Breast Cancer Symptoms - What You Need to Know (part 1)

Part 1 - Part 2
By the National Cancer Institute

Breast cancer is the most common type of cancer among women in this country (other than skin cancer). The number of new cases of breast cancer in women was estimated to be about 212,600 in 2003.

The Breasts

The breasts are glands that can make milk. Each breast sits on chest muscles that cover the ribs.

Each breast is divided into 15 to 20 sections called lobes. Lobes contain many smaller lobules. Lobules contain groups of tiny glands that can produce milk. Milk flows from the lobules through thin tubes called ducts to the nipple. The nipple is in the center of a dark area of skin called the areola. Fat fills the spaces between the lobules and ducts.

The breasts also contain lymph vessels, which carry a clear fluid called lymph. The lymph vessels lead to small, round organs called lymph nodes. Groups of lymph nodes are found near the breast in the axilla (underarm), above the collarbone, in the chest behind the breastbone, and in many other parts of the body. The lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the lymphatic system.

Understanding Breast Cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Not all tumors are cancer. Tumors can be benign or malignant:

• Benign tumors are not cancer:
  • Benign tumors are rarely life-threatening.
  • Usually, benign tumors can be removed, and they seldom grow back.
  • Cells from benign tumors do not spread to tissues around them or to other parts of the body.
• Malignant tumors are cancer:
  • Malignant tumors generally are more serious than benign tumors. They may be life-threatening.
  • Malignant tumors often can be removed, but they can grow back.
  • Cells from malignant tumors can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells spread from the original cancer (primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis.

When breast cancer cells enter the lymphatic system, they may be found in lymph nodes near the breast.

The cancer cells also may travel to other organs through the lymphatic system or bloodstream. When cancer spreads (metastasizes), the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if breast cancer spreads to the bone, the cancer cells in the bone are breast cancer cells. The disease is metastatic breast cancer, not bone cancer. It is treated as breast cancer, not as bone cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Breast Cancer - Who's at Risk?

No one knows the exact causes of breast cancer. Doctors can seldom explain why one woman gets breast cancer and another does not. Doctors do know that bumping, bruising, or touching the breast does not cause breast cancer. And breast cancer is not contagious. No one can "catch" this disease from another person.

However, research has shown that women with certain risk factors are more likely than others to develop breast cancer. A risk factor is anything that increases a person's chance of developing a disease. Studies have found the following risk factors for breast cancer:

• Age: The chance of getting breast cancer goes up as a woman gets older. A woman over age 60 is at greatest risk. This disease is very uncommon before menopause.
• Personal history of breast cancer: A woman who has had breast cancer in one breast has an increased risk of getting this disease in her other breast.
• Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer, especially at a young age (before age 40). Having other relatives with breast cancer on either her mother's or her father's side of the family may also increase a woman's risk.
• Certain breast changes: Some women have cells in the breast that look abnormal under a microscope. Having certain types of abnormal cells (atypical hyperplasia or lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.
• Genetic alterations: Changes in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, genetic testing can sometimes show the presence of specific genetic changes. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes. The Cancer Information Service can provide printed material about genetic testing.
• Reproductive and menstrual history:
  • The older a woman is when she has her first child, the greater her chance of breast cancer.
  • Women who began menstruation (had their first menstrual period) at an early age (before age 12), went through menopause late (after age 55), or never had children also are at an increased risk.
  • Women who take menopausal hormone therapy (either estrogen alone or estrogen plus progestin) for 5 or more years after menopause also appear to have an increased chance of developing breast cancer.
  • Much research has been done to learn whether having an abortion or a miscarriage affects a woman's chance of developing breast cancer later on. Large, well-designed studies have consistently shown no link between abortion or miscarriage and the development of breast cancer.
• Race: Breast cancer occurs more often in white women than Latina, Asian, or African American women.
• Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma. Studies show that the younger a woman was when she received radiation treatment, the higher her risk of breast cancer later in life.
• Breast density: Older women who have mostly dense (not fatty) tissue on a mammogram (x-ray of the breast) are at increased risk of breast cancer.
• Taking DES (diethylstilbestrol): DES is a synthetic form of estrogen that was given to some pregnant women in the United States between about 1940 and 1971. (DES is no longer given to pregnant women.) Women who took DES during pregnancy have a slightly increased risk of breast cancer. This does not yet appear to be the case for their daughters who were exposed to DES before birth. However, as these daughters grow older, more studies of their breast cancer risk are needed.
• Being obese after menopause: After menopause, women who are obese have an increased risk of developing breast cancer. Being obese means that the woman has an abnormally high proportion of body fat. Because the body makes some of its estrogen (a hormone) in fatty tissue, obese women are more likely than thin women to have higher levels of estrogen in their bodies. High levels of estrogen may be the reason that obese women have an increased risk of breast cancer. Also, some studies show that gaining weight after menopause increases the risk of breast cancer.
• Physical inactivity: Women who are physically inactive throughout life appear to have an increased risk of breast cancer. Being physically active may help to reduce risk by preventing weight gain and obesity.
• Alcoholic beverages: Some studies suggest that the more alcoholic beverages a woman drinks, the greater her risk of breast cancer.

