What You Need
To Know About™
Breast
Cancer
National Cancer Institute
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
National Institutes of Health
National Cancer Institute Services
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About This Booklet
This National Cancer Institute (NCI) booklet is for you—a woman who has just been diagnosed with breast cancer.
Words that may be new to you are shown in bold. See the Words To Know section on page 35 to learn what a new word means and how to pronounce it.
This booklet is about medical care for women with breast cancer. Learning about medical care for breast cancer can help you take an active part in making choices about your care.
You can read this booklet from front to back. Or, you can read only the sections you need right now.
This booklet has lists of questions that you may want to ask your doctor. Many people find it helpful to take a list of questions to a doctor visit. To help remember what your doctor says, you can take notes. You may also want to have a family member or friend go with you when you talk with the doctor—to take notes, ask questions, or just listen.
Breast cancer also develops in men. In 2012, about 2,200
American men will learn they have breast cancer.
NCI’s website has information about breast cancer in men at http://www.cancer.gov/cancertopics/types/breast.
In addition, NCI’s Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) and at LiveHelp (https://livehelp.cancer.gov) can answer questions about breast cancer in men.
Contents
45 National Cancer Institute Publications
The Breasts
Inside a woman’s breast are 15 to 20 sections (lobes). Each lobe is made of many smaller sections (lobules). Lobules have groups of tiny glands that can make milk.
After a baby is born, breast milk flows from the lobules through thin tubes (ducts) to the nipple. Fibrous tissue and fat fill the spaces between the lobules and ducts.
This picture shows the lobes and ducts inside the breast.
It also shows lymph nodes near the breast.
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Cancer Cells
Cancer begins in cells, the building blocks that make up all tissues and organs of the body, including the breast.
Normal cel s in the breast and other parts of the body grow and divide to form new cel s as they are needed. When normal cel s grow old or get damaged, they die, and new cel s take their place.
Sometimes, this process goes wrong. New cel s form when the body doesn’t need them, and old or damaged cel s don’t die as they should. The buildup of extra cel s often forms a mass of tissue called a lump, growth, or tumor.
Tumors in the breast can be benign (not cancer) or malignant (cancer):
■■ Benign tumors:
• Are usual y not harmful
• Rarely invade the tissues around them
• Don’t spread to other parts of the body
• Can be removed and usual y don’t grow back
■■ Malignant tumors:
• May be a threat to life
• Can invade nearby organs and tissues (such as the chest wall)
• Can spread to other parts of the body
• Often can be removed but sometimes grow back Breast cancer cel s can spread by breaking away from a breast tumor. They can travel through blood vessels or lymph vessels to reach other parts of the body. After 2
spreading, cancer cel s may attach to other tissues and grow to form new tumors that may damage those tissues.
For example, breast cancer cel s may spread first to nearby lymph nodes. Groups of lymph nodes are near the breast under the arm (axilla), above the col arbone, and in the chest behind the breastbone.
When breast cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cel s and the same name as the primary (original) tumor. For example, if breast cancer spreads to a lung, the cancer cel s in the lung are actual y breast cancer cel s. The disease is metastatic breast cancer, not lung cancer. For that reason, it’s treated as breast cancer, not lung cancer.
Types
Breast cancer is the most common type of cancer among women in the United States (other than skin cancer). In 2012, about 227,000 American women will be diagnosed with breast cancer.
The most common type of breast cancer is ductal carcinoma. This cancer begins in cel s that line a breast duct.
See page 1 for a picture of breast ducts. About 7 of every 10
women with breast cancer have ductal carcinoma.
The second most common type of breast cancer is lobular carcinoma. This cancer begins in a lobule of the breast. See page 1 for a picture of lobules. About 1 of every 10 women with breast cancer has lobular carcinoma.
Other women have a mixture of ductal and lobular type or they have a less common type of breast cancer.
3
Tests
After you find out that you have breast cancer, you may need other tests to help choose the best treatment for you.
