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Monday, April 3, 2017
Breast cancer
Breast cancer is cancer that starts in the breast tissue.
The breasts
Breasts are made of fat, connective tissue, and gland tissue divided into lobes.
A network of ducts spreads from the lobes towards the nipple.
Breast size and density
One breast is usually smaller than the other. Your breasts may feel different at different times in the month. It is common for breasts to feel lumpy just before your period.
Younger women have more glandular tissue than fat in their breasts, making them dense.
After the menopause the glandular tissue is gradually replaced by fat, which is less dense.
Where it starts
Breast cancer most commonly starts in the cells that line the ducts of the breast.
9 out of 10 of these cancers have no special features when the cells are looked at under the microscope. They are called invasive breast cancer (NST). NST stands for No Special Type.
Around 1 in 10 breast cancers (10%) are invasive lobular carcinoma. This means that the cancer started in the cells that line the lobules of the breast.
There are other rarer types of breast cancer.
Invasive breast cancer
Invasive breast cancer (no special type) is the most common type of breast cancer. Find out about it and how it is treated.
What invasive breast cancer (NST) is
Invasive breast cancer means that the cancer cells have grown through the lining of the ducts into the surrounding breast tissue. NST stands for No Special Type.
Special type means that when the doctor looks at the cancer cells under a microscope, the cells have particular features. Breast cancers that are classed as special type include lobular breast cancer and some rare types of breast cancer.
Most invasive breast cancers have no special features and so are classed as No Special Type. NST is also sometimes called NOS (not otherwise specified). It used to be called ductal carcinoma. Remember that if your doctor has told you that you have ductal carcinoma in situ (DCIS), you don't have invasive breast cancer.
Go to information about DCIS
Symptoms of invasive breast cancer
Make an appointment to see your doctor if you notice anything different or unusual about the look and feel of your breasts.
The possible symptoms of breast cancer include:
a lump or thickening in an area of the breast
a change in the size, shape or feel of the breast
dimpling of the skin
a change in the shape of your nipple, particularly if it turns in, sinks into the breast, or has an irregular shape
a blood stained discharge from the nipple
a rash on a nipple or surrounding area
a swelling or lump in the armpit
Diagnosing invasive breast cancer
You go to a specialist breast clinic. At the breast clinic the doctor or specialist nurse takes your medical history and examines your breasts. They also feel for any swollen (enlarged) lymph nodes under your arms and at the base of your neck.
You have some of the following tests:
a mammogram (an x-ray of the breasts)
an ultrasound (if you are under 35 you are more likely to have an ultrasound scan instead of a mammogram)
a biopsy – a small sample of cells or tissue is taken from your breast and looked at under a microscope
Read about tests for breast cancer
Treatment
To decide on the most appropriate treatment, doctors generally take into account:
the type of breast cancer
the size of the cancer and whether it has spread (the stage)
how abnormal the cells look under the microscope (the grade)
whether the cancer cells have receptors for particular hormones
whether the cells have receptors for biological therapies
For invasive breast cancer you might have:
surgery
radiotherapy
chemotherapy
hormone therapy
a combination of these treatments
Find out more about treatment decisions for breast cancer
Follow up
You will have regular check ups once you finish your treatment. Your doctor will examine you and ask about your general health.
This is your chance to ask questions and to tell your doctor if anything is worrying you.
It’s important to remember that you can still contact someone if you are concerned about a symptom and it is a while before your next appointment. Speak to your GP, or contact your consultant or specialist nurse.
How often you have check ups depends on your individual situation.
Guidelines say that everyone who has had treatment for early breast cancer should have a copy of a written care plan.
The care plan has information about tests, and signs and symptoms to look out for. It will also include contact details for specialist staff, such as your breast care nurse.
After your treatment you have regular check ups for at least 5 years. This usually includes yearly mammograms for at least 5 years if you are already part of the national screening programme. Or yearly mammograms until you are able to go for breast screening, at which point they change to every 3 years.