Other possible risk factors are under study.

Many risk factors can be avoided. Others, such as family history, cannot be avoided. It is helpful to be aware of risk factors. But it is also important to keep in mind that most women who have these risk factors do not get breast cancer.

Also, most women who develop breast cancer have no history of the disease in their family. In fact, except for growing older, most women with breast cancer have no strong risk factors.

Still, a woman who thinks she may be at risk of breast cancer should discuss this concern with her health care provider. The health care provider may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

The NCI's Breast Cancer Risk Assessment Tool is at http://bcra.nci.nih.gov/brc/ on the Internet. This tool allows a health care provider to estimate a woman's risk of developing invasive cancer of the breast.

Breast Cancer Screening

A woman should talk with her health care provider about her personal risk of getting breast cancer. She should ask questions about when to start and how often to be checked for the disease. These decisions, like many other medical decisions, should fit each woman's needs.

Screening for cancer before there are symptoms can be important. It can help doctors find and treat cancer early. Treatment is more likely to be effective when cancer is found early.

The health care provider may suggest screening tests to check for breast cancer before any symptoms develop:

• Screening mammogram
• Clinical breast exam
• Breast self-exam

Screening Mammogram

To find breast cancer early, the NCI recommends that:

• Women in their 40s and older should have mammograms (pictures of the breast made with x-rays) every one to two years.
• Women who are at higher than average risk of breast cancer should talk with their health care providers about whether to have mammograms before age 40 and how often to have them.

Screening mammograms can often show a breast lump before it can be felt. They also can show a cluster of very tiny specks of calcium. These specks are called microcalcifications. Lumps or specks can be signs of cancer.

If the doctor sees an abnormal area on the mammogram, the woman may need more pictures taken. Also, the woman may need to have a biopsy. A biopsy is the only way to tell for sure if cancer is present.

Mammograms are the best tool doctors have to find breast cancer early. However, it is good for a woman to keep in mind that:

• A mammogram may miss some cancers that are present. (This is called a "false negative.")
• A mammogram may show things that turn out not to be cancer. (This is called a "false positive.")
• Some fast-growing tumors may already have spread to other parts of the body before a mammogram detects them.

Mammograms (as well as dental x-rays, and other routine x-rays) use very small doses of radiation. Although the benefits nearly always outweigh the risks, repeated exposure to x-rays could be harmful. It is a good idea for a woman to talk with her health care providers about the need for each x-ray and to ask about the use of shields during the x-ray to protect other parts of the body.

Clinical Breast Exam

During a clinical breast exam, the health care provider feels the breasts while the woman is standing or sitting up and lying down. The woman may be asked to raise her arms over her head, let them hang by her sides, or press her hands against her hips.

The health care provider looks for differences between the breasts, including unusual differences in size or shape. The skin of each breast is checked for a rash, dimpling, or other abnormal signs. The nipples may be squeezed to see if fluid is present.

Using the pads of the fingers to feel for lumps, the health care provider checks the entire breast, the underarm, and the collarbone area, first on one side, then on the other. A lump is generally the size of a pea before anyone can feel it. The lymph nodes near the breast may be checked to see if they are swollen.

A thorough clinical breast exam may take 10 minutes.

Breast Cancer Self-Exam

Some women perform monthly breast self-exams to check for any changes in their breasts. When a woman does this exam, it is important for her to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period.

Women who notice anything unusual during a breast self-exam or at any other time should contact their health care provider.

Also, it is important to remember that breast self-exams cannot replace regular screening mammograms and clinical breast exams. Although breast self-exams lead to more breast biopsies, studies so far have not shown that breast self-exams reduce the number of deaths from breast cancer.

Breast Cancer Symptoms

Breast cancer can cause changes that women should watch for these symptoms:

• A change in how the breast or nipple feels
  • A lump or thickening in or near the breast or in the underarm area
  • Nipple tenderness
• A change in how the breast or nipple looks
  • A change in the size or shape of the breast
  • The nipple is turned inward into the breast
  • The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
• Nipple discharge (fluid)

Although early breast cancer usually does not cause pain, a woman should see her health care provider about breast pain or any other symptom that does not go away. Most often, these symptoms are not cancer, but it is important to check with the health care provider so that any problems can be diagnosed and treated as early as possible.

Diagnosis

If a woman has a breast change, her doctor must determine whether it is due to breast cancer or some other cause. The woman has a physical exam. The doctor asks about her personal and family medical history. She may have a mammogram or other imaging procedure that makes pictures of tissues inside the breast. After the tests, the doctor may decide that no further tests are needed and no treatment is necessary. Or the woman may need a biopsy to examine the suspicious area for cancer cells.