Lab Tests with Breast Tissue
The breast tissue that was removed during your biopsy can be used in special lab tests:
■■ Hormone receptor tests: Some breast cancers need hormones to grow. These cancers have hormone receptors for the hormones estrogen, progesterone, or both. If the hormone receptor tests show that the breast cancer has these receptors, then hormone therapy is often recommended as part of the treatment plan. (The
Hormone Therapy section is on page 23.)
■■ HER2 test: Some breast cancers have large amounts of a protein called HER2, which helps them to grow. The HER2 test shows whether a woman’s breast cancer has a large amount of HER2. If so, then targeted therapy against HER2 may be a treatment option. (The Targeted
Therapy section is on page 26.)
It may take several weeks to get the results of these tests. The test results help your doctor decide which cancer treatments may be options for you.
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Triple-negative breast cancer
About 15 of every 100 American women with breast cancer have triple-negative breast cancer. These women have breast cancer cells that…
■■ Do not have estrogen receptors (estrogen negative)
■■ Do not have progesterone receptors (progesterone negative)
■■ Do not have a large amount of HER2 (HER2 negative) Staging Tests
Staging tests can show whether cancer cel s have spread to other parts of the body.
When breast cancer spreads, cancer cel s are often found in the underarm lymph nodes (axillary lymph nodes). Breast cancer cel s can spread from the breast to almost any other part of the body, such as the lungs, liver, bones, or brain.
Your doctor needs to learn the stage (extent) of the breast cancer to help you choose the best treatment. Staging tests may include…
■■ Lymph node biopsy: If cancer cel s are found in a lymph node, then cancer may have spread to other lymph nodes and other places in the body. Surgeons use a method called sentinel lymph node biopsy to remove the lymph node most likely to have breast cancer cel s. The NCI fact sheet Sentinel Lymph Node Biopsy has more information, including pictures of the method.
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If cancer cel s are not found in the sentinel node, the woman may be able to avoid having more lymph nodes removed. The method of removing more lymph nodes to check for cancer cel s is called axillary dissection.
■■ CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your chest or abdomen. You may receive contrast material by mouth and by injection into a blood vessel in your arm or hand. The contrast material makes abnormal areas easier to see. The pictures from a CT scan can show cancer that has spread to the lungs or liver.
■■ MRI: A strong magnet linked to a computer is used to make detailed pictures of your chest, abdomen, or brain.
An MRI can show whether cancer has spread to these areas. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
■■ Bone scan: The doctor injects a small amount of a radioactive substance into a blood vessel. It travels through the bloodstream and collects in the bones.
A machine called a scanner detects and measures the radiation. The scanner makes pictures of the bones.
Because higher amounts of the substance collect in areas where there is cancer, the pictures can show cancer that has spread to the bones.
■■ PET scan: You’ll receive an injection of a small amount of radioactive sugar. The radioactive sugar gives off signals that the PET scanner picks up. The PET scanner makes a picture of the places in your body where the sugar is being taken up. Cancer cel s show up brighter in the picture because they take up sugar faster than normal cel s do. A PET scan can show cancer that has spread to other parts of the body.
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Questions you may want to ask your doctor about tests
■■ What did the hormone receptor test show?
■■ What did the HER2 test show?
■■ May I have a copy of the report from the pathologist?
■■ Do any lymph nodes show signs of cancer?
■■ What is the stage of the disease? Has the cancer spread?
■■ Would genetic testing be helpful to me or my family?
Stages
The stage of breast cancer depends on the size of the breast tumor and whether it has spread to lymph nodes or other parts of the body.
Doctors describe the stages of breast cancer using the Roman numerals 0, I, II, III, and IV and the letters A, B, and C.
A cancer that is Stage I is early-stage breast cancer, and a cancer that is Stage IV is advanced cancer that has spread to other parts of the body, such as the liver.
The stage often is not known until after surgery to remove the tumor in the breast and one or more underarm lymph nodes.
