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The normal breast To understand breast cancer, it helps to have some basic knowledge about the normal structure

of the breasts, shown in the diagram below. The female breast is made up mainly of lobules (milk-producing glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels).

Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues. The lymph (lymphatic) system of the breast The lymph system is important to understand because it is one way breast cancers can spread. This system has several parts. Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Ly mphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes. Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular nodes)

What is breast cancer? Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too If the cancer cells have spread to lymph nodes, there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. The more lymph nodes that have breast cancer, the more likely it is that the cancer may be found in other organs as well. Because of this, finding cancer in one or more lymph nodes often affects the treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases, and some women can have no cancer cells in their lymph nodes and later develop metastases. Types of breast cancers There are several types of breast cancer, but some of them are quite rare. In some cases a single breast tumor can be a combination of these types or be a mixture of invasive and in situ cancer. Ductal carcinoma in situ Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is the most common type of non-invasive breast cancer. DCIS means that the cancer cells are inside the ducts but have not spread through the walls of the ducts into the surrounding breast tissue. About 1 in 5 new breast cancer cases will be DCIS. Nearly all women diagnosed at this early stage of breast cancer can be cured. A mammogram is often the best way to find DCIS early. When DCIS is diagnosed, the pathologist (a doctor specializing in diagnosing disease from tissue samples) will look for areas of dead or dying cancer cells, called tumor necrosis, within the tissue sample. If necrosis is present, the tumor is likely to be more aggressive. The term comedocarcinoma is often used to describe DCIS with necrosis. Lobular carcinoma in situ This is not a true cancer, and is discussed in the section What are the risk factors for breast cancer?.

Invasive (or infiltrating) ductal carcinoma This is the most common type of breast cancer. Invasive (or infiltrating) ductal carcinoma (IDC) starts in a milk passage (duct) of the breast, breaks through the wall of the duct, and grows into the fatty tissue of the breast. At this point, it may be able to spread (metastasize) to other parts of the body through the lymphatic system and bloodstream. About 8 of 10 invasive breast cancers are infiltrating ductal carcinomas. cinoma Invasive lobular carcinoma (ILC) starts in the milk-producing glands (lobules). Like IDC, it can spread (metastasize) to other parts of the body. About 1 in 10 invasive breast cancers is an ILC. Invasive lobular carcinoma may be harder to detect by a mammogram than invasive ductal carcinoma. Less common types of breast cancer Inflammatory breast cancer: This uncommon type of invasive breast cancer accounts for about 1% to 3% of all breast cancers. Usually there is no single lump or tumor. Instead, inflammatory breast cancer (IBC) makes the skin of the breast look red and feel warm. It also may give the breast skin a thick, pitted appearance that looks a lot like an orange peel. Doctors now know that these changes are not caused by inflammation or infection, but by cancer cells blocking lymph vessels in the skin. The affected breast may become larger or firmer, tender, or itchy. In its early stages, inflammatory breast cancer is often mistaken for an infection in the breast (called mastitis). Often this cancer is first treated as an infection with antibiotics. If the symptoms are caused by cancer, they will not improve, and a biopsy will find cancer cells. Because there is no actual lump, it may not show up on a mammogram, which may make it even harder to find it early. This type of breast cancer tends to have a higher chance of spreading and a worse outlook (prognosis) than typical invasive ductal or lobular cancer. For more details about this condition, see our document, Inflammatory Breast Cancer. Triple-negative breast cancer: This term is used to describe breast cancers (usually invasive ductal carcinomas) whose cells lack estrogen receptors and progesterone receptors, and do not have an excess of the HER2 protein on their surfaces. (See the section, "How is breast cancer diagnosed?" for more detail on these receptors.) Breast cancers with these characteristics tend to occur more often in younger women and in African-American women. Triple-negative breast cancers tend to grow and spread more quickly than most other types of breast cancer. Because the tumor cells lack these certain receptors, neither hormone therapy nor drugs that target HER2 are effective treatments (but chemotherapy can still be useful if needed). Paget disease of the nipple: This type of breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola, the dark circle around the nipple. It is rare, accounting for only about 1% of all cases of breast cancer. The skin of the nipple and areola often appears crusted, scaly, and red, with areas of bleeding or oozing. The woman may notice burning or itching. Paget disease is almost always associated with either ductal carcinoma in situ (DCIS) or infiltrating ductal carcinoma. Treatment often requires mastectomy. If no lump can be felt in the breast tissue, and the biopsy shows DCIS but no invasive cancer, the outlook (prognosis) is excellent. If invasive cancer is present, the prognosis is not as good, and the cancer will need to be staged and treated like any other invasive cancer. Phyllodes tumor: This very rare breast tumor develops in the stroma (connective tissue) of the breast, in contrast to carcinomas, which develop in the ducts or lobules. Other na

