called ductal lavage may be used. Ductal lavage collects cells from inside the milk ductal system – the location where most breast cancers begin.
In addition to a physical examination by your physician, an imaging test may be performed. Imaging tests may include one or more of the following:
- Digital mammography (also called full-field digital mammography or FFDM) — a type of mammography in which the images are electronically captured and stored on a computer, rather than X-ray film. The images are viewed on a computer screen. A diagnostic mammogram is an X-ray of the breast used to diagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, or a change in breast size or shape. A diagnostic mammogram is also used to evaluate abnormalities detected on a screening mammogram.
It is a basic medical tool and is appropriate in the workup of breast changes, regardless of a woman's age. Images can be changed, including the degree of magnification, brightness or contrast, to help visualization. They can also be transmitted electronically. While this procedure currently costs more than standard mammography, studies are being done to see which type of mammography will be of more benefit to women for the long term.
Some studies have found FFDM to be more accurate in finding cancers in women younger than 50. Also, it has been found that women undergoing digital mammography do not have to return for additional studies as often as with standard mammography, because the digital images have fewer questionable spots needing more investigation. However, not all hospitals and mammography facilities have digital equipment available.
- Ultrasonography — uses high-frequency sound waves not heard by humans. The sound waves enter the breast and bounce back. The pattern of their echoes produces a picture called a sonogram which is displayed on a screen. This exam is often used along with mammography.
- Scintimammography — a specialized radiology procedure used to assess the breasts when other examinations have been inconclusive. Scintimammography, or breast scan, is a type of nuclear radiology procedure. This means that a tiny amount of a radioactive substance is used during the procedure to assist in the examination of the breasts. The radioactive substance, called a radionuclide (radiopharmaceutical or radioactive tracer), is absorbed by certain types of body tissues.
- Magnetic resonance imaging (MRI) — a diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
Invasive Procedures: Biopsy
A biopsy is a procedure performed to remove tissue or cells from the body for examination under a microscope. A breast biopsy is a procedure in which samples of breast tissue are removed with a special biopsy needle or during surgery to determine if cancer or other abnormal cells are present. Biopsies may be performed under local or general anesthesia. There are several types of breast biopsy procedures. The type of biopsy performed will depend upon the location and size of the breast lump or abnormality.
Types of breast biopsy procedures include, but are not limited to, the following:
- Fine needle aspiration biopsy — A very thin needle is placed into the lump or suspicious area to remove a small sample of fluid and/or tissue. No incision is necessary. A fine needle aspiration biopsy may be performed to help to differentiate a cyst from a lump.
- Core needle biopsy — A large needle is guided into a lump or suspicious area to remove a small cylinder of tissue (also called a core). No incision is necessary.
- Surgical biopsy (also called an open biopsy) — A surgeon removes part or all of a lump or suspicious area through an incision into the breast. There are two types of surgical biopsies. During an incisional biopsy, a small part of the lump is removed; whereas during an excisional biopsy, the entire lump is removed. In some cases, if the breast lump is very small and deep and is difficult to locate, the wire localization technique may be used during surgery. With this technique, a special wire is placed into the lump under X-ray guidance. The surgeon follows this wire to help locate the breast lump.
There are special instruments and techniques that may be used to guide the needles and to assist with biopsy procedures. These include, but are not limited to, the following:
- Stereotactic biopsy – finds the exact location of a breast lump or suspicious area by using a computer and mammogram results to create a three-dimensional (3D) picture of the breast. A sample of tissue is removed with a needle.
The following techniques use a stereotactic approach:
- Advanced breast biopsy instrumentation (ABBI) — uses a rotating knife and cylinder to remove a large sample of tissue. Although this type of procedure has not received widespread acceptance, it is often possible to remove the entire breast lesion with this method.
- Mammotome® breast biopsy system (also called vacuum-assisted biopsy) — a type of tube is inserted into the breast lump or mass. The breast tissue is gently suctioned into the tube, and a rotating knife removes the tissue. In 1999, the U.S. Food and Drug Administration (FDA) approved the use of the hand-held Mammotome device.
- Ultrasound-guided biopsy — uses a computer and a transducer that sends out ultrasonic sounds waves to create images of the breast lump or mass. This technique helps to guide the needle biopsy.