7
Stage 0
Stage 0 is carcinoma in situ. In ductal carcinoma in situ (DCIS), abnormal cel s are in the lining of a breast duct, but the abnormal cel s have not invaded nearby breast tissue or spread outside the duct.
Stage IA
The breast tumor is no more than 2 centimeters (no more than 3/4 of an inch) across. Cancer has not spread to the lymph nodes.
1 cm
2 cm
4 cm
5 cm
© 2007 Terese Winslow. U.S. Govt has certain rights A tumor that is 2 centimeters is about the size of a peanut, and a tumor that is 5 centimeters is about the size of a lime.
Stage IB
The tumor is no more than 2 centimeters across. Cancer cel s are found in lymph nodes.
Stage IIA
The tumor is no more than 2 centimeters across, and the cancer has spread to underarm lymph nodes.
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Or, the tumor is between 2 and 5 centimeters (between 3/4 of an inch and 2 inches) across, but the cancer hasn’t spread to underarm lymph nodes.
Stage IIB
The tumor is between 2 and 5 centimeters across, and the cancer has spread to underarm lymph nodes.
Or, the tumor is larger than 5 centimeters across, but the cancer hasn’t spread to underarm lymph nodes.
Stage IIIA
The breast tumor is no more than 5 centimeters across, and the cancer has spread to underarm lymph nodes that are attached to each other or nearby tissue. Or, the cancer may have spread to lymph nodes behind the breastbone.
Or, the tumor is more than 5 centimeters across. The cancer has spread to underarm lymph nodes that may be attached to each other or nearby tissue. Or, the cancer may have spread to lymph nodes behind the breastbone but not spread to underarm lymph nodes.
Stage IIIB
The breast tumor can be any size, and it has grown into the chest wall or the skin of the breast. The breast may be swollen or the breast skin may have lumps.
The cancer may have spread to underarm lymph nodes, and these lymph nodes may be attached to each other or nearby tissue. Or, the cancer may have spread to lymph nodes behind the breastbone.
9
Stage IIIC
The breast cancer can be any size, and it has spread to lymph nodes behind the breastbone and under the arm.
Or, the cancer has spread to lymph nodes above or below the col arbone.
Stage IV
The tumor can be any size, and cancer cel s have spread to other parts of the body, such as the lungs, liver, bones, or brain.
Inflammatory Breast Cancer
Inflammatory breast cancer is a rare type of breast cancer.
It occurs in about 1 of every 100 American women with invasive breast cancer.
The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast.
When a doctor diagnoses inflammatory breast cancer, it’s at least Stage IIIB, but it could be more advanced.
10
Treatment
Women with breast cancer have many treatment options.
Treatment options include…
■■ Surgery
■■ Radiation therapy
■■ Hormone therapy
■■ Chemotherapy
■■ Targeted therapy
You may receive more than one type of treatment.
You and your doctor will develop a treatment plan.
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The treatment that’s best for one woman may not be best for another. The treatment that’s right for you depends mainly on…
■■ The stage of breast cancer
■■ Whether the tumor has hormone receptors
■■ Whether the tumor has too much HER2
■■ Your general health
In addition, your treatment plan depends on…
■■ The size of the tumor in relation to the size of your breast
■■ Whether you have gone through menopause
At any stage of disease, care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. You can get information about coping on NCI’s website at http://www.cancer.gov/
Also, you can get information about coping from NCI’s Cancer Information Service at 1-800-4-CANCER
(1-800-422-6237). Or, chat using NCI’s instant messaging service, LiveHelp (https://livehelp.cancer.gov).
Doctors Who Treat Breast Cancer
Your health care team will include specialists. There are many ways to find doctors who treat breast cancer:
■■ Your doctor may be able to refer you to specialists.
■■ You can ask a local or state medical society, or a nearby hospital or medical school for names of specialists.