mes for these tumors include phylloides tumor and cystosarcoma phyllodes. These tumors are usually benign but on rare occasions may be malignant. Benign phyllodes tumors are treated by removing the tumor along with a margin of normal breast tissue. A malignant phyllodes tumor is treated by removing it along with a wider margin of normal tissue, or by mastectomy. Surgery is often all that is needed, but these cancers may not respond as well to the other treatments used for more common breast cancers. When a malignant phyllodes tumor has spread, it can be treated with the chemotherapy given for soft-tissue sarcomas (this is discussed in detail in our document, Soft-tissue Sarcomas. Angiosarcoma: This is a form of cancer that starts in cells that line blood vessels or lymph vessels. It rarely occurs in the breasts. When it does, it usually develops as a complication of previous radiation treatments. This is an extremely rare complication of breast radiation therapy that can develop about 5 to 10 years after radiation. Angiosarcoma can also occur in the arms of women who develop lymphedema as a result of lymph node surgery or radiation therapy to treat breast cancer. (For information on lymphedema, see the section, "How is breast cancer treated?") These cancers tend to grow and spread quickly. Treatment is generally the same as for other sarcomas. See our document, Sarcoma - Adult Soft Tissue Cancer. Breast cancer is the most common cancer among American women. One in every eight women in the United States develops breast cancer. There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues. The causes of breast cancer are not yet fully known although a number of risk factors have been identified. There are many different types of breast cancer. Breast cancer is diagnosed with physician and self-examination of the breasts, mammography, ultrasound testing, and biopsy. Treatment of breast cancer depends on the type of cancer and its stage (the extent of spread in the body). According to the American Cancer society: Over 200,000 new cases of invasive breast cancer are diagnosed each year. Nearly 40,000 women will die of breast cancer in 2011. There are over 2.5 million breast cancer survivors in the United States. A woman should have a baseline mammogram between the 35 and 40 years of age. Between 40 and 50 years of age, mammograms are recommended every other year. After 50 years of age, yearly mammograms are recommended. What causes breast cancer? There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know how these factors cause the development of a cancer cell. What are breast cancer risk factors? Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with your health-care provider anytime new therapies are started (for example, postmenopausal hormone therapy). The following are risk factors for breast cancer: Age: The chances of breast cancer increase as you get older.

Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk. Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast. Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed. Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went through menopause later (after 55) have a slightly increased risk. Breast tissue: Women with dense breast tissue (as documented by mammogram) have a higher risk of breast cancer. Race: White women have a higher risk of developing breast cancer, but AfricanAmerican women tend to have more aggressive tumors when they do develop breast cancer. Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer. Having no children or the first child after age 30 increases the risk of breast cancer. Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer. Being overweight or obese increases the risk of breast cancer. Use of oral contraceptives in the last 10 years increases the risk of breast cancer. Using combined hormone therapy after menopause increases the risk of breast cancer. Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used. Exercise seems to lower the risk of breast cancer. What are breast cancer symptoms and signs? The most common sign of breast cancer is a new lump or mass in the breast. In addition, the following are possible signs of breast cancer: Nipple discharge or redness Breast or nipple pain Swelling of part of the breast or dimpling You should discuss these or any other findings that concern you with your health-care provider. How is breast cancer diagnosed? Although breast cancer can be diagnosed by the above signs and symptoms, the use of screening mammography has made it possible to detect many of the cancers early before they cause any symptoms. The American Cancer Society has the following recommendations for breast cancer screenings: Women age 40 and older should have a screening mammogram every year and should continue to do so as long as they are in good health. Mammograms are a very good screening tool for breast cancer. As in any test, mammograms have limitations and will miss some cancers. The results of your mammogram, breast exam, and family history should be discussed with your health-care provider.

