Source: Cancer Resource Room

What is Breast Cancer?
Cancer that begins in any part of the breast is called Breast Cancer. Cancer is caused by abnormal cells that grow and multiply without control. In breast cancer, the abnormal cells can develop in the glands or lobules that make breast milk; this is called, "lobular carcinoma."

Or the cancer cells can start in the tubes or ducts that carry the milk to the nipple; this is called, "ductal carcinoma."

About Breast Anatomy
Breasts are special organs that develop in women during puberty when female hormones are produced. Men have breast tissue too. But male breast tissue does not change during puberty because men do not have female hormones. There are two types of breast tissue:

1. Lobular tissue, groups of cells that make the breast milk
2. Duct or ductal tissue that drains milk from the glands where it is made, and carries it to the nipple.

The lobules and ducts are arranged in groups that are similar to the sections of an orange. In each section there are many groups of glands (lobules) making milk. The milk made by the glands drains into tiny tubes (ducts) that come together to form bigger ducts. Each group of ducts has a main channel or tube that connects to the nipple. The main channels are used to drain the breast milk from the different sections to the nipple. The sections of lobules and ducts are surrounded by fat for protection, and supported by a stringy tissue called connective tissue that holds it all together. The breasts are held in place by ligaments that attach the breast tissue to the muscles of the chest. Breasts are covered by ordinary skin everywhere except the nipple and the areola around it.

Breast cancer can start in either the lobular or ductal tissue. Both are breast cancers. If the abnormal cells are gland cells, the cancer is called lobular cancer. Ductal cells that become cancerous cause ductal cancer. Because the tissues are different, the cancers they cause are different, too. Ductal and lobular cancers will be explained separately.

Ductal Cancer
The duct cells form the tissue that drains breast milk to the nipple. There are many groups of ducts and they all drain together at the nipple. The cells that make up the ducts can become cancer cells. When cancer cells develop in the duct tissue the cancer is called "ductal carcinoma in situ ." In situ is Latin; it means, ‘in that place and not anywhere else.' This is a very early (or beginning) stage of breast cancer. It is abbreviated DCIS.

Ductal cancer cells can grow through the ducts and into nearby tissues. When breast cancer cells grow beyond the ducts, it is called invasive ductal carcinoma. The cancer cells started in the duct tissue and grew into other tissues such as lymph or blood vessels or into the supporting (or stromal) tissue around the ducts. Invasive ductal cancers are measured by tumor size, which is important when planning each patient's treatment.

Invasive ductal cancer means the cancer cells have invaded the tissue next to the milk ducts. It also means the cells can spread from the original tumor to nearby lymph nodes and/or to other organs (lungs, liver, bones). When breast cancer spreads to other organs, for example the lungs, it is still breast cancer and does not become lung cancer. Cancer spread is called metastasis.

Lobular Carcinoma
The lobular tissue is the milk-producing gland tissue of the breast. It is arranged in clusters or rings of cells. Each cluster is called a gland. The glands produce the breast milk that goes into the ducts. Cancer that starts in the lobular tissue is different from ductal cancer in two ways.

1. Lobular carcinoma in situ (LCIS) is an area of precancerous cells that are unlikely to become invasive cancer. But these abnormal cells in a lobule show that the woman has a high risk of developing invasive breast cancer.
2. Lobular breast cancer is more likely to develop in both breasts than is ductal cancer.

Other Breast Cancers
There are some unusual types of breast cancer that affect women and do not fit into the ductal or lobular categories. These are described briefly below:

• Inflammatory Breast Cancer-this type of breast cancer starts as a rash in the skin of the breast. It is uncommon and aggressive.
• Sarcoma or Paget's disease of the breast-another rare form of breast cancer that does not begin with abnormal cells of breast tissue. It starts in the support tissues of the breast.
• Lymphoid breast cancer-this is a form of lymphoma, a cancer of the lymph tissues.

Screening for Breast Cancer
Screening for cancer means testing for something abnormal before it makes a person sick. In this way cancer can be found earlier. The earlier a cancer is found, the smaller it is likely to be. Smaller, earlier cancers are more likely to be curable. In the case of breast cancer, screening means doing mammograms and self breast exams. A mammogram is a set of breast xrays. The mammogram xrays can show small white spots of calcium or lumps in the breast tissue. These spots can show that there are breast cancer cells in the tissue even when the cancer is too small to feel.

