The female breast is a remarkable collection of glands and fatty tissue that lies between the skin and the chest wall. Its main function is to produce milk for a baby.
Inside this collection of glands are lobules where milk is produced. There are also blood vessels that feed into these glands, as well as lymphatic vessels that lead into the breast, making the breast a hyperdynamic structure of fatty tissues, glands, blood vessels, and lymphatic vessels.
But the very things that make this structure so remarkable also make it highly dangerous when cancer occurs. When cells in the breast grow out of control and form cancerous tumors, they can easily and rapidly spread via those blood vessels and lymphatic vessels into nearby tissues and other parts of the body.
Every woman is at risk for developing breast cancer. About 200,000 cases are diagnosed every year, and it is second only to lung cancer in the number of deaths caused among American women annually. In terms of lifetime risk, that means that one out of eight women will develop breast cancer, and one out of 28 will die from it.
All women age 40 and older are at risk for breast cancer, though most breast cancers occur in women over the age of 50.
Some risk factors for breast cancer are avoidable. Taking birth control pills or hormone replacement therapy, not breast-feeding after having a child, having two to five alcoholic drinks a day, being overweight, and not exercising all increase the risk for breast cancer.
But most of the factors that put a woman at risk for breast cancer are unavoidable. Getting older is one risk you can do nothing about. Being Caucasian is another. Having a family history of breast cancer in a sister or mother doubles your risk. The risk also increases if you had your first period before the age of 12, had menopause after the age of 50, or never had children.
There are some genetic mutations, especially in Jewish families, such as the BRCA1 or BRCA2 mutations, which women may inherit from their parents, and which result in a 50 percent chance of getting breast cancer before the age of 70.
Every effort is being made to prevent breast cancer. But since, unlike with lung cancer, there’s no clear cause of breast cancer, all we can do right now is manage the risk factors.
Avoid excess alcohol and long-term estrogen replacement therapy, watch your weight, exercise regularly, and, if you have a child, be sure to breast-feed. If you have a familial genetic predispositions based on the mutation of BRCA1 or BRCA2, or a history of breast cancer in the family, you can take certain drugs like tamoxifen or raloxifene, which have been found to be effective in preventing breast cancer.
If your mother or sister had breast cancer, you should begin screening for the disease 10 years before the age at which they were diagnosed. (If your mother got breast cancer at the age of 47, for instance, you should begin screening at age 37.)
Screening tests for breast cancer are fundamental. The most important thing a woman can do to minimize her chances of getting breast cancer is to have regular mammograms, to learn how to perform breast self-examination, to actually perform the breast self-examinations, and to undergo regular physicals. The earlier the breast cancer is picked up, the more effective the treatment and the more curable the disease.
Many times a mammogram can pick up a tumor before it is even felt. Women should get a yearly mammogram starting at the age of 40 (earlier for those with a family history of the disease or a genetic mutation that increases the risk of breast cancer). Women between the ages of 20 to 39 should have clinical breast exams at least every two to three years and then annually after the age of 40.
What to Expect at Your First Mammogram
The entire mammography exam, during which a medical technician takes two images of each breast, lasts about 15 minutes. You will be asked to stand in front of the mammography machine and place your breast on a small platform. The technician will lower a plastic plate directly on top of the breast to compress it in order to get a clear view of the tissue.
This is not normally painful, but it may be somewhat uncomfortable. (If you have very sensitive breasts, take acetaminophen or ibuprofen a half hour before your appointment.)
The breast will be compressed for less than 30 seconds, as the machine releases the plate after each image. You will be asked to remain still and hold your breath while each X-ray is taken. Later that day a radiologist will interpret the images. If there are abnormalities, your doctor will contact you.
But don’t depend entirely on the mammograms. About 15 percent of the tumors you can feel in the breast never appear on a mammogram. That’s the reason why every woman should do a breast self-examination at least once a month. Once you become familiar with your breast, it should be easy to recognize any abnormality that occurs.