Women in their 20s and 30s should have a clinical breast exam (CBE) as part of regular health exams by a health-care professional about every three years for women in their 20s and 30s and every year for women 40 years of age and over. CBE are an important tool to detect changes in your breast and also trigger a discussion with your health-care provider about early cancer detection and risk factors. Breast self-exam (BSE) is an option for women starting in their 20s. Women should report any breast changes to their health-care professional. If a woman wishes to do BSE, the technique should be reviewed with her health-care provider. The goal is to feel comfortable with the way the woman's breast feels and looks and therefore detect changes. Women at high risk (greater then 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderate risk (15%-20%) should talk to their doctor about the benefits and limitations of adding MRI screening to their yearly mammogram. How is breast cancer staging determined? Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival. To determine if the cancer has spread, several different imaging techniques can be used. Chest X-ray: It looks for spread of the cancer to the lung. Mammograms: More detailed and additional mammograms provide more images of the breast and may locate other abnormalities. Computerized tomography (CT scan): These specialized X-rays are used to look at different parts of your body to determine if the breast cancer has spread. It could include a CT of the brain, lungs, or any other area of concern. Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones. Low level radioactive material is injected into the bloodstream, and over a few hours, images are taken to determine if there is uptake in certain bone areas, indicating metastasis. Positron emission tomography (PET scan): A radioactive material is injected that is absorbed preferentially by rapidly growing cells (such as cancer cells). The PET scanner then locates these areas in your body. Staging system: This system is used by your health-care team to summarize in a standard way the extent and spread of your cancer. This staging can then be used to determine the treatment most appropriate for your type of cancer. The most widely used system in the U.S. is the American Joint Committee on Cancer TNM system. Besides the information gained from the imaging tests, this system also uses the results from surgical procedures. After surgery, a pathologist looks at the cells from the breast cancer as well as from the lymph nodes. This information gained is incorporated into the staging as it tends to be more accurate than the physical exam and X-ray findings alone. TNM staging: T: describes the size of the tumor. It is followed by a number from 0 to 4. Higher numbers indicate a larger tumor or greater spread: TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ

T1: Tumor is 2 cm or less across T2: Tumor is 2 cm-5 cm T3: Tumor is more than 5 cm T4: Tumor of any size growing into the chest wall or skin. N: describes the spread to lymph node near the breast. It is followed by a number from 0 to 3. NX: Nearby lymph nodes cannot be assessed (for example if they have previously been removed). N0: There has been no spread to nearby lymph nodes. In addition to the numbers, this part of the staging is modified by the designation "i+" if the cancer cells are only seen by immunohistochemistry (a special stain) and "mol+" if the cancer could only be found using PCR (special detection technique to detect cancer at the molecular level). N1: Cancer has spread to one to three axillary lymph nodes (underarm lymph nodes) or tiny amounts of cancer are found in internal mammary lymph nodes (lymph nodes near breastbone). N2: Cancer has spread to four to nine axillary lymph nodes or the cancer has enlarged the internal mammary lymph nodes. N3: Any of the conditions below o Cancer has spread to 10 or more axillary lymph nodes with at least one cancer spread larger than 2 mm o Cancer has spread to lymph nodes under the clavicle with at least area of cancer spread greater than 2 mm M: This letter is followed by a 0 or 1, indicating whether the cancer has spread to other organs. MX: Metastasis can not be assessed. M0: No distant spread is found on imaging procedures or by physical exam. M1: Spread to other organs is present. Once the T, N, and M categories have been determined they are combined into staging groups. There are five major staging groups, stage 0 to stage IV, which are subdivided into A and B, or A and B and C, depending on the underlying cancer and the T, N, and M scale. Cancers with similar stages often require similar treatments Causes Over the course of a lifetime, 1 in 8 women will be diagnosed with breast cancer. Risk factors you cannot change include: Age and gender -- Your risk of developing breast cancer increases as you get older. Most advanced breast cancer cases are found in women over age 50. Women are 100 times more likely to get breast cancer than men. Family history of breast cancer -- You may also have a higher risk for breast cancer if you have a close relative who has had breast, uterine, ovarian, or colon cancer. About 20 - 30% of women with breast cancer have a family history of the disease. Genes -- Some people have genes that make them more likely to develop breast cancer. The most common gene defects are found in the BRCA1 and BRCA2 genes. These genes normally produce proteins that protect you from cancer. If a parent passes you a defective gene, you have an increased risk for breast cancer. Women with one of these defects have up to an 80% chance of getting breast cancer sometime during their life. Menstrual cycle -- Women who got their periods early (before age 12) or went through menopause late (after age 55) have an increased risk for breast cancer.