Who should have a mammogram?
Women who are 40 years old or older should have a mammogram every other year till age 50; then every year. This is the general rule. It may change for individual health reasons, or it may change in the future as new technologies are developed. Mammograms may be done at a younger age for women who are more "at risk." At risk means there is something about a woman's health history that makes her more likely to get breast cancer.

Mammograms are good for finding many breast cancers but they are not perfect. Sometimes a mammogram can miss an area of breast cancer that is there, or it can show something that looks like cancer but it is not. The test is accurate enough to be a useful screening method and one that saves many lives by finding tumors when they are small.

The other useful screening test is the breast self-exam. A breast exam finds tumors that are big enough to feel. Even tumors that are big enough to feel can be missed on a mammogram. So breast exams are important to do. Self-exams are done about once a month. A woman knows the way her breasts usually feel and will notice even slight changes in the tissue. Most of the lumps or thickenings women find in breast self-exams are benign (not cancer), but should be checked by a doctor to be sure. The breast exam can be taught to a woman by her doctor or other health care provider. It is not a substitute for a yearly breast exam by a woman's doctor or nurse practitioner, or for a mammogram.
There is no blood test that can detect breast cancer. So the screening tests, mammograms and self-exam are important in finding breast cancer as early as possible.

A new screening test is being used in some medical centers. It is called, "ductal lavage." This test washes (lavage means wash) cells out of the breast ducts. The cells are looked at with a microscope for signs of cancer. This test can find cancers very early, but it may also miss cancers that are really there. Several studies are being done to find out how useful this test is and who should have it.

What are the symptoms of breast cancer?
Most women who have a breast tumor that is large enough to feel do not have any other symptoms. Sometimes breast cancer does not form a lump, but other changes in the breast can occur. These might be:

• Thickening of breast tissue
• Lumps under the arm (enlarged lymph nodes in the armpit)
• Change in the size or shape of the breast
• Rash, ridges or swelling of the breast skin
• Nipple discharge, tenderness, or the nipple being pulled inward

Making the diagnosis of breast cancer
Breast cancer is diagnosed by taking breast tissue suspected of being abnormal and checking the cells for cancer. The abnormal tissue can be found on a mammogram or by feeling a lump or thickening in the breast. But to make the diagnosis of breast cancer, the abnormal cells must be seen with a microscope by a pathologist.

What is a biopsy and how is it done?
A biopsy means getting cells or tissue from a lump or abnormal spot and looking for cancerous cells with a microscope. Cancer cells look different from normal cells to a specially trained pathologist. There are different types of biopsies. Each one is a way to collect some cells or tissue from the breast. Some biopsy methods are:

• Fine Needle Aspiration
• Core Needle Biopsy
• Excisional Biopsy
• Needle Localization Biopsy
• Sentinel Node Biopsy

How is a biopsy done?

