Breast Cancer

About Breast Cancer

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The National Cancer Institute estimates that approximately 2.3 million women were breast cancer survivors in January 2002. Doctors cannot always explain why one person gets cancer and another does not. However, scientists have studied general patterns of cancer in the population to learn what things around us and what things we do in our lives may increase our chance of developing cancer.

Anything that increases a person’s chance of developing a disease is called a risk factor; anything that decreases a person’s chance of developing a disease is called a protective factor. Some of the risk factors for cancer can be avoided, but many cannot. For example, although you can choose to quit smoking, you cannot choose which genes you have inherited from your parents. Both smoking and inheriting specific genes could be considered risk factors for certain kinds of cancer, but only smoking can be avoided. Prevention means avoiding the risk factors and increasing the protective factors that can be controlled so that the chance of developing cancer decreases.

Although many risk factors can be avoided, it is important to keep in mind that avoiding risk factors does not guarantee that you will not get cancer. Also, most people with a particular risk factor for cancer do not actually get the disease. Some people are more sensitive than others are to factors that can cause cancer. Talk to your doctor about methods of preventing cancer that might be effective for you. More information also exists on these web pages.

Breast Cancer Well-Fit Program
Gathering at The Viking Store in Atlanta for the kick-off of PINK are: (Front Row) Jeffrey Allen, M.D., medical director, Doris Shaheen Breast Health Center at Piedmont Hospital; Laurel Sybilrud, grant committee chair, and Randi Passoff, executive director, Atlanta Two Day-It's a Journey; (back row) Carolyn Helmer, manager of Cancer Wellness at Piedmont Hospital; and Quito McKenna, vice president and general manager of The Viking Store. All seats were occupied at the Viking Cooking School for the launch of PINK: a cancer well-fit program for women completing treatment for breast cancer. PINK is sponsored by It’s the Journey, the producer of the Atlanta 2-Day Walk for Breast Cancer, and is offered free of charge. See the Cancer Wellness tab on this website for more information.

To learn more, click on www.piedmont.org.

Detailed Information about Breast Cancer

• Breast Cancer Treatment for Patients.
• Breast Cancer Facts and Figures.
• Piedmont Hospital Stats and Outcomes.

Breast Cancer Prevention

The breast consists of lobes, lobules, and bulbs that are connected by ducts. The breast also contains blood and lymph vessels. These lymph vessels lead to structures that are called lymph nodes. Clusters of lymph nodes are found under the arm, above the collarbone, in the chest, and in other parts of the body. Together, the lymph vessels and lymph nodes make up the lymphatic system, which circulates a fluid called lymph throughout the body. Lymph contains cells that help fight infection and disease.

When breast cancer spreads outside the breast, cancer cells are most often found under the arm in the lymph nodes. In many cases, if the cancer has reached the lymph nodes, cancer cells may have also spread to other parts of the body via the lymphatic system or through the bloodstream.

Significance of breast cancer

Breast cancer is second only to lung cancer as the leading cause of cancer death among women in the United States. Breast cancer occurs in men also, but the number of new cases is small. Early detection and effective treatment is expected to reduce the number of women who die from breast cancer, and development of new methods of prevention continue to be studied.

Breast cancer prevention

Breast cancer can sometimes be associated with known risk factors for the disease. Many risk factors are modifiable though not all can be avoided.

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) FOR PREVENTION OF BREAST CANCER: SERMs are drugs that act like estrogen on some tissues in the body such as bones, but block the effect of estrogen on other tissues. Tamoxifen is a SERM that blocks the effect of estrogen on breast cancer cells. A large study has shown that tamoxifen lowers the risk of getting breast cancer in women who are at elevated risk of getting breast cancer. However, tamoxifen may also increase the risk of endometrial cancer, stroke, and blood clots in veins and in the lungs. Women who are concerned that they may be at an increased risk of developing breast cancer should talk with their doctor about whether to take tamoxifen to prevent breast cancer. It is important to consider both the benefits and risks of taking tamoxifen.

Raloxifene is another SERM that is being studied for the prevention of breast cancer. A study of postmenopausal women with osteoporosis has shown that raloxifene lowered the risk of breast cancer for women at both high risk and low risk of developing the disease. It is not known if women who do not have osteoporosis would benefit in the same way. Like tamoxifen, raloxifene may increase the risk of blood clots in veins and in the lungs, but does not appear to increase the risk of endometrial cancer.

HORMONAL FACTORS: Hormones produced by the ovaries appear to increase a woman’s risk for developing breast cancer. The removal of one or both ovaries reduces the risk. The use of drugs that suppress the production of estrogen may inhibit tumor cell growth. The use of estrogen-progestin therapy, also called combination hormone replacement therapy (HRT), is associated with an increased risk of developing breast cancer. The use of oral contraceptives may also be associated with a slight increase in breast cancer risk.

Beginning to menstruate at an older age and having a full-term pregnancy reduces breast cancer risk. Also, a woman who has her first child before the age of 20 experiences a greater decrease in breast cancer risk than a woman who has never had children or who has her first child after the age of 35. Beginning menopause at a later age increases a woman’s risk of developing breast cancer.

RADIATION: Studies have shown that reducing the number of chest x-rays, especially at a young age, decreases the risk of breast cancer. Radiation treatment for childhood Hodgkin’s lymphoma may put women at a greater risk for breast cancer later in life. A small number of breast cancer cases can be linked to radiation exposure.