Other risk factors include: Alcohol use -- Drinking more than 1 - 2 glasses of alcohol a day may increase your risk for breast cancer. Childbirth -- Women who have never had children or who had them only after age 30 have an increased risk for breast cancer. Being pregnant more than once or becoming pregnant at an early age reduces your risk of breast cancer. DES -- Women who took diethylstilbestrol (DES) to prevent miscarriage may have an increased risk of breast cancer after age 40. This drug was given to the women in the 1940s - 1960s. Hormone replacement therapy (HRT) -- You have a higher risk for breast cancer if you have received hormone replacement therapy with estrogen for several years or more. Obesity -- Obesity has been linked to breast cancer, although this link is controversial. The theory is that obese women produce more estrogen, which can fuel the development of breast cancer. Radiation -- If you received radiation therapy as a child or young adult to treat cancer of the chest area, you have a much higher risk for developing breast cancer. The younger you started such radiation and the higher the dose, the higher your risk -- especially if the radiation was given during breast development. Breast implants, using antiperspirants, and wearing underwire bras do not raise your risk for breast cancer. There is no evidence of a direct link between breast cancer and pesticides. The National Cancer Institute provides an online tool to help you figure out your risk of breast cancer. See: www.cancer.gov/bcrisktool Back to TopSymptoms Early breast cancer usually does not cause symptoms. This is why regular breast exams are important. As the cancer grows, symptoms may include: Breast lump or lump in the armpit that is hard, has uneven edges, and usually does not hurt Change in the size, shape, or feel of the breast or nipple -- for example, you may have redness, dimpling, or puckering that looks like the skin of an orange Fluid coming from the nipple -- may be bloody, clear to yellow, green, and look like pus Men can get breast cancer, too. Symptoms include breast lump and breast pain and tenderness. Symptoms of advanced breast cancer may include: Bone pain Breast pain or discomfort Skin ulcers Swelling of one arm (next to the breast with cancer) Weight loss The doctor will ask you about your symptoms and risk factors. Then the doctor will perform a physical exam, which includes both breasts, armpits, and the neck and chest area. Tests used to diagnose and monitor patients with breast cancer may include: Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram Breast ultrasound to show whether the lump is solid or fluid-filled Breast biopsy, using methods such as needle aspiration, ultrasound-guided, stereotactic, or open

CT scan to see if the cancer has spread Mammography to screen for breast cancer or help identify the breast lump PET scan Sentinal lymph node biopsy to see if the cancer has spread If your doctor learns that you do have breast cancer, more tests will be done to see if the cancer has spread. This is called staging. Staging helps guide future treatment and follow-up and gives you some idea of what to expect in the future. Breast cancer stages range from 0 to IV. The higher the staging number, the more advanced the cancer.