Read more about breast cancer follow up
Trials and research
Invasive breast cancer is the most common type of breast cancer. So most breast cancer research will be looking at this type.
Research includes:
the causes and prevention of breast cancer
screening and diagnosis
new treatments
ways to improve existing treatments
ways to cope with cancer and its treatment
Look for breast cancer trials
Nearby lymph nodes
There is a network of lymph glands (also called lymph nodes) close to the breast. They are part of the lymphatic system that runs throughout the body. The lymph nodes and lymph vessles have a yellow fluid called lymph that flows through your lymphatic system. It collects waste products and drains into your veins for the waste to be removed. Cancer cells released from the breast tissue can be trapped in the nearby lymph nodes. Lymph nodes around the breastThe lymph glands in the armpit (axilla) are called the axillary lymph glands. There is also a chain of lymph nodes that runs up the centre of your chest, close to your breast bone. This is called the internal mammary chain.
Who gets it
Around 55,200 people are diagnosed with breast cancer in the UK each year. That is around 150 people a day.
It is more common in women than men. Around 54,800 women are diagnosed each year and around 390 men.
1 in 8 women in the UK develop breast cancer during their lifetime. 1 in 870 men develop it. Most of the women who get breast cancer have had their menopause, but about 2 out of every 10 (20%) are under 50 years old.
Breast cancer risk can be affected by age, family history and lifestyle factors such as obesity and smoking.
Read about risk factors for breast cancer
How common it is
Breast cancer is the most common cancer in the UK.
15% of all newly diagnosed cancers in the UK are breast cancer.
Symptoms
Find out about the symptoms of breast cancer and when to see your doctor.
These symptoms are more often caused by other medical conditions. But if you have any of them it is important to see your doctor.
Breast lump
A new lump or thickening in your breast or armpit could be a sign of cancer. Many women have breast lumps and 9 out of 10 (90%) of these are not cancer. They are called benign lumps.
It’s important to get any breast lump checked out by your doctor.
Change in size, shape or feel of a breast
Your breast might look bigger or have a different shape than usual. It might feel different. Many healthy women find that their breasts feel lumpy and tender before their period.
Get to know the size, shape and feel of your breasts. See your doctor if you notice any changes or anything that is unusual for you.
Breast pain
Breast pain is very common and it’s not normally due to cancer. You might get pain in one or both breasts for a while, which goes after a time. There might be no obvious reason for this pain, even if you have a lot of tests.
See your doctor if you have breast pain.
Skin changes
Skin changes include puckering, dimpling, a rash, or redness of the skin.
The skin on your breast might look like orange peel. Or the skin might feel a different texture than usual. This can be caused by other things than cancer but get anything that is not normal for you checked out by your doctor.
Change in the position of your nipple
One nipple might turn in or sink into the breast. It might look or feel different to usual.
Fluid leaking from your nipple
Fluid leaking from a nipple in a woman who isn't pregnant or breast feeding can be a sign of cancer. But it can also be caused by other medical conditions.
See your doctor if you have leakage from a nipple and you aren't pregnant or breast feeding.
Inflammatory breast cancer symptoms
A rare type of breast cancer called inflammatory breast cancer can have different symptoms to other types.
Your whole breast might look red and inflamed and feel sore. The breast might feel hard and the skin might look like orange peel.
See your doctor if you have any of these symptoms.
Paget’s disease of the breast
This is a rare skin condition that is sometimes a sign of an underlying breast cancer. The symptoms are a red, scaly rash on the breast. It can be itchy and looks a bit like eczema. It is sometimes mistaken for eczema at first.
See your doctor if you have any changes in the skin of your breast.
When to see your doctor?
You should see your doctor if you have:
a change in the size, shape or feel of a breast
a new lump or thickening in a breast or armpit
skin changes such as puckering, dimpling, a rash or redness of the skin
fluid leaking from a nipple and you aren't pregnant or breastfeeding
changes in the position of a nipple
breast pain
Your symptoms are unlikely to be cancer but it is important to get them checked by a doctor.