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■■ NCI’s Cancer Information Service can give you information about treatment centers near you. Call 1-800-4-CANCER (1-800-422-6237). Or, chat using LiveHelp (https://livehelp.cancer.gov), NCI’s instant messaging service.
■■ Other sources can be found in the NCI fact sheet How To Find a Doctor or Treatment Facility If You Have Cancer.
Your health care team may include the following specialists:
■■ Surgeon: This type of doctor can perform surgery. You may want to find a breast cancer surgeon.
■■ Medical oncologist: A medical oncologist is a doctor who specializes in treating cancer with drugs, such as chemotherapy, hormone therapy, and targeted therapy.
■
■
Radiation oncologist: A radiation oncologist is a doctor who specializes in treating cancer with radiation therapy.
Your health care team may also include a plastic surgeon or reconstructive surgeon, an oncology nurse, a physical therapist, a social worker, and a registered dietitian.
Your health care team can describe your treatment choices, the expected results of each treatment, and the possible side effects. Because cancer treatments often damage healthy cel s and tissues, side effects are common. These side effects depend on many factors, including the type of treatment.
Side effects may not be the same for each woman, and they may even change from one treatment session to the next.
Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities.
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You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.
You may want to talk with your health care team about taking part in a research study (clinical trial) of new treatment methods. Research studies are an important option for women at any stage of breast cancer. See the
Cancer Treatment Research section on page 33.
Questions you may want to ask your doctor about treatment choices
■■ 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?
■■ How can the side effects be managed?
■■ What can I do to prepare for treatment?
■■ Will I need to stay in the hospital? If so, for how long?
■■ What is the treatment likely to cost? Will my insurance cover it?
■■ How will treatment affect my normal activities?
■■ Would a research study (clinical trial) be right for me?
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Second Opinion
Before starting treatment, you might want a second opinion about your treatment plan. Some women worry that the doctor will be offended if they ask for a second opinion.
Usual y the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies actual y require a second opinion.
If you get a second opinion, the second doctor may agree with your first doctor’s treatment plan. Or, the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you’ve looked at all of your options.
It may take some time and effort to gather your medical records and see another doctor. In most cases, it’s not a problem to take several weeks to get a second opinion. The delay in starting treatment usual y will not make treatment less effective. To make sure, you should discuss this delay with your doctor.
Surgery
Surgery is the most common treatment for breast cancer.
There are several kinds of surgery.
Your surgeon can describe each kind of surgery, compare the benefits and risks, and help you decide which kind might be best for you:
■■ Removing part of the breast: Breast-sparing surgery is an operation to remove the cancer and a small amount of the normal tissue that surrounds it. This is also called 15
breast-conserving surgery. It can be a lumpectomy or a segmental mastectomy (also called a partial mastectomy). A woman usual y has radiation therapy after breast-sparing surgery to kill cancer cel s that may remain in the breast area.
Some women will have more tissue removed but not the whole breast. For these women, the surgeon will remove lymph nodes under the arm and some of the lining over the chest muscles below the tumor.
■■ Removing the whole breast: Surgery to remove the whole breast (or as much of the breast tissue as possible) is a mastectomy. In some cases, a skin-sparing mastectomy may be an option. For this approach, the surgeon removes as little skin as possible.
• In total (simple) mastectomy, the surgeon removes the whole breast but not the underarm lymph nodes.
• In modified radical mastectomy, the surgeon removes the whole breast and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscle may also be taken out to make it easier to remove the lymph nodes.
The choice between breast-sparing surgery and mastectomy depends on many factors:
■■ The size, location, and stage of the tumor
■■ The size of your breast
■■ Certain features of the cancer
■■ How you feel about how surgery will change your breast 16
■■ How you feel about radiation therapy
■■ Your ability to travel to a radiation treatment center for daily treatment sessions
The surgeon usual y removes one or more lymph nodes from under the arm to check for cancer cel s. If cancer cel s are found in the lymph nodes, othe