Breast Cancer

Breast cancer is a disease in which cells in your breast grow uncontrollably and can form tumors. It can start in one or both breasts. Breast cancer is the second most common type of cancer in women after skin cancer.

Further, breast cancer is majorly diagnosed in women, however, it can also occur in men and younger women. Moreover, the risk of developing breast cancer increases with age, particularly for women who are 50 years or older.

In addition to the above, about 80% of breast cancer cases are invasive, meaning a tumor can spread from your breast to nearby lymph nodes and other parts of your body. Therefore, it is important to understand that, any lump or change in your breast should be checked by your doctor to analyze if it may lead to cancer in future.

Types of Breast Cancer

There are many types of breast cancer. The types are based on which breast cells become cancer or where the cancer starts in the breast.

Common types of breast cancer include:

Invasive Ductal Carcinoma (IDC): It is the most common type of breast cancer. Please note, in breast, ducts are small tubes that carry milk to the nipples. Invasive ductal carcinoma starts in your milk ducts and may spreads to nearby breast tissues. This cancer may also spread to other parts of your body through lymph nodes or bloodstream. Approximately 80% of breast cancers are of this type.
Invasive lobular carcinoma (ILC): It is the second most common type of breast cancer. Please note, lobules are the glands in your breast that make milk. Invasive lobular carcinoma starts in your lobules and may spreads to nearby breast tissues. This cancer may also spread to other parts of your body through lymph nodes or bloodstream. Moreover, women diagnosed with ILC may have cancer affecting both breasts. Approximately 15% of breast cancers are of this type.
Ductal carcinoma in situ (DCIS): It is a very early form of breast cancer. This starts in your milk ducts, however, it does not spread beyond your milk ducts. Which means, it remains inside your milk ducts. Furthermore, it is sometimes called noninvasive or stage 0 breast cancer.

Less common types of breast cancer include:

Inflammatory breast cancer (IBC): It is a rear and fast-growing type of breast cancer in which, cancer cells block “lymph vessels” in the skin of your breast and cause the breast to look swollen. Moreover, the skin of your breast may look red or purple. Therefore, contact your doctor right away if you notice any skin changes on your breast. IBC accounts for about 1% to 5% of all breast cancers.

Paget disease of the breast: This rare type of cancer starts in the nipple. Further, it may also affects the dark circle of skin around the nipple, called the areola. It can cause flaky or scaly red skin that may tingle or itch. Furthermore, it accounts for only about 1% to 3% of all cases of breast cancer.

It is important to note that, most people with Paget disease of the breast also have “Ductal Carcinoma” in the same breast.
Angiosarcoma: It is a vary rare cancer that develops in the inner lining of blood vessels and lymph vessels. This cancer can occur anywhere in the body but most often in the skin, breast, liver and spleen. Furthermore, angiosarcoma makes up less than 1% of all breast cancers.
Phyllodes tumor: A rare breast tumors that start in the connective tissue (stromal) of the breast. Most phyllodes tumors are benign (non-cancerous) but some can be malignant (cancer). Phyllodes tumor is super rare, accounting for 0.3% to 0.9% of all breast tumors.

Subtypes of Breast Cancer

Breast cancers are further categorized by the doctors according to their hormone receptor status. Please note, receptors are protein molecules on the surfaces of cancer cells, which can attach to the hormones in your blood, such as estrogen and progesterone. These hormones help cancer cells to grow.

Following are the subtypes of Breast Cancer:

ER-positive (ER+): Breast cancers have estrogen receptors, indicating that its growth can be due to estrogen hormone.
PR-positive (PR+): Breast cancers have progesterone receptors, indicating that its growth can be due to progesterone hormone.
HR-positive (HR+): Breast cancers have estrogen and progesterone receptors, indicating that its growth can be due to both hormones.
HR-negative (HR-): Breast cancers do not have estrogen and progesterone receptors.
HER2-positive (HER2+): Br HER2-positive.

Please note, (HER2) means Human epidermal growth factor receptor 2.

Triple-negative breast cancer (TNBC): It is an aggressive subtype of breast cancer in which the tumor cells do not have estrogen receptors, progesterone receptors and HER2 protein. TNBC accounts for about 15% of all breast cancers and is known for its rapid spread.