Read about how to find breast cancer early
About breast cancer staging and grades
Find out about the different staging systems for breast cancer and about breast cancer grading.
Staging means how big the cancer is and whether it has spread.
Grading means how abnormal the cancer cells look under the microscope.
Doctors use the stage and grade of a cancer to help them decide on which treatment you need.
There are different systems used in the UK to stage breast cancer. The most common one is the TNM system. Another is the number staging system.
Your doctor might also talk about early, locally advanced or secondary breast cancer.
TNM stages
The TNM staging system stands for Tumour, Node, Metastasis.
T describes the size of the tumour
N describes whether there are any cancer cells in the lymph nodes
M describes whether the cancer has spread to a different part of the body
TNM staging
Number stages
The number staging system divides breast cancers into 4 stages, from 1 to 4.
Number staging
Early, locally advanced and secondary breast cancer
Early breast cancer means the cancer hasn't spread beyond the breast or the lymph nodes in the armpit on the same side of the body. So, the cancer hasn't spread to any other part of the body. Local recurrence means cancer that has come back in the area of the breast after treatment.
Locally advanced breast cancer means the cancer hasn't spread to another part of the body but might be:
bigger than 5 cm across
growing into the skin or muscle of the chest
present in the lymph nodes in the armpit, and the nodes are stuck to each other or to other structures
Secondary breast cancer is also called metastatic breast cancer or stage 4 breast cancer. It means that the cancer has spread to other parts of the body, such as the liver or bones.
Grading
Grade means what the cancer cells look like under the microscope.
Breast cancers can be:
low grade – grade 1 (slow growing)
intermediate grade – grade 2
high grade – grade 3 (faster growing)
Low grade cancers tend to grow more slowly than high grade. High grade cancers are more likely to come back after they have first been treated. But the grade can only give a guide to how any individual cancer will behave and individual cancers may behave differently.
Find out more about stages, types and grades
TNM staging
Find out about tumour, node and metastasis (TNM) staging for breast cancer.
Your scans and tests give some information about the stage of your cancer. But your doctor might not be able to tell you the exact stage until you have surgery.
The TNM staging system is the most common way that doctors stage breast cancer. TNM stands for Tumour, Node, Metastasis. Doctors may also use a number staging system.
Find out about the number stages
The TNM system
Here is a slightly simplified description of the TNM staging system for breast cancer.
Tumour (T)
Tumour describes the size of the tumour (area of cancer). This is a simplified description of the T stage. TX means that the tumour size can't be assessed. Tis means ductal carcinoma in situ (DCIS).
Find out about ductal carcinoma in situ
T1 means that the tumour is 2 centimetres (cm) across or less. T1 is further divided into 4 groups:
T1mi means the tumour is 0.1cm across or less
T1a means the tumour is more than 0.1 cm but not more than 0.5 cm
T1b means the tumour is more than 0.5 cm but not more than 1 cm
T1c means the tumour is more than 1 cm but not more than 2 cm
T2means that the tumour is more than 2 centimetres but no more than 5 centimetres across. T3 means the tumour is bigger than 5 centimetres across. T4 is divided into 4 groups:
T4a means the tumour has spread into the chest wall (the structures surrounding and protecting the lungs)
T4b means the tumour has spread into the skin and the breast might be swollen
T4c means the tumour has spread to both the skin and the chest wall
T4d means inflammatory carcinoma – this is a cancer in which the overlying skin is red, swollen and painful
Read about inflammatory breast cancer
Node (N)
Node (N) describes whether your cancer has spread to the lymph nodes. NX means that the lymph nodes can't be assessed (for example, if they were previously removed). N0 means there are no cancer cells in any nearby nodes. Isolated tumour cells (ITCs) are small clusters of cancer cells less than 0.2 mm across, or a single tumour cell, or a cluster of fewer than 200 cells in one area of a lymph node. Lymph nodes containing only isolated tumour cells are not counted as positive lymph nodes.
