The breasts
Women and men both have breasts. In women, breasts are made up of milk glands. The milk gland consists of lobules, where milk is made, and tubes called ducts that take milk to the nipples. In men, the development of the lobules is suppressed at puberty by testosterone, the male sex hormone. Both female and male breasts contain supportive fibrous tissue and fatty tissue. Some breast tissue extends into the armpit (axilla). The armpits contain a collection of lymph nodes (also called lymph glands), which are part of the lymphatic system. The lymphatic system is part of the immune system and protects the body against disease and infection.
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What is breast cancer?
Breast cancer starts in the ducts or lobules of the breast. Cells lining the ducts or lobules can grow out of control and develop into cancer. Some breast cancers are found when they are still confined to the ducts or lobules of the breast. This is called pre-invasive breast cancer. The most common types are ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). Most breast cancers are found when they are invasive. This means the cancer has spread outside the ducts or lobules of the breast into surrounding tissue. Invasive (infiltrating) ductal cancer is the most common type of breast cancer, accounting for eight out of ten cases, invasive (infiltrating) lobular cancer is the second most common accounting for one in ten cases. There are other less common types of breast cancer including inflammatory breast cancer.
There are several categories of invasive breast cancer.
- Early breast cancer - contained in the breast but may have spread to one or more lymph nodes in the armpit.
- Locally advanced breast cancer - may have spread to places near the breast, such as the chest (including the skin, muscles or bones of the chest), but the cancer isn’t found in other areas of the body.
- Metastatic breast cancer - the cancer cells spread from the breast to other areas of the body, such as the bones, liver or the lungs. It may also be called advanced breast cancer.
How common is it?
Breast cancer is the most common cancer in Australian women. One in 8 women will be diagnosed with breast cancer by the age of 85. Around 13,000 women are diagnosed with breast cancer each year. Breast cancer can occur at any age. It is more common in women aged over 60 but around one-quarter of women are younger than 50. Men can also develop breast cancer, although this is rare. Around 110 men are diagnosed each year in Australia.
What are the causes?
The exact cause of breast cancer is not known, but some factors increase the risk:
- getting older
- having several close relatives, like a mother, sister or daughter, diagnosed with breast cancer or ovarian cancer– these relatives can be from either the mother’s or father’s side of the family.
- if you have had breast cancer before
- if you have had certain breast conditions such as atypical ductal hyperplasia, ductal carcinoma in situ or lobular carcinoma in situ.
Having some of these risk factors does not mean that you will develop breast cancer. Most women with breast cancer have no known risk factors, aside from getting older. In men, breast cancer usually occurs over the age of 60. It is most common in men who have:
- several close members of their family (male or female) who have had breast cancer
- a relative diagnosed with breast cancer under the age of 40
- several members of the family with cancer of the ovary, pancreas or prostate
- a rare genetic syndrome called Klinefelter’s syndrome. Men with this syndrome have three sex chromosomes (XXY) instead of the usual two (XY).
Familial (hereditary) breast cancer
A set of genes is inherited from each parent. Sometimes there is a fault in one copy of a gene, which stops that gene working properly. This fault is called a mutation. A small number of breast cancers (about 5% or 1 in 20) may be caused by an inherited gene fault. Two breast cancer genes have been found: Breast cancer (BRCA)1 and BRCA2.Women in families with an inherited gene change could be at increased risk of ovarian cancer. Men in these families may also be at increased risk of breast cancer and prostate cancer.
People with a strong family history of breast and associated cancers can be referred to the Family Cancer Clinic so that a genetics specialist can discuss their situation in more detail.
Diagnosis
Types of tests
Several tests are usually used to find out if your breast change is due to breast cancer.
Physical examindation
Your doctor will feel your breasts and the lymph nodes under your arms, take a full medical history and ask about your family history.
Mammogram
This is a low-dose x-ray of the breast. It can find changes that are too small to be felt through physical examination. Both breasts are checked. Your breast is pressed between two x-ray plates, which spread the breast tissue out so clear pictures can be taken. Many women find this procedure uncomfortable, but it’s over in about 20 seconds. Sometimes, a lump that can be felt is not seen on a mammogram and other tests will need to be done. Women who wish to attend at BreastScreen Sydney South West, may complete the electronic appointment request form.
Ultrasound
Ultrasound uses soundwaves to make a picture of your breast. A gel is spread on the breast, and a small device called a transducer is moved over the area. It sends out soundwaves that echo when they meet something dense like an organ or tumour. A computer creates a picture from these echoes. This test is painless and takes 15 to 20 minutes.
Biopsy
Your doctor will suggest a biopsy if an abnormal or unusual area of tissue is found in your breast. You may need one or more biopsies. A biopsy means removing a small amount of breast tissue. There are a few ways of doing this:
- Fine needle aspiration - A thin needle is used to take some cells from the breast lump or abnormal area. Sometimes an ultrasound is used to help guide the needle. The test is a bit uncomfortable, similar to having blood taken for a blood test. It is usually done in a specialist’s rooms, a hospital outpatient department or at a radiology practice.
- Core biopsy - A wider needle is used to remove a small piece of tissue, called a core, from the lump or abnormal area. It is usually done under local anaesthetic. A mammogram or ultrasound is used to help guide the needle. A core biopsy may be uncomfortable and you may experience some pain.
- Surgical biopsy - If the lump is too small to be biopsied using the method above, a surgical biopsy is needed. To help the surgeon find the abnormal tissue, a needle and wire may be put into the breast under local anaesthetic before the biopsy. The biopsy is then done in a separate operation using a general anaesthetic. The lump and a small area of normal breast tissue around the lump are removed, along with the wire. This operation is usually done as day surgery but may mean an overnight stay in hospital. If the surgical biopsy removes all of the cancer, no further treatment is needed.