Stages of Breast Cancer

A breast cancer stage is a way of saying how large a cancer is and whether it has spread to other parts of the body. It also helps doctors to decide the best treatment for breast cancer. Further, there are two staging systems used for breast cancer:

TNM staging system
Numerical staging system (0 to IV).

The aim of both staging system is to provide information about the breast cancer, best course of treatment and prognosis.

1. TNM staging system: The TNM staging system is used worldwide to know the severity of breast cancer. It is an accurate staging system that helps doctors to understand the exact stage of breast cancer and plan the most effective treatment for patients.

Furthermore, the TNM system is based on three key factors, Tumor size (T), Nodes (N) and Metastasis (M): Moreover, in TNM system a letter or number is assigned after TNM to give additional details about breast cancer. Higher numbers mean the cancer is more advanced. Details are as following:

Tumor Size (T): The T describes the tumor on the basis of its size and location. Further, detailed breakdown of (T) is as follows:
- TX: It means that there is no tumor in the breast to measure.
- T0: There is no evidence of a tumor in the breast. Please note, this can occur if the tumor is too small to be detected.
- Tis: It means the tumor is present in the place where it has first formed and has not spread to surrounding healthy breast tissues or other parts of the body. This is also known as in situ cancer or pre-invasive cancer.
- T1: It means the tumor is 2 cm or smaller.
- T2: It means the tumor is larger than 2 cm but not more than 5 cm.
- T3: It means the tumor is larger than 5 cm.
- T4: It means, the tumor (of any size) has spread to the chest wall or skin. T4 is further divided into 4 categories:
  - T4a: The tumor has grown into the chest wall.
  - T4b: The tumor has caused swelling of the breast skin.
  - T4c: The tumor has spread to both the chest and the skin wall.
  - T4d: This is specifically for inflammatory breast cancer, a rare and aggressive type.

Nodes (N): The N describes whether the cancer has spread to the nearby lymph nodes, particularly those located in the armpit (axillary lymph nodes). Please note, lymph nodes are small bean-shaped structure that is part of your body’s immune system. Further, detailed breakdown of (N) is as follows:
- NX: It means nearby lymph nodes cannot be assessed.
- N0: It means there is no spread of cancer to nearby lymph nodes. In other words, nearby lymph nodes does not contain cancer.
- N1: It means the cancer has spread to 1-3 armpit lymph nodes.
- N2: It means the cancer has spread to 4-9 armpit lymph nodes.
- N3: It means the cancer has spread to 10 or more armpit lymph nodes or to lymph nodes above the collarbone.

Metastasis (M): It indicates whether the cancer has spread to other parts of the body. This is the most crucial factor in finding out the overall stage of breast cancer. Further, detailed breakdown of (M) is as follows:
- M0: It means that there is no sign of cancer spread to other parts of the body. In other words, the cancer is limited to the breast and nearby lymph nodes only.
- M1: It means distant metastasis is present. In other words, the cancer has spread to other organs such as the bones, lungs, liver or brain. Please note, breast cancer with M1 status is automatically categorized as Stage IV breast cancer.

2. Numerical staging system (0 to IV):

In numerical staging system, breast cancer has been grouped into five stages from 0 to IV. A lower number (0) typically means the cancer is smaller and might only be in the breast. The higher number (IV) indicates that the cancer has spread outside the breast to other parts of the body also known as Metastasis.

Causes and Risk Factors of Breast Cancer

Researchers know that breast cancer starts when there are changes in the genetic material (DNA) inside breast cells. Due to these genetic changes, your breast cells become cancerous that divide and multiply to create tumors. Furthermore, the exact cause of these genetic changes is often unknown. However, there are several risk factors that may increase your risk of developing breast cancer.

These risk factors can be divided into those you cannot change (non-modifiable) and those you can change (modifiable).

