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Breast cancer

Breast cancer is caused by an abnormal and uncontrolled growth of cells in your breast tissue.

Your breasts are made up of fat, connective tissue and gland tissue that’s divided into lobes. The lobes are connected to your nipple by milk ducts. Breast cancer usually starts in the cells that line your milk ducts.

In the UK, breast cancer is the most common cancer in women – over 49,000 women are diagnosed each year. The risk of breast cancer increases with age – it’s most common in women over 50. Men can also get breast cancer but it’s less common – about 400 men are diagnosed each year in the UK.

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How cancer develops
Cells begin to grow in an uncontrolled way
Image showing the structures of the breast

Details

  • Types of breast cancer Types of breast cancer

    There are different types of breast cancer named after the type of cell the cancer first occurs in, and how far it has spread. The three most common types of breast cancer are described below.

    • Ductal carcinoma in situ (DCIS), or ‘non-invasive breast cancer’ is the earliest possible type of breast cancer. The cancer cells are only found inside the milk ducts and haven’t spread into the breast tissue.
    • Invasive (or infiltrating) ductal carcinoma (IDC) is breast cancer that has spread outside the milk ducts into the breast tissue. This is the most common type of breast cancer.
    • Invasive lobular carcinoma (ILC) is breast cancer that starts in the cells that line your lobes.
  • Symptoms Symptoms of breast cancer

    It’s important to check your breasts regularly as this will help you spot any changes. Symptoms of breast cancer include:

    • a lump in your breast or armpit
    • a change in your skin, such as dimpling
    • a change in the shape of your nipple – for example, it may turn inwards
    • a rash on or around your nipple
    • discharge from your nipple
    • a change in the size or shape of your breast

    If you have any of these symptoms, see your GP. If you do have breast cancer, the sooner you’re diagnosed and can start treatment, the more successful it’s likely to be.

    It’s possible you might not have any symptoms of breast cancer and it might be found during breast screening.

    Bupa Health Assessment: Breast check

    If you are concerned about breast cancer, Bupa can help you get a diagnosis.

  • Diagnosis Diagnosis of breast cancer

    Your GP will ask you about your symptoms and examine you. He or she may also ask you about your medical history.

    If your GP suspects you have breast cancer, or it was detected in screening, you will be referred to a specialist breast clinic.

    A process called triple assessment is used to diagnose breast cancer. There are three stages to this.

    • Examination. A doctor or nurse will ask about your medical history and examine one or both of your breasts.
    • Imaging. A radiographer (a health professional trained to perform imaging procedures) will take pictures of the inside of your breast. He or she may use ultrasound, X-rays or a combination of both.
    • Needle biopsy. A doctor will remove a sample of your breast tissue and send it to a laboratory for testing. This will determine if the lump is cancerous or non-cancerous (benign).

    The results of a triple assessment can help your doctor decide if you need any more investigations and treatment.

    If you’re diagnosed with breast cancer, you may need to have other tests to find out how advanced it is. This process, known as staging, takes into account whether the cancer has spread and how big it is. Your doctor will usually advise you to have scans, such as an ultrasound, MRI or CT, to check your breasts, abdomen (tummy) and lymphatic system. Your lymphatic system is the tissues and organs that are part of your immune system.

    You may also need to have a needle biopsy of the lymph nodes (glands) in your armpits. This will check if the cancer has spread.

  • Treatment Treatment options for breast cancer

    There are a number of treatment options for breast cancer. The treatment you have will depend on your personal circumstances, such as your general health, age and if the cancer has spread.

    A multidisciplinary team, including a surgeon, radiologist and oncologist (a doctor who specialises in cancer care) will discuss your treatment options with you. This team will also help you with the wider aspects of your care, such as emotional support and help with your day-to-day activities.

    Surgery

    Surgery is usually the first treatment option if your cancer is early-stage or hasn’t spread beyond your breast. Depending on the position and size of the cancer, your surgeon may suggest either surgery that means you keep your breast or a mastectomy.

    • Breast conserving surgery means that you don’t have your whole breast removed. It can range from a lumpectomy (removal of the lump) to removing part of your breast. Your surgeon will remove only the affected breast tissue (or lump), usually with some healthy tissue around it. You will need to have radiotherapy after breast conserving surgery for invasive disease, and possibly for DCIS.
    • In a mastectomy, your surgeon will remove the whole of your affected breast.

    Your surgeon may also take a sample of tissue from the lymph nodes in your armpit and check to see if they are cancerous. This is called a sentinel lymph node biopsy. You may have this even if you had a small cancer and an ultrasound of your armpit suggested the lymph nodes were healthy. This is because your sentinel nodes are the first place that breast cancer spreads to. If your sentinel nodes are found to contain cancer cells, your surgeon will remove these during your operation.