N1
N1 means cancer cells are in the lymph nodes in the armpit but the nodes are not stuck to surrounding tissues. pN1mi means one or more lymph nodes contain areas of cancer cells called micrometastases that are larger than 0.2mm. Or the nodes contain more than 200 cancer cells but are less than 2mm. pN1a means that cancer cells have spread (metastasised) into 1 to 3 lymph nodes and at least one is larger than 2mm. pN1b means there are cancer cells in the lymph nodes behind the breast bone (internal mammary nodes) found with a sentinel node biopsy but the areas are too small to feel. pN1c means there are cancer cells in 1 to 3 lymph nodes in the armpit and in the lymph nodes behind the breast bone, but they are too small to feel.
N2
N2 is divided into 2 groups: N2a means there are cancer cells in the lymph nodes in the armpit, which are stuck to each other and to other structures. N2b means there are cancer cells in the lymph nodes behind the breast bone (the internal mammary nodes), which have been seen on a scan or felt by the doctor. There is no evidence of cancer in lymph nodes in the armpit.
N3
N3 is divided into 3 groups: N3a means there are cancer cells in lymph nodes below the collarbone. N3b means there are cancer cells in lymph nodes in the armpit and behind the breast bone. N3c means there are cancer cells in lymph nodes above the collarbone.
Metastasis (M)
Metastasis (M) describes whether the cancer has spread to a different part of the body. M0 means that there is no sign that the cancer has spread. cMo(i+) means there is no sign of the cancer on physical examination, scans or x-rays. But cancer cells are present in blood, bone marrow, or lymph nodes far away from the breast cancer – the cells are found by laboratory tests M1 means the cancer has spread to another part of the body.
Treatment
The stage of your cancer helps your doctor to decide which treatment you need. Treatment also depends on:
your type of cancer (the type of cells the cancer started in)
where the cancer is
other health conditions that you have
The stage of the cancer and these other factors can also give an idea of your outlook (prognosis). Other factors that may influence treatment are:
the grade of your cancer cells
whether you have had your menopause
whether your cancer cells have receptors for particular cancer drugs
Your doctor will take many different factors into account when deciding which treatment is best for you. Treatment may include:
surgery
radiotherapy
chemotherapy
hormone therapy
biological treatments
a combination of these treatments
Find out about treatment
Breast cancer
Stages, types and grades
Number stages of breast cancer
Stage 2
Find out what stage 2 breast cancer means and about treatment options.
Stage 2 breast cancer means that the cancer is either in the breast or in the nearby lymph nodes or both.
It is an early stage breast cancer.
Stage 2 breast cancer has two groups.
Stage 2A
Stage 2A means one of the following
there is no tumour or a tumour 2 centimetres (cm) or smaller in the breast and cancer cells are found in 1 to 3 lymph nodes in the armpit or in the lymph nodes near the breastbone
the tumour is larger than 2cm but not larger than 5cm and there is no cancer in the lymph nodes
Stage 2B
Stage 2B means one of the following
the tumour is larger than 2cm but not larger than 5cm and small areas of cancer cells are in the lymph nodes
the tumour is larger than 2cm but not larger than 5cm and the cancer has spread to 1 to 3 lymph nodes in the armpit or to the lymph nodes near the breastbone
the tumour is larger than 5cm and has not spread to the lymph nodes
TNM stages
The TNM staging system stands for Tumour, Node, Metastasis.
T describes the size of the tumour
N describes whether there are any cancer cells in the lymph nodes
M describes whether the cancer has spread to a different part of the body
In the TNM staging system stage 2A breast cancer is the same as:
T0 N1 M0
T1 N1 M0
T2 N0 M0
Stage 2B is the same as:
T2 N1 M0
T3 N0 M0
Read more about the TNM staging system
Treatment
The usual treatment is surgery to remove the cancer. Your doctor will also check the lymph nodes close to the breast to see if they contain cancer cells. You either have a test called a sentinel lymph node biopsy (SLNB) or surgery to remove some of the lymph nodes under the arm.