Non-modifiable risk factors include:

Gender: Women are much more likely to develop breast cancer than men, due to having more breast tissue. Everyone is born with some breast tissue, so anyone can get this disease.
Age: The risk of breast cancer increases as you get older. Most breast cancers are diagnosed after age 50.
Personal history of breast cancer: If you have had breast cancer in one breast, you have an increased risk of developing it in the other breast.
A family history of breast cancer: Having a mother, sister, daughter or close relatives with breast cancer increases your risk. However, most people diagnosed with breast cancer do not have a family history of the breast cancer.
Menstrual history: Starting period before age 12 and experiencing menopause after age 55, leads you to longer lifetime exposure to hormones, which may increase your risk of breast cancer.
Dense breast tissue: The breasts are made up of dense breast tissue and fatty breast tissue. Dense breast tissue includes the milk glands, milk ducts and fibrous tissue in the breast. Fatty tissues are made of fat cells. A women with dense breast has more dense tissue than fatty tissue.

Dense breasts can sometimes make it hard to detect tumors on a mammogram. If a mammogram showed that you have dense breasts, your risk of breast cancer is increased.
Previous radiation therapy: Previous radiation therapy to your neck, chest or breast increases your risk of breast cancer.
Genetic mutations in genes: Genetic Mutations in certain genes like BRCA1 and BRCA2 greatly increase your risk of breast cancer and ovarian cancer. Approximately 15% of all breast cancer cases are due to theses genetic mutations.
Exposure to the drug (diethylstilbestrol-DES): Exposure to the drug (diethylstilbestrol-DES), given to some pregnant women between 1940 and 1971, has been linked to a higher risk of breast cancer in both the women who took the drug and their daughters.

Please note, this drug was given to some pregnant women between 1940 and 1971 to prevent miscarriage

Modifiable risk factors include:

Less physical activity: Women who are not physically active have a higher risk of developing breast cancer. Further, regular exercise can reduce this risk.
Being overweight (obesity): Women who are overweight or have obesity have a higher risk of breast cancer.

Taking hormones: People who take hormone replacement medicines (that include both estrogen and progesterone) to control the symptoms of menopause may increase the risk of breast cancer. Moreover, certain oral contraceptives (birth control pills) have also been found with the risk of breast cancer.

Please note, hormone replacement therapy (HRT) means using medicines to replace hormones that your body no longer produces naturally, often during menopause.
Reproductive history: Your reproductive history also plays a role. Never having a full-term pregnancy may increase your risk of breast cancer.
Drinking alcohol: Drinking alcohol is clearly linked to an increased risk of breast cancer. Even one alcoholic drink per day can slightly increase the risk.
Smoking: Smoking has been linked to many different types of cancer, including breast cancer.
Night shift working: Hormonal changes due to working in night shits may also increase the risk of breast cancer.

Signs and Symptoms of Breast Cancer

Early detection of breast cancer is important for successful treatment. Therefore, being aware of the signs and symptoms can help find breast cancer at an early stage.

Symptoms of breast cancer are as following:

Presence of a new lump in the breast or in the underarm area. Further, the lump may be feel like a small pea. Moreover, the consistency of the lump may be soft, rubbery or hard.
A change in the size, shape or appearance of the breast.
A dimple or puckering in the skin of the breast that may look like the skin of an orange.
A nipple turned inward into the breast (inverted nipple).
Nipple discharge other than breast milk, especially if it is bloody or occurs in only one breast.
Scaly, red or swollen skin on the breast, nipple or areola (dark circle of skin around the nipple).
Pain may occur in any area of the breast. However, it is hardly the sole symptom of breast cancer.
Swelling of all or part of a breast, even if no lump is felt.
An ulcer on the breast or nipple.
Swollen lymph nodes under the arm or near the collar bone may indicate the spread of breast cancer.

Diagnosis of Breast Cancer

Your doctor may use following methods to diagnose breast cancer.

Mammography: Mammography is commonly used to look for breast cancer. It is an X-ray of the breast that can detect tumors, lumps and abnormalities even before they can be felt.

There are two main types of mammography:
- 2D mammograms: In 2D mammogram, usually two X-ray images are taken of each breast, one from the side and one from above.
- 3D mammograms (tomosynthesis): It involves taking several images of your breast from multiple angles and converting them into highly focused three-dimensional images. Further, a computer then puts the images together in slices, which allows your doctor to see your breast tissues in 3D, to find out abnormalities.
- Clinical breast exam (CBE): It is a physical examination of your breasts and underarm area by a doctor. This involves checking for any lumps in breasts and armpits. Furthermore, your doctor may also look for any changes in color of the skin of breasts.