Further tests
If the tests described under Types of tests show you have breast cancer, some more tests may be done to see if the cancer has spread to other parts of the body. You may have one or more of these tests.
Staging breast cancer
The tests described under Further tests show if the cancer has spread to other parts of your body. Working out how far the cancer has spread is called staging. This helps your doctor recommend the best treatment for you. Stages of breast cancer are numbered from I to IV. Early breast cancer may be called stage IA, stage IIA and stage IIB (early).
- Stage I - The tumour is small, less than 2cm in diameter, and has not spread to the lymph nodes.
- Stage IIA - The tumour is less than 2cm and has spread to the lymph nodes or it is larger (2-5cm) and has not spread to the lymph nodes.
- Stage IIB (early) - The tumour is between 2-5cm and has spread to the lymph nodes.
- Stages IIB (advanced) to Stage III and Stage IV refers to advanced breast cancer.
Treatment for early breast cancer aims to remove the cancer and to reduce the risk of the cancer spreading or coming back. Your doctor will advise you on the best treatment for your cancer. The choice of treatment will depend on your test results, where the cancer is and if it has spread, whether your cancer has oestrogen or progesterone receptor protein, your age and general health, and what you choose. If you talk to other people with breast cancer, remember there are different types of breast cancer and the best treatment for one person may not be the best treatment for another.
Treatment
Surgical procedures for breast cancer
Most women with breast cancer have some type of surgery. The main purpose of surgery is to remove as much of the cancer as possible. Surgery is also undertaken to find out whether the cancer has spread to the lymph nodes.
Mastectomy
Mastectomy involves removing all of the breast tissue, sometimes in conjunction with nearby tissues.
Lumpectomy
Lumpectomy removes only the breast lump and some of the normal tissue surrounding it. Radiotherapy is usually given after this type of surgery. If there is cancer in the edge (the margin) of the tissue surrounding the tumour the surgeon may need to remove some more tissue.
Axillary lymph node dissection
This is done to find out whether the cancer has spread to the lymph nodes under the arm. The nodes are removed and looked at under the microscope. This information assists in making decisions about further treatment. Lymphoedema is a possible side effect of removing lymph nodes.
Sentinel lymph node biopsy
This is a way of examining the lymph nodes without having to remove them all. A radioactive substance and a dye are injected near to the tumour. This is carried by the lymphatics to the first (sentinel) nodes that get lymph from the tumour. This lymph node is the one most like to contain cancer cells if the cancer has spread. If the sentinel node contains cancer, further lymph nodes are removed.
Grading breast cancer and determining hormonal status
A pathologist will carry out further tests on the cancer that has been removed during surgery or biopsy to assess the grade and hormone receptor status of your cancer.
The grade shows how fast the cancer is growing.
- Grade 1 - Low grade (well differentiated). Cells look abnormal and grow faster than normal cells but not as fast as grade 2.
- Grade 2 - Intermediate grade (moderately differentiated). Cells look abnormal and grow faster than grade 1 but not as fast as grade 3.
- Grade 3 - High grade (poorly differentiated). A faster growing cancer.where the cells do not look like the normal breast cells they originated from.
The higher the grade, the more likely that you’ll have chemotherapy or hormone therapy after the surgery.
Hormones and breast cancer
There is a hormonal factor in some breast cancers. The ovaries produce two hormones, oestrogen and progesterone, which can help cancer cells grow. The pathologist will test breast tissue for proteins found inside some cancer cells. These proteins are called receptors. In breast cancer they are called hormone receptors because they allow oestrogen and progesterone to attach to the cancer cell. A cancer cell that has oestrogen receptors is called oestrogen receptor positive (ER+). A cell that binds progesterone is called progesterone receptor positive (PR+). Breast cells that do not have receptors are called negative for these hormones. Knowing whether a breast cancer contains oestrogen receptors helps your doctors decide on treatment. Breast cancers that are either ER+ or PR+ are more likely to respond to hormonal treatments, which reduce oestrogen in the body (see page 28). A tumour that is oestrogen receptor negative (ER-) is unlikely to benefit from hormonal treatment but other suitable treatments are available.
HER2 receptor test HER2 (human epidermal-growth-factor receptor 2) is a protein found on the surface of some cancer cells. Tumours that have high levels of these receptors are known as HER2-postive. These tend to divide and grow more rapidly than other types of breast cancer. This receptor test can help determine whether the drug Herceptin will be effective as part of your treatment. About one in five women have HER2-positive cancer cells.
The grade and hormone receptor status of your cancer will be written in a pathology report. You can ask for a copy of your pathology report.
Which health professionals will I see?
You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This multidisciplinary team will probably include:
- breast surgeon – specialises in surgery and performs biopsies
- pathologist – examines cells and tissue that is removed from the breast to determine the type and extent of the cancer
- radiologist – specialises in reading x-rays, such as mammograms
- medical oncologist – is responsible for chemotherapy and hormone therapy
- radiation oncologist – is responsible for radiotherapy
- nurses, including breast care nurses – support and help you through all stages of your treatment.
You may also see the following:
- physiotherapist and occupational therapist– assist in restoring range of movement after surgery and help treat lymphoedema
- social worker – links you to support services
- plastic surgeon or reconstructive surgeon - performs breast reconstruction for women who have a mastectomy
- counsellor, psychologist and psychiatrist – provide emotional support and help manage anxiety and depression
- genetic counsellor - provides advice for people with a strong family history of breast cancer.
Your general practitioner (GP) is also an important member of your treatment team. GPs can explain information provided by your specialists, help you with treatment decisions and assist you in obtaining practical and emotional support.