    If you have a mastectomy, you should also be offered surgery to have your breast reconstructed afterwards. Whether or not to have a reconstruction is your personal choice. Some women choose to have their breast reconstructed straight away, whereas others decide to have it at a later date, or not at all. Your surgeon will talk to you about your options.

    Non-surgical treatments

    Your doctor may recommend you have non-surgical treatments before surgery to help shrink your tumour, or after surgery to help stop it coming back. You may also be offered these treatments if you have cancer that has spread or come back. Non-surgical treatments available for breast cancer are listed below.

    • Radiotherapy is a treatment to destroy cancer cells with radiation. You may have it after surgery to destroy any remaining cancer cells. The aim of the treatment is to destroy cancer cells with minimal damage to your surrounding healthy tissue. There are a number of different methods of having radiotherapy. The method you have will depend on the type of cancer you have and what operation you have, such as a mastectomy or a lumpectomy.
    • Chemotherapy uses medicines to destroy cancer cells. You may need one or more different medicines as part of your treatment. You may have chemotherapy as a treatment for breast cancer that has spread or come back.
    • Endocrine therapy uses medicines to block certain hormones. Hormones, such as oestrogen, can affect the growth of breast cancer cells. Taking medicines that block these hormones can treat some types of breast cancer. You may have endocrine therapy after surgery and chemotherapy or before surgery to shrink the cancer.
    • Biological therapy uses specific antibodies that have been grown in a laboratory (monoclonal antibodies) to block the action of a substance called HER2. HER2 stimulates some types of cancer cells to grow. You may be offered treatment with the monoclonal antibody trastuzumab (Herceptin) if your cancer is this type.

    You might be able to take part in a clinical trial as new treatments become available and need to be tested. Ask your doctor for information about clinical trials.

    After treatment for breast cancer, you will have regular check-ups with your doctor to see if there is any sign that the cancer has returned. If the cancer has already spread, further support is available from specialist cancer doctors and nurses to get treatment for any symptoms. This is called palliative care.

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  • Causes Causes of breast cancer

    The exact reasons why you may develop breast cancer aren’t fully understood at present. However, you’re more likely to develop it if you:

    • have a family history of breast cancer or ovarian cancer
    • started your periods early, or the menopause late
    • don’t have children
    • have children, but had your first child when you were older (over 30)
    • have never breastfed
    • take a contraceptive pill that contains oestrogen
    • take hormone replacement therapy (HRT) – combined HRT (oestrogen and progesterone) is more likely to cause breast cancer than oestrogen-only HRT
    • are overweight or obese
    • regularly drink alcohol
    • don’t regularly exercise
  • Prevention Prevention of breast cancer

    You can help to reduce your risk of breast cancer by living a healthy lifestyle. This means eating a healthy, balanced diet, staying a healthy weight, exercising and if you drink alcohol, only doing so in moderation.

    If you have a high risk of getting breast cancer, you may decide to have a mastectomy to prevent it developing. If you take medicines such as tamoxifen, it may also reduce your risk of breast cancer. Ask your doctor for more information.

  • Breast screening Breast screening

    Having regular breast screening can help to detect changes in your breast that may be an early sign of breast cancer. The NHS Breast Screening Programme invites all women between the ages of 50 and 70 for breast screening every three years. If you’re in your late 40s or up to 73 years old, you may also receive an invitation to go for screening.

  • FAQs FAQs

    How do I check my breasts for signs of breast cancer?

    Answer

    Just look at and feel your breasts regularly. If you spot or feel anything unusual, see your GP.

    Explanation

    Being breast aware means getting into the habit of checking the look and feel of your breasts regularly. If you know what your breasts look and feel like, you will be able to spot any changes straight away.

    Check yourself in a way that is comfortable and convenient for you. You may find it easiest to check your breasts when you have a bath or shower or when you’re getting dressed in the morning. If you use a mirror, it can make it easier to see your breasts from different angles. It’s also important to make sure you check the whole of your breast area, including under your armpits.

    See your doctor if you feel or spot any changes, such as:

    • unusual pain or discomfort in your breast or armpit
    • a lump in your breast or armpit
    • a change in the skin around your breast, such as dimpling
    • a change in the shape of your nipple, such as it turning inwards
    • a rash on or around your nipple
    • discharge from your nipple
    • a change in breast size or shape

    Remember, your breasts react to changes in your hormone levels. For example, your breasts may feel lumpy and painful just before your period. If you feel a lump or spot any change, try not to panic. Make an appointment to see your GP to discuss your symptoms.