Clinical Breast Exam

The health care provider feels each breast for lumps and looks for other problems. If a woman has a breast lump, the health care provider can tell a lot about it by feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The health care provider can check the size, shape, and texture of the lump and feel whether it moves easily. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic Mammography

Diagnostic mammograms involve x-ray pictures of the breast to get clearer, more detailed pictures of any area that looks abnormal on a screening mammogram. They also are used to help the doctor learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasonography

Using high-frequency sound waves, ultrasonography (ultrasound) can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). The doctor can view these pictures on a monitor. After the test, the pictures can be stored on video and printed out. This exam may be used along with a mammogram.

Magnetic Resonance Imaging

For magnetic resonance imaging (MRI), a powerful magnet linked to a computer is sometimes used to make detailed pictures of tissue inside the breast. The doctor can view these pictures on a monitor and can print them on film. MRI may be used along with a mammogram.

Biopsy

Often, fluid or tissue must be removed from the breast to help the doctor learn whether cancer is present. This is called a biopsy. For the biopsy, the doctor may refer the woman to a surgeon or breast disease specialist.

Sometimes a suspicious area that can be seen on a mammogram cannot be felt during a clinical breast exam. The doctor can use imaging devices to help see the area to then obtain tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.

Doctors can remove tissue from the breast in different ways:

• Fine-needle aspiration: The doctor uses a thin needle to remove fluid and/or cells from a breast lump. If the fluid appears to contain cells, it goes to a lab where a pathologist uses a microscope to check for cancer cells. If the fluid is clear, it may not need to be checked by a lab.
• Core biopsy: The doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
• Surgical biopsy: In an incisional biopsy, the surgeon removes a sample of a lump or abnormal area. In an excisional biopsy, the surgeon removes the entire lump or abnormal area. A pathologist examines the tissue for cancer cells.

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called lobular carcinoma, begins in the lobules.

A woman who needs a biopsy may want to ask her doctor the following questions:

• What kind of biopsy will I have? Why?
• How long will it take? Will I be awake? Will it hurt? Will I have anesthesia? What kind?
• How soon will I know the results?
• Are there any risks? What are the chances of infection or bleeding after the biopsy?
• If I do have cancer, who will talk with me about treatment? When?

Additional Tests

If the diagnosis is cancer, the doctor may order special lab tests on the tissue that was removed. The results of these tests help the doctor learn more about the cancer and plan appropriate treatment.

Many women with breast cancer will have the hormone receptor test. It shows whether the cancer needs hormones (estrogen or progesterone) to grow. The result helps the doctor plan treatment.

Sometimes a sample of breast tissue is checked for the human epidermal growth factor receptor-2 (HER2) or the HER2/neu gene. The presence of the HER2 receptor or gene may increase the chance that the breast cancer will come back.

Breast Cancer STAGING

To plan a woman's treatment, the doctor needs to know the extent (stage) of the disease. The stage is based on the size of the tumor and whether the cancer has spread. Staging may involve x-rays and lab tests to learn whether the cancer has spread and, if so, to what parts of the body. When breast cancer spreads, cancer cells are often found in lymph nodes under the arm (axillary lymph nodes). The extent of the cancer often is not known until after surgery to remove the tumor in the breast and the lymph nodes under the arm.

A woman may want to ask her doctor these questions after staging:

• What kind of breast cancer do I have?
• What did the hormone receptor test show? What other lab tests were done on the tumor tissue, and what did they show?
• What is the stage of the disease? Has the cancer spread?
• How will this information help in deciding what type of treatment or further tests I will need?

Stages of Breast Cancer

Doctors describe breast cancer by the following stages:

Stage 0 is called carcinoma in situ.
Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. (See picture of lobule in the Diagram section.) These abnormal cells are a marker of increased risk. That means a woman with LCIS has an increased risk of developing invasive cancer in either breast sometime in the future. (Both breasts are at risk.)
Ductal carcinoma in situ (DCIS) is a precancerous condition in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread outside the duct to invade the surrounding breast tissue. However, if not treated, DCIS sometimes becomes invasive cancer.
Stage I is an early stage of invasive breast cancer. Stage I means that the tumor is no more than 2 centimeters (less than three-quarters of an inch) across, and cancer cells have not spread beyond the breast. See Diagram

Stage II is one of the following: The tumor in the breast is no more than 2 centimeters (less than three-quarters of an inch) across, and the cancer has spread to the lymph nodes under the arm; or

The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches), and the cancer may have spread to the lymph nodes under the arm; or

The tumor is larger than 5 centimeters (2 inches) but has not spread to the lymph nodes under the arm.