The early stages of breast cancer are completely without symptoms. But as a tumor grows in the breast, you might feel some lumps or very hardened areas of the breast or of the tissue underneath your arm, your breast might change in size as compared to the other, you might have some discharge from the nipple, the nipple might invert internally, or there might be some discoloration of the skin of the breast. While taken individually, these symptoms don’t necessarily mean that you have breast cancer, they are all signs that should be brought to the attention of your doctor immediately.
Once breast cancer is suspected, whether it’s on a diagnostic mammogram or otherwise, other tests will follow—usually a biopsy, because this is probably the only way to make sure you have or don’t have cancer. Biopsies involve removing a small sample of the suspect tissue for further examination under a microscope by a pathologist. Not only do pathologists look for the cancer, they also seek to determine what kind of receptors—estrogen or progesterone—the cancer tissue has. The receptors help determine what type of therapy you will receive for the cancer; there are specific therapies directed at each type of receptor that improve the outcome.
The “stage” or location of the cancer is also determined during the diagnosis. If it’s located in a lobule or duct of the breast, the cancer is at Stage 0. If the tumor is less than 2 centimeters but has not spread beyond the breast itself, it’s Stage 1.
Stage 2 involves tumors that are less than 2 centimeters and have migrated beyond the breast to the lymphatic nodes, or are greater than 2 centimeters and haven’t spread outside the breast.
Stage 3 involves more advanced breast cancers, greater than 5 centimeters, that have spread to the lymphatic nodes under the arm.
Stage 4 is metastatic cancer, meaning that it has spread outside the breast to other organs.
Surgery plays a major role in the treatment by essentially removing as much of the cancer as possible. For the very early stages of breast cancer, the treatment is called a lumpectomy, which is the removal of the tumor and a little bit of normal tissue around the tumor. A lumpectomy is usually combined with radiation therapy.
Partial mastectomies involve removing a larger piece of the breast.
More advanced cancers are treated with modified radical mastectomies, meaning that the entire breast and the lymph nodes are removed. Most women who have total breast removal get reconstructive surgery in order to create a substitute breast mound. Those with high stages of cancer often also receive chemotherapy, with surgery or without surgery, in order to decrease the risk of the cancer’s recurrence, though the side effects of chemotherapy can be considerable.
Similarly, radiation therapy, which uses high-energy X-rays to kill cancer cells, is often used to reduce the risk of recurrence and to kill tumor cells that may be living in lymph nodes. Depending on whether the tumor expressed estrogen or progesterone receptors, patients may also receive hormonal therapy. Patients whose tumors expressed estrogen, for example, may receive an estrogen-blocking drug called tamoxifen for five years after their surgery.
Ask Dr. Manny: Not for Women Only
“Dr. Manny, why is it that when we talk about breast cancer, it’s always a reference to women’s breast cancer? Men have breasts, too. Why don’t they get breast cancer?”
Good point. Most people don’t realize it, but men can develop breast cancer, too. All cells in the body can undergo cancer, including a man’s breast cells. But because women have many more breast cells than men do, and perhaps because a woman’s breast cells are constantly exposed to the growth-promoting effects of female hormones, breast cancer is one hundred times more common in women than in men.
Still, each year, there are almost 2,000 cases of invasive breast cancer in men, and, stage for stage, the survival rates are equal in men and women. Men usually do not get mammograms, but self-examination is important. Most breast lumps in men are due to gynecomastia, the most common male breast disorder. Gynecomastia is an increase in the amount of a man’s breast tissue due to hormonal changes, but it is not cancer.
Follow-up is very important for anyone who has been diagnosed with breast cancer. Women should be checked every three to four months. The longer they are free of disease, the better their long-term prognosis. After their five-year anniversary, they may need to see their doctor only once a year.
Take breast cancer seriously. It’s a very deadly disease. But it’s also very curable if caught early in the game.