    If you feel uncomfortable or anxious about checking your breasts, you may find it helpful to discuss your worries with your GP or a nurse.

    I have been treated for breast cancer and now have swelling in my arm. Why has this happened and will it get better?

    Answer

    The swelling in your arm is called lymphoedema and it means the lymph nodes in your armpit aren’t draining fluid properly. This can happen after you have breast cancer surgery or radiotherapy and can last a long time. There isn’t a cure, but treatments are available to help manage your symptoms.

    Explanation

    Lymph nodes are glands throughout your body that are part of the immune system. Their main function is to fight infection and filter lymphatic fluid. If you have surgery or radiotherapy treatment to the lymph nodes in your armpit, it can block the channels that drain the fluid. The fluid then begins to collect and this causes swelling. You can also get lymphoedema if cancer spreads to your lymph nodes and blocks the drainage system.

    Most people who develop lymphoedema get it in the arm on the same side as the affected breast. Lymphoedema can occur months or years after you have breast cancer treatment.

    Certain things can increase your risk of getting lymphoedema, such as being overweight. The location of breast cancer can also affect your risk.

    You can help to reduce your risk of lymphoedema by regularly doing the arm and shoulder exercises you’re given after surgery for breast cancer.

    There isn’t a cure for lymphoedema but there are ways to manage your symptoms. The main treatment is complex decongestive therapy (CDT). This involves:

    • massage to stimulate the flow of fluid and reduce swelling
    • wearing bandages and compression garments to move fluid out of your arm
    • doing exercises that are designed to activate muscles in your arm to improve lymph drainage

    If you don’t get treatment for lymphoedema, the swelling is likely to get worse, become painful and make it difficult to move your arm. It can also affect your skin, and make it tight and dry. The longer you leave it, the harder it becomes to manage your symptoms. So, if you notice any signs of swelling, such as your rings or watch strap feeling tighter, talk to your doctor.

    I’ve been advised to have a lumpectomy – what does this involve?

    Answer

    A lumpectomy is an operation to remove a cancerous lump in your breast and some of the tissue around it. Your surgeon will try to keep the appearance of your breast as similar as possible to how it was before.

    Explanation

    If you have a cancerous, or possibly cancerous, lump in your breast, your doctor may advise you to have a lumpectomy. This procedure is also called a wide local excision or breast conserving surgery because it aims to leave as much healthy tissue as possible. This is compared with a mastectomy in which your entire breast is removed.

    Your surgeon will remove the cancer and also some healthy tissue from around it. This is to try to reduce the risk of the cancer coming back or of leaving any cancerous cells behind. Your surgeon may be able to reshape or reconstruct your breast during your operation.

    The tissue your surgeon removes will be sent to a laboratory for testing. This is to check that there is an area of healthy cells around the cancer – known as a ‘clear margin’. If the results of this show that there are no cancer cells, you probably won’t need any further surgery. If the margin isn’t clear, you may need another operation.

    Another type of breast conserving surgery is a quadrantectomy, which involves removing about a quarter of your breast. The difference in appearance between your breasts will be more noticeable after a quadrantectomy. However, your surgeon may be able to reconstruct your breast during the procedure to improve how it looks.

    You will usually be advised to have radiotherapy after a lumpectomy or quadrantectomy. This is to prevent new cancers growing within your remaining breast tissue. If you have early breast cancer, a lumpectomy followed by radiotherapy is as effective at treating breast cancer as a mastectomy.

    Any type of surgery to remove a breast lump will leave a scar and may affect how your breast looks. The scar will probably be quite small if you have a lumpectomy. Talk to your surgeon about what to expect about the appearance of your breast after any type of surgery. You may wish to consider surgery to reconstruct the breast that was treated or to reduce the size of your other one.

    What is TNM staging for breast cancer?

    Answer

    The TNM staging system is a way for doctors to assess cancer and understand how far it has spread. Staging is important to help decide what your treatments options are.

    Explanation

    Your doctor will use information from tests, such as ultrasound and biopsies, to stage your breast cancer. This is called TNM staging. TNM stands for ‘tumour, nodes, metastasis’. Metastasis means the spread of cancer. The TNM system can help your doctor understand how big your breast cancer tumour is and whether it has spread. This may be to your lymph nodes or to other parts of your body. For example, your cancer may be staged as T2N1M0. This code is a way for doctors to explain detailed information about your cancer.

    • ‘T’ refers to the size of the cancer and it can be between 1 and 4. T1 is small (less than 2cm) and T4 can be any size but means the cancer has spread to your chest wall or skin.
    • ‘N’ refers to whether the cancer has spread to your lymph nodes. It can be between 0 (no spread) and 3 (where lots of your lymph nodes are affected).
    • ‘M’ refers to whether the cancer has spread to another part of your body. It can either be 0 (the cancer hasn’t spread) or 1 (the cancer has spread).