Stage III may be a large tumor, but the cancer has not spread beyond the breast and nearby lymph nodes. It is locally advanced cancer.

Stage IIIA means the tumor in the breast is smaller than 5 centimeters, the cancer has spread to the underarm lymph nodes, and the lymph nodes are attached to each other or to other structures. Or the tumor is large (more than 5 centimeters across), and the cancer has spread to the underarm lymph nodes.

Stage IIIB means the tumor may have grown into the chest wall or the skin of the breast; or the cancer has spread to lymph nodes under the breastbone.

Inflammatory breast cancer is a type of Stage IIIB breast cancer. It is rare. The breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

• Stage IIIC means the cancer has spread to the lymph nodes under the breastbone and under the arm, or to the lymph nodes under or above the collarbone. The primary breast tumor may be of any size.

Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body.

Recurrent cancer is cancer that has come back (recurred) after treatment. It may recur locally (in the breast or chest wall) or in any other part of the body (such as bone, liver, or lungs).

Breast Cancer Treatment

Many women with breast cancer want to learn all they can about their disease and their treatment choices. They want to take an active part in making decisions about their medical care. Learning more about the disease helps many women cope. But how much information to seek and how to deal with it are personal choices. Each woman can make her own decision about how much she wants to know.

The shock and stress after a diagnosis of cancer can make it hard to think of everything to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, a woman can take notes or ask whether she may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

The doctor may refer a woman with breast cancer to a specialist, or the woman may ask for a referral. Specialists who treat breast cancer include surgeons, medical oncologists, radiation oncologists, and plastic surgeons. A woman may have a different specialist for each type of treatment.

Treatment generally begins within a few weeks after the diagnosis. Usually, there is time for a woman to talk with her doctor about treatment options, get a second opinion, and learn more about breast cancer before making a treatment decision.

Getting a Second Opinion

Before starting treatment, a woman with breast cancer may want to get a second opinion about her diagnosis and treatment options. Some insurance companies require a second opinion; others may cover a second opinion if the woman or doctor requests it. It may take time and effort to gather medical records (mammogram films, biopsy slides, pathology report, and proposed treatment plan) and arrange to see another doctor. In general, taking several weeks to get a second opinion does not make treatment less effective.

There are a number of ways to find a doctor for a second opinion:

• The woman's doctor may refer her to one or more specialists. At cancer centers, several specialists often work together as a team.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.
• A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
• The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on "Who's Certified.")
• The NCI provides a helpful fact sheet on how to find a doctor called "How To Find a Doctor or Treatment Facility If You Have Cancer." It is available on the Internet at http://cancer.gov/publications.

Treatment Methods

Women with breast cancer have many treatment options. These include surgery, chemotherapy, radiation therapy, hormonal therapy, and biological therapy. These options are described below.

In most cases, the most important factor in treatment choices is the stage of the disease. See the section called Treatment Choices by Stage.

Many women receive more than one type of treatment. In addition, at any stage of disease, women with breast cancer may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of treatment, and to ease emotional problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.

Treatment for cancer is either local therapy or systemic therapy:

• Local therapy: Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas but not elsewhere.
• Systemic therapy: Chemotherapy, hormonal therapy, and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.

Most women want to know how treatment may change their normal activities. They want to know how they will look during and after treatment. The doctor is the best person to describe treatment choices, side effects, and the expected results of treatment. Each woman can work with her doctor to develop a treatment plan that meets her needs and personal values.

A woman may want to ask her doctor these questions before treatment begins:

• What are my treatment choices? Which do you recommend for me? Why?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• What is the treatment likely to cost? Is this treatment covered by my insurance plan?
• How will treatment affect my normal activities?
• Would a clinical trial (research study) be appropriate for me?

Women do not need to ask all of their questions at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery. The doctor can explain each type, discuss and compare the benefits and risks, and describe how each will affect the woman's appearance:

• Breast-sparing surgery: An operation to remove the cancer but not the breast is called breast-sparing surgery, breast-conserving surgery, lumpectomy, segmental mastectomy, or partial mastectomy. Through a separate incision, the surgeon often removes the underarm lymph nodes to learn whether cancer cells have entered the lymphatic system. The procedure to remove the underarm lymph nodes is called an axillary lymph node dissection. After breast-sparing surgery, most women receive radiation therapy to the breast to destroy cancer cells that may remain in the breast.
• Mastectomy: An operation to remove the breast (or as much of the breast tissue as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm. After surgery, the woman may receive radiation therapy.

Studies have found equal survival rates for breast-sparing surgery (with radiation therapy) and mastectomy for Stage I and Stage II breast cancer.

A new method of checking for cancer cells in the lymph nodes is called sentinel lymph node biopsy. In this operation, a specially trained surgeon removes only one or a few lymph nodes (the sentinel nodes) instead of removing a much larger number of underarm lymph nodes.