- Sentinel node biopsy — used to determine if cancer cells have spread to the lymph nodes. This surgical procedure may be performed during the initial diagnostic period to aid in staging of the breast cancer. This procedure involves injecting a dye and/or radioactive substance near the tumor. This injection helps to locate the lymph node closest to the tumor (sentinel node) — the one that is most likely to have cancer cells present if the cancer has spread. The surgeon removes the lymph node that absorbs the dye and radioactive substance and sends it to the pathologist to examine it closely for the presence of cancer cells.
How Is Breast Cancer Treated?
The treatment choices for each woman depend on the size and location of the tumor in her breast, the results of lab tests (such as hormone receptor tests) and the stage or extent of the disease. A doctor also considers the woman's age, general health, the size of her breasts and whether or not she is in menopause when making recommendations about a treatment plan for her. A woman considers these recommendations based on a range of personal factors as well.
Many women want to learn all they can about their disease and their treatment choices so that they can take an active part in decisions about their care. They are likely to have many questions and concerns about their treatment options. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. The doctor is the best person to answer such questions as treatment options, how successful each is expected to be, what the risks and side effects may be, and how much it is likely to cost. Many times, treatments are given in a sequential fashion.
Types of Treatment
Treatments for breast cancer are either local or systemic. Local treatments remove, destroy or control the cancer cells in one certain area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the entire body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have one treatment or a combination of different treatments.
Different types of treatments have different goals. Below is a list of various treatments and how they may be used.
- Surgery — Surgery is used to remove the tumor from the breast. Sometimes only the tumor is removed (lumpectomy) and the breast is left intact. Sometimes the entire breast is removed. Surgery is also used to see if the cancer has spread to the lymph nodes under the arm. This information can help the patient and her doctors make important decisions about other treatments that may be helpful. Surgery may also be used to reconstruct a breast mound after the breast is removed. These three ways of using surgery are sometimes done as one operation or may be done separately.
- Radiation therapy — The goal of radiation therapy is to kill cancer cells using x-rays and other types of radiation. This treatment can be used to shrink a tumor before surgery, to kill cancer cells that may remain in the breast or chest area after surgery or to treat tumors in other areas of the body. Radiation therapy is usually given daily, Monday through Friday, for several weeks. Accelerated techniques are also used.
- Chemotherapy — Chemotherapy is used to kill cancer cells with medicines that can go throughout the body. It may be used to shrink a tumor before surgery, to kill cancer cells that may remain in the body after local treatments or to treat tumors that have already developed in other areas of the body. Chemotherapy is usually given in cycles, with treatments given every two to four weeks over several months. Treatment of breast cancer that has spread will usually involve hormone therapy and/or chemotherapy with or without trastuzumab (Herceptin), depending on whether or not the cancer cells overexpress the HER-2 protein.
- Hormonal therapy — Hormonal therapy is used to stop the growth of cancer cells that rely on hormones. Hormonal therapy may be used to decrease the chances of cancer returning or a new cancer developing after surgery. It can also be used to treat cancer that has spread. Hormonal therapy may include the use of any of the following agents: anastrozole (Arimidex®), fulvestrant (Faslodex®), letrozole (Femara®), exemestane (Aromasin®), and tamoxifen (Nolvadex®). These may be given as a daily pill or as an injection with treatment continuing for several years or as long as it appears to be working, if it is being given for active disease.
Doctors are finding new ways to treat breast cancer. These new methods are tested in clinical trials. Before beginning treatment, a woman may want to ask her doctor if there are any clinical trials she should consider.
Questions to Ask about Treatment
At first, the information you receive about treatment options may seem overwhelming. It is important that you take the time to gather as much information as possible about your disease and its treatment, and to discuss the issues with your doctors, nurses and loved ones. Your doctor is the best person to answer your questions about treatment.
Many people find it helpful to make a list of their questions before seeing their doctor. To make it easier to remember what the doctor says, you may want to take notes or ask if you can use a tape recorder. It might also help to have a family member or friend with you to take part in discussion, to take notes or just to listen.
What Are the Risk Factors for Breast Cancer?
Anyone may develop breast cancer. However, the following risk factors may increase the likelihood of developing the disease.
Risk factors that cannot be changed:
- Gender — Breast cancer occurs nearly 100 times more often in women than in men.