Your surgeon might remove just the cancerous area with a border of normal breast tissue (a wide local excision or lumpectomy). After this you usually have several weeks of radiotherapy to the rest of the breast.
Or you might have the whole breast removed (mastectomy) and then a new breast made (breast reconstruction). You don't usually need radiotherapy to the breast after this kind of surgery. But you might have radiotherapy to the lymph nodes under your arm if they contain cancer cells. Or you might have surgery to remove the lymph nodes.
Your surgeon might suggest that you have breast reconstruction at the same time as surgery to remove the cancer. But if you need to have radiotherapy after the surgery your surgeon is likely to suggest that you wait to have the reconstruction until after the radiotherapy has finished.
Find out about surgery and radiotherapy
You usually have other treatments too.
You might have chemotherapy or hormone therapy before surgery. These treatments can shrink a cancer down and make it possible to have a lumpectomy instead of mastectomy for some women.
If your cancer cells have receptors for hormone therapy drugs you are likely to have hormone therapy for at least 5 years.
Hormone therapy
You might have chemotherapy after your surgery if the cancer was large, high grade, had spread into several lymph nodes or didn't have hormone receptors.
Chemotherapy
You have a biological therapy called trastuzumab (Herceptin) as well as chemotherapy if your cancer cells have particular proteins called HER2 receptors. You usually have this treatment for a year.
Biological therapy
Stage 3
Find out what stage 3 breast cancer is and about treatment options. Stage 3 means that the cancer has spread from the breast to lymph nodes close to the breast or to the skin of the breast or to the chest wall. It is also called locally advanced breast cancer. Stage 3 breast cancer is divided into 3 groups.
Stage 3A
Stage 3A means one of the following:
no tumour is seen in the breast or the tumour may be any size and cancer is found in 4 to 9 lymph glands under the arm or in the lymph glands near the breastbone
the tumour is larger than 5cm and small clusters of breast cancer cells are in the lymph nodes
the tumour is more than 5cm and has spread into up to 3 lymph nodes in the armpit or to the lymph nodes near the breastbone
Stage 3B
Stage 3B means the tumour has spread to the skin of the breast or the chest wall (the structures surrounding and protecting the lungs, such as the ribs, muscles, skin or connective tissues). It has made the skin break down (an ulcer) or caused swelling.
the cancer may have spread to up to 9 lymph nodes in the armpit or to the lymph nodes near the breastbone.
Cancer that has spread to the skin of the breast may also be inflammatory breast cancer.
Find out more about inflammatory breast cancer
Stage 3C
Stage 3C means the tumour can be any size, or there may be no tumour, but there is cancer in the skin of the breast causing swelling or an ulcer and it has spread to the chest wall. It has also spread to:
10 or more lymph nodes in the armpit
lymph nodes above or below the collar bone
lymph nodes in the armpit and near the breastbone
For treatment, doctors divide stage 3C breast cancer into cancers that can be operated on (operable breast cancers) and those that can't (inoperable cancer).
TNM stages
The TNM staging system stands for Tumour, Node, Metastasis.
T describes the size of the tumour
N describes whether there are any cancer cells in the lymph nodes
M describes whether the cancer has spread to a different part of the body
In the TNM staging system stage 3A breast cancer is the same as:
T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage 3B is the same as:
T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage 3C is the same as:
Any T N3 M0
Read about the TNM staging system
Treatment
You might have drug treatments such as chemotherapy or biological therapy as a first treatment. This is followed by surgery and then more drug treatments.
Or you might have surgery as a first treatment followed by chemotherapy or other drug treatments.
Drug treatment before surgery
You might have chemotherapy as a first treatment to shrink the cancer down.