• Fine Needle Aspiration: a thin needle is used to draw out cells from an area of abnormal tissue. For comfort, local anesthetic is injected in the skin of the breast. The biopsy is done in a doctor's office or in a radiology room. If the abnormal area in the breast cannot be felt or is difficult to feel, ultrasound can usually locate the right place for the biopsy needle. Ultrasound uses sound waves that travel from a probe on the skin through the breast tissue and back to the probe. The sound wave pattern makes a "picture" of the tissue, so a spot that is different will show in the picture. A biopsy needle is guided to that spot. Once the cells are drawn into the needle, they can be placed on a microscope slide for the pathologist to look at. Fine needle aspiration can identify cancerous cells, but it cannot show whether the cancer is invasive or noninvasive.
• Core Needle Biopsy: this is similar to Fine Needle Aspiration but the needle is thicker, about as thick as a pencil lead. It also takes a core or column of tissue from a breast mass rather than separate cells. The tissue is put on microscope slides and looked at by a pathologist. The pathologist looks for cancerous cells. A core biopsy takes enough tissue to show whether or not a cancer is invasive. This biopsy is done with local anesthetic to numb the skin but it can still be a bit painful. More anesthetic can be added if you let the doctor know you are feeling pain. Also like the Fine Needle Aspiration, the Core Needle Biopsy is done in a doctor's office or in a radiology room. Ultrasound or breast xrays may be needed to put the needle in the correct part of the breast.
• Excisional biopsy: this biopsy removes the whole mass or lump of abnormal tissue. The entire lump is removed and all parts of the tissue are looked at by the pathologist. The advantage of this biopsy is that nearly all the tissue in a lump is looked at under the microscope. A needle biopsy only examines the part of the tissue the needle goes into. The excisional biopsy is a short surgical procedure done in a day surgery center. The doctor uses injections of local anesthetic to numb the skin. A pulling sensation is felt but not pain. If any part of the procedure is painful, tell the doctor so she or he can put in more anesthetic. It takes several days to get the results from an excisional biopsy. Ask your doctor when and where to call for the results.
• Needle Localization: this procedure places a tiny wire strand (hardly bigger than a hair) into the breast tissue that looks abnormal on the breast xrays. It is done by a radiologist who guides the needle using ultrasound or breast xrays to show the abnormal spot in the breast. Once the needle is in the right place, a surgeon can remove the tissue around the tip of the needle. After the tissue is taken out, it is checked by xray again to be sure the correct area was removed. The tissue is then sent to the pathologist who looks for cancerous cells. It takes about a week to test all the tissue.
• Sentinel node biopsy: this biopsy tests the sentinel lymph nodes in the armpit for cancer cells. Breast cancer can spread from the breast to the lymph nodes in the armpit. If cancer cells are found in the nodes, a patient's treatment may be different than if no cancer is found there. A sentinel node biopsy is done by injecting a radioactive or colored fluid near the breast tumor. The fluid will flow away from the breast in the lymph channels to the nearby lymph nodes. The surgeon uses a radioactivity detector to find the test fluid that has collected in the lymph nodes. Since the fluid started at the tumor, it makes sense that cells from the tumor would travel along the same path and collect in the same lymph nodes. So the surgeon removes one or a few lymph nodes that collected the radioactive fluid. The nodes are tested for cancer cells by the pathologist.
  • Lymph channels drain fluid from the breast to the lymph nodes in the armpit. If cancer cells flow with the lymph from a breast tumor to lymph nodes in the armpit, the cells can get caught in the nodes. The sentinel nodes are the first or second nodes that the lymph flows to from the breast. These sentinel nodes are tested for cancer cells. If no cancer cells are in the sentinel nodes, then it is unlikely that there would be any cancer in lymph nodes further along in the armpit. But if there are cancer cells in the sentinel node, then as many lymph nodes as possible need to be removed to look for the spread of cancer.
  • Sentinel node biopsy is most accurate when it is done by a surgeon who performs this test frequently. It is more reliable in younger women. It cannot be done if the woman was operated on or radiated before in that breast or underarm.

What information comes from a biopsy? How is it used to help the patient?
When a biopsy shows that cancer is present, it is called "positive." If no cancer is found, the biopsy is "negative." Here are some ways each biopsy method helps plan the next step in a patient's care.

1. Fine Needle Aspiration
   Positive-next do a Core Needle or Excisional biopsy to determine whether the cancer is ductal or lobular and whether or not it is invasive.
   Negative-try a different biopsy technique if cancer is highly suspected, or plan careful follow-up to re-examine the breast by clinical exam and mammogram.
2. Core Needle Biopsy
   Positive-plan surgery to remove all of the cancer.
   Negative-do an Excisional biopsy if there is any doubt about having sampled the correct tissue. Or plan careful follow-up with clinical exam and mammogram.
3. Excisional Biopsy
   Positive-determine the type (ductal or lobular), the hormone receptors, and check the edges (margins) of the tissue to be sure all the cancer was removed. If there are cancer cells at any margin, then more tissue must be removed until the edges or margins are completely free of cancer cells.
   Negative-plan careful follow-up with clinical exam and mammogram.