- Race/Ethnicity — It has been noted that Caucasian women develop breast cancer slightly more often than African-American women. However, African-American women tend to die of breast cancer more often. This may be partly due to the fact that African-American women often develop a more aggressive type of tumor, although why this happens is not known. The risk for developing breast cancer and dying from it is lower in Hispanic, Native American, and Asian women.
- Aging — Two out of three women with invasive cancer are diagnosed after age 55.
- A personal history of breast cancer.
- Previous breast irradiation.
- Family history and genetic factors — Having a close relative, such as a mother or sister, with breast cancer increases the risk. This includes changes in certain genes such as BRCA1, BRCA2 and others. A family history of ovarian or prostate cancer is a concern.
- Benign breast disease — Some, but not all types, can increase risk.
- Previous breast biopsy in which the tissue showed atypical hyperplasia.
- Menstrual periods that began early in life.
- Menopause that occurs later in life.
- Therapeutic radiation to the chest.
The most frequently cited lifestyle-related risk factors:
- Not having children, or first child after age 30
- Oral contraceptives
- A high-fat diet
- Long-term, post-menopausal use of combined estrogen and progestin (HRT)
- Weight gain and obesity after menopause
What Is Breast Reconstruction Surgery?
With advances in breast reconstruction surgery, many women undergoing breast removal choose to have their breast(s) rebuilt. Even though medical, surgical and radiation therapy treatments for breast cancer have increased the number of breast-sparing procedures available leading to an acceptable cosmetic result, some breast cancer patients may still need a mastectomy — removal of the breast(s). In addition, other women have their breast(s) removed due to other diseases.
Breast reconstruction surgery involves creating a breast mound that comes as close as possible to the form and appearance of the natural breast. The goal of reconstructive surgery is to create a breast mound that matches the opposite breast and to achieve symmetry. If both breasts have been removed, the goal of breast reconstructive surgery is to create both breast mounds approximately the size of the patient's natural breasts.
What Are the Criteria for Breast Reconstruction Surgery?
In general, all women undergoing a mastectomy are candidates for immediate or delayed breast reconstruction. However, there are criteria for selecting the best candidates for the procedure:
- The size and location of the cancer — which determines the amount of skin and tissue to be removed in the mastectomy — are primary factors when making recommendations for reconstruction
- Whether tissue has been damaged by radiation therapy or aging and is not sufficiently healthy to withstand surgery
Other considerations include:
- Potential for complications
- Patient's desires
- The amount of tissue removed from the breast
- The health of the tissue at the planned operation site
- Whether radiation therapy is part of treatment
- The patient's general health and physique
- Past medical history
- Co-existing illnesses
- Other risk factors such as cardiac disease, diabetes mellitus, smoking and obesity
When Is Breast Reconstruction Surgery Performed?
The patient is usually educated and counseled in breast reconstructive possibilities prior to mastectomy, so that she can make the decision for or against reconstruction before going into surgery. Based on the personal medical history of each patient, a recommendation will be made for either:
- Immediate reconstruction — reconstructive surgery performed at the same time as mastectomy
- Delayed reconstruction — a second operation (to reconstruct missing breast tissue) is performed after recovery from the mastectomy is complete. If radiation therapy is part of the treatment protocol, the surgeon may recommend delayed reconstruction.
What Complications Are Commonly Associated with Breast Reconstructive Surgery?
Any type of surgery carries some risk. Patients differ in their anatomy and their ability to heal. Some complications from breast reconstruction may include:
- Anesthesia problems
- Fluid collection
- Excessive scar tissue
- Loss of viable tissue at the graft site
The most common complication of breast reconstruction surgery with implants is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten. Occasionally, this and other complications are severe enough to require a second operation.
What are the Different Types of Breast Reconstruction Surgery?
The two most effective approaches available for both monolateral (one breast) and bilateral (both breasts) reconstructions are:
- Expander/implant reconstruction — The use of an expander to create a breast mound, followed by placement with a permanently filled breast implant. Expanders are empty silicone "envelopes" placed under the pectoralis muscle, located between the breast and the chest wall. To enable the skin and soft tissues of the breast to grow, the expander is gradually filled with saline solution over a period of several weeks. The saline is injected into the expander through a valve or port in the expander. Once the expander has been completely filled, it is left in for several more weeks to months, allowing for maximal skin and soft tissue growth.