Read about chemotherapy
If your cancer cells have particular proteins called HER2 receptors you might also have a biological therapy drug called trastuzumab (Herceptin).
Biological therapy
These treatments might shrink the tumor enough to allow your surgeon to remove just the area of cancer. If the cancer doesn’t shrink enough, you need to have the whole breast removed (a mastectomy). Your surgeon will also remove lymph nodes under the arm to check for cancer cells.
Read about surgery
You usually have radiotherapy to the breast after surgery.
Find out about radiotherapy
If you have a new breast shape made (breast reconstruction) you usually have it after the radiotherapy has finished.
Breast reconstruction
You might also have hormone therapy if your cancer cells have hormone receptors. Or you might have more chemotherapy.
Find out about hormone therapy
Surgery as a first treatment
You usually have the whole breast removed (a mastectomy). Your surgeon will also remove some of the lymph nodes under the arm to check them for cancer cells.
Read about mastectomy
After the surgery you have radiotherapy to the breast.
Radiotherapy
You might then have surgery to create a new breast shape (breast reconstruction).
Find out about breast reconstruction
You might have treatment with chemotherapy for a few months.
Chemotherapy
If your cancer cells have receptors for a protein called HER2 you might have a biological therapy drug called trastuzumab (Herceptin) as well as chemotherapy. You have this for a year.
Biological therapy
If your cancer cells have hormone receptors you might then have hormone therapy for at least 5 years.
Hormone therapy
Inflammatory breast cancer
Some stage 3 cancers are a type called inflammatory breast cancers. The treatment is slightly different than for other stage 3 breast cancers.
Read about inflammatory breast cancer
Stage 4
Find out what stage 4 breast cancer means and about treatment options.
Stage 4 breast cancer means that the cancer has spread to other parts of the body.
It is also called advanced cancer, secondary breast cancer or metastatic breast cancer.
In stage 4 breast cancer:
the tumour can be any size
the lymph nodes may or may not contain cancer cells
the cancer has spread (metastasised) to other parts of the body such as the bones, lungs, liver or brain
TNM stages
The TNM staging system stands for Tumour, Node, Metastasis.
T describes the size of the tumour
N describes whether there are any cancer cells in the lymph nodes
M describes whether the cancer has spread to a different part of the body
In the TNM staging system stage 4 breast cancer is the same as:
Any T Any N M1
Read about the TNM staging system
Treatment
Your specialist will take a number of different factors into account when deciding which treatment is best for you, including:
which part of your body the cancer has spread to
the treatment you have already had
your general health
whether you have had your menopause
whether the cancer is growing slowly or more quickly
whether the cancer cells have receptors for particular types of drug treatment
Secondary breast cancer may respond to several types of treatment. Doctors try to start with treatment that has as few side effects as possible.
Remember that treatment can often keep secondary breast cancer under control for many months or years.
Types of treatment
Hormone therapy is a common treatment for secondary breast cancer. It can often shrink and control the cancer wherever it is in the body. It works well if the cancer cells have particular proteins called hormone receptors.
If one hormone therapy stops working so well, another might then help.
Find out about hormone therapy
Your specialist might suggest chemotherapy if your cancer doesn't have hormone receptors or has spread to the liver or lungs.
Chemotherapy for advanced cancer
You might have treatment with a biological therapy such as the monoclonal antibody trastuzumab (Herceptin). Herceptin targets and blocks a protein that stimulates breast cancer cells to grow and multiply. It only works if your breast cancer cells make too much of a protein called HER2.
Biological therapy for advanced cancer
You might have radiotherapy if the cancer has spread to:
the bones
the brain
the skin near the breast or on the mastectomy scar
Radiotherapy for advanced cancer
Your doctor or nurse can prescribe medicines to control symptoms that the cancer causes. The symptoms will depend on where the cancer has spread to but may include a cough, constipation, sickness, or high blood calcium levels for example.
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