    This code will be written on your test forms and in your medical records. It will help your doctors try to predict how your cancer will develop and to plan your treatment.

    If you need more information about the stage of your cancer or what it means, ask your doctor or surgeon.

  • Resources Resources

    Further information

    Sources

    • Breast cancer. Medscape. www.emedicine.medscape.com, published 9 April 2014
    • Breast cancer. PatientPlus. www.patient.co.uk/patientplus.asp, published 13 June 2012
    • Familial breast cancer: classification and care of people at risk of familial breast cancer and management of breast cancer and related risks in people with a family history of breast cancer. National Institute for Health and Care Excellence (NICE), June 2013. www.nice.org.uk
    • NHS breast screening: helping you decide. NHS Screening Programmes. www.cancerscreening.nhs.uk, published September 2013
    • Breast cancer (non-metastatic). BMJ Clinical Evidence. www.clinicalevidence.bmj.com, published 8 February 2011
    • Breast cancer – suspected. Map of Medicine. www.mapofmedicine.com, published 15 January 2014
    • Reproductive history and breast cancer risk. National Cancer Institute. www.cancer.gov, published May 2011
    • Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013, Issue 6. doi: 10.1002/14651858.CD001877.pub5
    • What does the NHS breast screening programme do? NHS Cancer Screening Programmes. www.cancerscreening.nhs.uk, published 24 April 2014
    • Breast cancer screening. PatientPlus. www.patient.co.uk/patientplus.asp, published 13 June 2012
    • Clinical guidelines for breast cancer screening assessment. NHS Cancer Screening Programmes. www.cancerscreening.nhs.uk, published June 2010
    • Secondary care – triple assessment clinic. Map of Medicine. www.mapofmedicine.com, published 15 January 2014
    • Early and locally advanced breast cancer: diagnosis and treatment. National Institute for Health and Care Excellence (NICE), February 2009. www.nice.org.uk
    • Breast stereotactic core biopsy/fine needle aspiration. Medscape. www.emedicine.medscape.com, published 21 October 2013
    • Best practice diagnostic guidelines for patients presenting with breast symptoms. Department of Health. www.associationofbreastsurgery.org.uk, published November 2010
    • Surgical treatment of breast cancer. Medscape. www.emedicine.medscape.com, published 7 April 2014
    • Breast cancer quality standard. National Institute for Health and Care Excellence (NICE), September 2011. www.nice.org.uk
    • Khan F, Amatya B, Ng L, et al. Multidisciplinary rehabilitation for follow-up of women treated for breast cancer. Cochrane Database of Systematic Reviews 2012, Issue 12. doi:10.1002/14651858.CD009553.pub2
    • Treatment of primary breast cancer. Scottish Intercollegiate Guidelines Network (SIGN), September 2013. www.sign.ac.uk
    • Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2014; (Apr 7). doi:10.1200/JCO.2013.54.1177
    • Your guide to breast reconstruction. British Association of Plastic Reconstructive and Aesthetic Surgeons. www.bapras.org.uk, published 2010
    • Advanced breast cancer. Map of Medicine. www.mapofmedicine.com, published 15 January 2014
    • Khatcheressian JL, Hurley P, Bantug E, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013; 31(7):961–65. doi:10.1200/JCO.2012.45.9859.
    • Visvanathan K, Hurley P, Bantug E, et al. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013; 31(23):2942–62. doi:10.1200/JCO.2013.49.3122
    • Lymphedema. Medscape. www.emedicine.medscape.com, published 22 April 2014
    • Lymphatic system anatomy. Medscape. www.emedicine.medscape.com, published 19 September 2013
    • Early-stage breast cancer treatment fact sheet. Womenshealth.Gov. www.womenshealth.gov, published 16 July 2012
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    • Be breast aware. NHS Cancer Screening Programmes. www.cancerscreening.nhs.uk, published September 2006
    • Breast awareness. National Screening Unit. www.nsu.govt.nz, accessed 25 April 2014
    • Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology - American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Int J Radiat Oncol Biol Phys 2014; 88(3):553–64. doi:10.1016/j.ijrobp.2013.11.012
    • Oncoplastic breast reconstruction. British Association of Plastic Reconstructive and Aesthetic Surgeons. www.bapras.org.uk, published November 2012
    • Breast cancer (non-metastatic): less extensive mastectomy. BMJ Clinical Evidence. www.clinicalevidence.bmj.com, published 8 February 2011
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