Implants are envelopes filled with liquid that are implanted into the breast tissue and are used to form the shape of the breast. Implants may be filled with saline or silicone gel. Each type of implant has advantages and disadvantages. Your physician will discuss the types of implants with you and seek your input about the type of implant to be used.
Although there have been questions raised about the safety of silicone gel implants, the Institute of Medicine published a report in 2000 that refuted most of the claims about silicone implant hazards. After four years of extensive studies, the FDA announced in late 2006 that it had approved silicone gel-filled implants for breast augmentation for women ages 22 and older and for breast reconstruction for women of all ages.
The two manufacturers of the implants are required to conduct a large post-approval study following 40,000 women for a 10-year period after receiving implants.
- Autologous tissue reconstruction — the use of the patient's own tissues to reconstruct a new breast mound. The common technique is the TRAM (transverse rectus abdominous muscle) flap. A TRAM flap involves removing an area of fat, skin and muscle from the abdomen and stitching it in place to the mastectomy wound.
About the Procedures
Location options include:
- Surgeon's office-based surgical facility
- Outpatient surgery center
- Hospital outpatient
- Hospital inpatient
Probable length of procedure:
- When performed at the time of a mastectomy, it adds about an hour or so to the surgery. Drains are put in place, and recovery time is longer due to the additional surgery, but the care afterward is the same as for mastectomy alone.
- Delayed reconstruction, as second surgery, requires more than an hour, and drains are not routinely inserted. The recovery is much quicker than it is after immediate reconstruction, because the mastectomy wound has already healed.
Understanding Genetic Testing for Breast Cancer
The Cancer Genetic Program at the North Shore-LIJ Cancer Institute offers genetic risk assessment to individuals who may be at risk for a hereditary cancer syndrome based on their personal and/or family history of cancer. The experts at the Cancer Institute offer detailed assessments of inherited cancer risks, education and the opportunity for genetic testing when appropriate.
Cancer is a disease of the genes. Most cancers develop as a result of genetic damage we sustain over a lifetime. These are called "sporadic" cancers. The risk of developing cancer is higher in those who are born with certain genetic defects. These defects occur in areas of the DNA that affect cell division, cell death and the repair of damaged DNA. Cancers that result from DNA damage to genes and passed on to offspring are called "hereditary" cancers. They account for about 5-10 percent of all breast cancer cases. The likelihood of breast cancer being hereditary is influenced by your age at the time of diagnosis. The younger you are, the more likely the cancer is hereditary.
A number of genetic defects can result in an increased risk for breast cancer. All these defects occur in areas of the genes that influence cancer progression. The most common breast cancer attenuated defects are found on genes named BRCA1 (breast cancer gene 1) and BRCA2 (breast cancer gene 2). These genes may account for up to 80 percent of hereditary breast cancer cases. The discoveries of these breast cancer genes in the early 1990s greatly helped our understanding of the genetic basis of inherited breast cancer and ovarian cancer. Scientists continue to work to understand the significance of different alterations in these genes. BRCA tests are commercially available. Other rare conditions may warrant testing.
Deciding on Genetic Testing for Breast Cancer
Genetic testing is considered only for women with a certain family history. You might fall into this high-risk group if any of the following statements are true for you.
- You have two or more close relatives with breast cancer.
- You have relatives who developed breast cancer before age 50.
- You have breast cancer in more than one generation in your family.
- You have several family members who have had ovarian, pancreas or prostate cancer.
- You are of Ashkenazi (eastern and central European) Jewish ancestry.
If you are considering genetic testing for cancer risks, you face many complex issues. If you test positive, you will face difficult decisions about treatments to prevent breast cancer. You may have increased anxiety about developing breast cancer. You may have concerns about losing your health insurance coverage; however, to date, this has not been a problem. If you test negative, you may also face difficult challenges, such as survivor guilt, if other family members have tested positive.
To make an appointment or for more information on cancer genetic counseling, please contact us at (516) 734-8850.
Breast Cancer Clinical Trials
The North Shore-LIJ Cancer Institute offers a full array of clinical trials. The result of this research not only impacts survival, but also enhances the quality of life. For more information about clinical trials for Breast Cancer, visit Cancer Clinical Trials.
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