Staging

What is staging? What does the stage of disease mean to me?
The stage of breast cancer tells how much cancer there is and whether or not it has spread to lymph nodes or other parts of the body. A lower stage of cancer usually has a better chance to be treated without the cancer coming back or spreading. Treatment choices depend on the stage of a patient's disease.

How is the stage determined?

The stage of a patient's breast cancer is based on four facts:

1. whether the cancer cells are inside the breast ducts or lobules (noninvasive), or have invaded the walls of the ducts, lobules, blood vessels or lymph channels in the breast tissue (invasive).
2. how big the breast tumor is. This measurement is made by the pathologist after the tumor is completely removed.
3. whether or not the cancer cells have spread to the lymph nodes under the arm on the same side as the breast cancer.
4. whether the cancer cells have spread to other parts of the body (other lymph nodes, brain, liver, bones, lungs).

What are the stages of breast cancer?

• Stage 0-cancer cells are contained by the duct or lobule and do not invade any tissue outside these parts of the breast. This stage is also called, "in situ" cancer. For ductal cancer it would be DCIS, and for lobular cancer it would be LCIS.
• Stage I-cancer cells invade through the wall of the duct or lobule, the tumor is 2 cm or smaller, and no lymph nodes have cancer cells in them.
• Stage II-the cancer is invasive, the tumor is between 2 and 5 cm with cancer spread to the underarm lymph nodes, or the tumor is bigger than 5 cm but no cancer is in the lymph nodes.
• Stage III-cancer is invasive, the tumor is 5 cm or bigger, and there are cancer cells in the underarm lymph nodes.
• Stage IV-cancer is invasive, the tumor can be any size, and the cancer has spread to other parts of the body (lungs, liver, bones, brain, other lymph nodes). This stage is also called Metastatic because the cancer has spread (or metastasized) beyond the breast and underarm lymph nodes.

What tests are done to find metastatic disease?

• Blood tests
  • Tumor markers-some chemicals in the blood called, "markers" will go up (be elevated) in the blood of a patient with metastatic breast cancer. Two examples of markers for breast cancer are CEA and CA 15-3. These chemicals are not specific for breast cancer but many patients with metastatic disease do have higher than normal levels of these markers in their blood.
  • Liver enzymes-if breast cancer spreads to the liver, some of the normal liver cells are destroyed. The damaged liver cells will release their special chemicals into the blood. These chemicals, called enzymes, are easy to measure in a regular blood test. If the liver enzymes are too high, a CT scan of the liver can be done to see if there are abnormal spots of tissue in the liver that might be metastatic cancer.
  • Blood count-low blood count or anemia can occur when a patient has metastatic cancer.
  • Bone enzyme-when breast cancer spreads to the bones, it destroys the area of bone it is growing in. As the bone reacts to the cancer cells, an enzyme called alkaline phosphatase is released into the blood. An abnormal amount of alkaline phosphatase in a blood sample means that a bone scan and some regular xrays are needed to look for metastatic disease in the bones.
• Xrays
  • Chest xray-regular chest xrays can show spots in the lungs that might be metastatic breast cancer. If the chest xray looks abnormal, then a chest CT scan will be done to get a closer, 3-dimensional look at the lungs to see if the spots look like cancer.
  • Bone scan-this test scans the whole skeleton for spots in the bones that might be abnormal. If a spot shows on the scan, regular xrays and CT or MRI scans will be done to see whether or not it looks like metastatic cancer.
  • Abdominal CT scan-if a blood test shows that the liver enzymes are higher than normal, a CT scan of the abdomen (or belly) can be used to look for spots in the liver that could be caused by metastatic cancer.
  • Brain CT or MRI scan-because breast cancer can spread to the brain, a patient who has an abnormal neurological (brain function) exam should have a brain scan done. Both CT and MRI scans can show areas of abnormal tissue in the brain, but MRI is more commonly used.

What is most important in looking for metastatic disease is a patient's own report to her doctor about how she is feeling, any new symptoms or pain she has, and whether she thinks anything has changed about her health.

Support & Education Programs

We know that being diagnosed with cancer can be stressful for you and your family. We offer a variety of cancer support services to help patients and families gain the support and information they will need to meet the challenges ahead.

To find the Breast Support Group, education workshops, and wellness services offered this month, please view the HOPES calendar.

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