Treatment is based on many factors, including: Type and stage of the cancer Whether the cancer is sensitive to certain hormones Whether the cancer overproduces (overexpresses) a gene called HER2/neu In general, cancer treatments may include: Chemotherapy medicines to kill cancer cells Radiation therapy to destroy cancerous tissue Surgery to remove cancerous tissue -- a lumpectomy removes the breast lump; mastectomy removes all or part of the breast and possible nearby structures Hormonal therapy is prescribed to women with ER-positive breast cancer to block certain hormones that fuel cancer growth. An example of hormonal therapy is the drug tamoxifen. This drug blocks the effects of estrogen, which can help breast cancer cells survive and grow. Most women with estrogen-sensitive breast cancer benefit from this drug. Another class of hormonal therapy medicines called aromatase inhibitors, such as exemestane (Aromasin), have been shown to work just as well or even better than tamoxifen in postmenopausal women with breast cancer. Aromatase inhibitors block estrogen from being made. Targeted therapy, also called biologic therapy, is a newer type of cancer treatment. This therapy uses special anticancer drugs that target certain changes in a cell that can lead to cancer. One such drug is trastuzumab (Herceptin). It may be used for women with HER2-positive breast cancer. Cancer treatment may be local or systemic. Local treatments involve only the area of disease. Radiation and surgery are forms of local treatment. Systemic treatments affect the entire body. Chemotherapy is a type of systemic treatment. Most women receive a combination of treatments. For women with stage I, II, or III breast cancer, the main goal is to treat the cancer and prevent it from returning (curing). For women with stage IV cancer, the goal is to improve symptoms and help them live longer. In most cases, stage IV breast cancer cannot be cured. Stage 0 and DCIS -- Lumpectomy plus radiation or mastectomy is the standard treatment. There is some controversy on how best to treat DCIS. Stage I and II -- Lumpectomy plus radiation or mastectomy with some sort of lymph node removal is the standard treatment. Hormone therapy, chemotherapy, and biologic therapy may also be recommended following surgery.

Stage III -- Treatment involves surgery, possibly followed by chemotherapy, hormone therapy, and biologic therapy. Stage IV -- Treatment may involve surgery, radiation, chemotherapy, hormonal therapy, or a combination of these treatments. After treatment, some women will continue to take medications such as tamoxifen for a period of time. All women will continue to have blood tests, mammograms, and other tests after treatment. Women who have had a mastectomy may have reconstructive breast surgery, either at the same time as the mastectomy or later. In 2007 (the most recent year numbers are available) 202,964 women in the United States were diagnosed with breast cancer.* 40,598 women in the United States died from breast cancer.* *Incidence counts cover approximately 99% of the U.S. population. Death counts cover 100% of the U.S. population. Use caution in comparing incidence and death counts. http://www.cdc.gov/cancer/breast/statistics/

Breast cancer is the leading killer of women ages 35 to 54 worldwide. More than a million develop the disease without knowing it, and almost 500,000 women die from it every year. In Asia, the Philippines has the highest incidence rate of breast cancer and is considered to have the ninth highest incidence rate in the world today. These alarming statistics, obtained from reports of the International Agency for Research on Cancer, were cited by the World Health Organization (WHO) in a statement over the weekend. According to the WHO, approximately 70 percent of breast cancers occur in women with none of the known risk factors. Only about 5 percent of breast cancer are inherited. In the 1940s, the risk for breast cancer was 1 in 22. Today, it is 1 in 18. With the prevalence of breast cancer consistently rising for the past 30 years, particularly in developing countries, the organization said, supposed authorities in the field are baffled why. It also cited a study by Cancer Research UK that had found a significant explanation. Using detailed analysis of 47 published studies with nearly 150,000 participants from 30 countries, researchers found that the increase in incidence rate of the disease in Western countries is caused by women having fewer children and breastfeeding for shorter periods of time.

http://archives.manilatimes.net/national/2008/oct/05/yehey/metro/20081005met6.html

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