Breast ultrasound: Ultrasound uses sound waves to create images of breast tissues. It allows your doctor to look closely at any specific area of your breast. Further, breast ultrasound may give useful information about breast lumps. It may show whether the lump is a solid mass or a fluid-filled cyst.

Please note, a fluid-filled breast cyst is usually non-cancerous, but, a solid mass can be a cancer and may need further testing.
Breast MRI: It uses radio waves, strong magnets and computer to produce detailed images of the breast. It is a large tube and you lie inside the tube during the scan. Further, MRI is primarily used for screening women who are at high risk of breast cancer or having dense breast tissue.

Please note, a women with dense breast has more dense tissue, which can sometimes make it hard to detect tumors.
Breast biopsy: A biopsy involves the removal of a small sample of breast tissue for testing in a lab. To take the sample, your doctor puts a needle through the skin and into the breast tissue. Further, your doctor looks at the collected sample under a microscope to diagnose breast cancer and other breast diseases. Please note, breast biopsy is the only definitive way to diagnose breast cancer.

Treatment Options for Breast Cancer

Treatment for breast cancer depends on the type of cancer, stage of cancer and how quickly it is growing. Moreover, the treatment also depends upon your overall health status. Furthermore, a team of doctors typically develops a treatment plan for you as following:

Breast cancer surgery: It is the primary treatment option, in which doctors cut out the cancer tissues. Types of breast cancer surgery include:
- Lumpectomy: This surgery removes the cancer cells and some normal tissue around it. The rest of the breast is not removed.
- Mastectomy: It is a surgery to remove all of the breast. It removes the entire breast including the lobules, ducts, fatty tissue, nipple and skin.
Radiation therapy: It uses high doses of radiation (X-rays) to kill cancer cells in your breast and stop them from spreading. Radiation therapy is often used after surgery. It can kill any cancer cells that might be left after surgery.

Radiation therapy can be given as following:
- External beam radiation therapy: In this treatment you lie on a table and a machine moves around you and sends beams of high-energy radiation to your breast. Moreover, the machine sends radiation beams to exact points on your breast to kill cancer cells.
- Internal radiation therapy: Radiation therapy may also be given internally, by placing radioactive sources directly into your breast. This type of radiation is called brachytherapy.

Chemotherapy: Uses strong medicines to destroy cancer cells in your breast. Furthermore, your doctor may use one kind of chemotherapy medicine or combination of chemotherapy medicines to treat your breast cancer.

Further, the medicines are mostly given through veins. However, some medicines are in the form of pills. Your doctor will recommend, how the chemotherapy should be given to you (intravenously, orally or both).

Please note, chemotherapy given before surgery is known as “neoadjuvant” or after surgery known as “adjuvant”.
Hormonal therapy: It is a treatment in which medicines are used to block hormones “Estrogen” and “Progesterone” produced by your body. The cancer cells use these hormones as a fuel for their growth. Therefore, by blocking the hormones can cause the breast cancer cells to shrink or die. Furthermore, hormone therapy is often used after surgery, because, it can lower the risk of cancer returning.
Targeted therapy: It is a treatment in which medicines are used to attack or block the specific proteins in the cancer cells that are important for their survival. Moreover, your cancer cells will also be tested by your doctor to see which medicine may block the specific proteins that make the cancer cells multiply.

For example, some breast cancer cells make extra “HER2 protein”. This protein is important for the growth and survival of cancer cells. The targeted therapy medicines attacks the cancer cells that are making extra HER2 protein, without harming the healthy cells.
Immunotherapy: One reason cancer cells can keep growing and spreading is that they can hide from your immune system. Immunotherapy is a type of treatment that trains your immune system to recognize and attack breast cancer cells. Some immunotherapies can “mark” your cancer cells. This makes it easier for your immune system to find and kill the cancer cells.

Immunotherapy may be used before surgery to shrink a large cancer. It may also be used after surgery to lower the risk of the cancer coming back.

Furthermore, there are different forms of immunotherapy, so how they are given depends on the type of medicine. You can get immunotherapy through drip into your bloodstream (intravenously) or you may get immunotherapy through pills or capsules as advised by your doctor.

Please remember, it is important to discuss all your treatment options with your healthcare team and doctor.

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