DIET AND LIFESTYLE: Diet is being studied as a risk factor for breast cancer. Studies show that in populations that consume a high-fat diet, women are more likely to die of breast cancer than women in populations that consume a low-fat diet. It is not known if a diet low in fat will prevent breast cancer. Eating a diet rich in beta-carotene may decrease the risk of breast cancer. Exercise, especially in young women, may decrease hormone levels and contribute to a decreased breast cancer risk. Breast feeding may also decrease a woman’s risk of breast cancer. Postmenopausal weight gain, especially after natural menopause and/or after age 60, may increase breast cancer risk.

ALCOHOL: Drinking alcohol may be linked to increased breast cancer risk. The more alcohol a woman drinks, the more the risk of breast cancer may increase, compared to a woman who drinks no alcohol. In addition, a diet rich in beta-carotene, folate, and vitamins A and C may reverse the higher risk of breast cancer linked to alcohol use.

PROPHYLACTIC MASTECTOMY: Following cancer risk assessment and counseling, the removal of both breasts may reduce the risk of breast cancer in women with a family history of breast cancer.

GENETICS: Women who inherit specific genes are at a greater risk for developing breast cancer. Research is underway to develop methods of identifying high-risk genes.

National Cancer Institute

Breast Cancer and Pregnancy

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts.

Anatomy of the breast, showing lymph nodes and lymph vessels.

Each breast also contains blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. The lymph vessels lead to small, bean-shaped organs called lymph nodes that help the body fight infection and disease. Lymph nodes are found throughout the body. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

Breast cancer is sometimes detected (found) in women who are pregnant or have just given birth.

In women who are pregnant or who have just given birth, breast cancer occurs most often between the ages of 32 and 38. Breast cancer occurs about once in every 3,000 pregnancies.

It may be difficult to detect (find) breast cancer early in pregnant or nursing women, whose breasts are often tender and swollen.

Women who are pregnant, nursing, or have just given birth usually have tender, swollen breasts. This can make small lumps difficult to detect and may lead to delays in diagnosing breast cancer. Because of these delays, cancers are often found at a later stage in these women.

Breast examination should be part of prenatal and postnatal care.

To detect breast cancer, pregnant and nursing women should examine their breasts themselves. Women should also receive clinical breast examinations during their routine prenatal and postnatal examinations.

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

If an abnormality is found, one or all of the following tests may be used:

• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
• Mammogram: An x-ray of the breast. A mammogram can be performed with little risk to the fetus. Mammograms in pregnant women may appear negative even though cancer is present.
  
  Mammography of the right breast.
• Biopsy: The removal of cells or tissues by a pathologist so they can be viewed under a microscope to check for signs of cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it is in the breast only or has spread to other places in the body).
• The size of the tumor.
• The type of breast cancer.
• The age of the fetus.
• Whether there are symptoms.
• The patient’s general health.

Stages of Breast Cancer

After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.

The process used to find out if the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. (Refer to the PDQ summary on Breast Cancer Treatment for more information on the stages used for breast cancer.)

Methods used to stage breast cancer can be changed to make them safer for the fetus.

Standard methods for giving imaging scans can be adjusted so that the fetus is exposed to less radiation. Tests to measure the level of hormones in the blood may also be used in the staging process.

There are different types of treatment for patients with breast cancer.

Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Treatment options for pregnant women depend on the stage of the disease and the age of the fetus.

Three types of standard treatment are used:

Surgery

Most pregnant women with breast cancer have surgery to remove the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Types of surgery to remove the breast include:

• Simple mastectomy: A surgical procedure to remove the whole breast that contains cancer. Some of the lymph nodes under the arm may also be removed for biopsy. This procedure is also called a total mastectomy.
  
  Total mastectomy. Dotted line shows entire breast is removed. Some lymph nodes under the arm may also be removed.
• Modified radical mastectomy: A surgical procedure to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.
  
  Modified radical mastectomy. Dotted line shows entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

• Lumpectomy: A surgical procedure to remove a tumor (lump) and a small amount of normal tissue around it. Most doctors also take out some of the lymph nodes under the arm.
• Partial mastectomy: A surgical procedure to remove the part of the breast that contains cancer and some normal tissue around it. Some of the lymph nodes under the arm may also be removed for biopsy. This procedure is also called a segmental mastectomy.

Breast-conserving surgery. Dotted lines show area containing the tumor that is removed and some of the lymph nodes that may be removed.

Even if the doctor removes all of the cancer that can be seen at the time of surgery, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Treatment given after surgery to increase the chances of a cure is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Radiation therapy should not be given to pregnant women with early stage (stage I or II) breast cancer because it can harm the fetus. For women with late stage (stage III or IV) breast cancer, it should not be given during the first 3 months of pregnancy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Chemotherapy should not be given during the first 3 months of pregnancy. Chemotherapy given after this time does not usually harm the fetus but may cause early labor and low birth weight.

New types of treatment are being tested in clinical trials. These include the following:

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy are used to reduce the production of hormones or block them from working.

The effectiveness of hormone therapy, alone or combined with chemotherapy, in treating breast cancer in pregnant women is not yet known.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

Ending the pregnancy does not seem to improve the mother’s chance of survival and is not usually a treatment option.

If the cancer must be treated with chemotherapy and radiation therapy, which may harm the fetus, ending the pregnancy is sometimes considered. This decision may depend on the stage of cancer, the age of the fetus, and the mother’s chance of survival.

Treatment Options by Stage

Early Stage Breast Cancer (Stage I and Stage II)

Treatment of early stage breast cancer (stage I and stage II) may be surgery followed by adjuvant therapy as follows:

• Modified radical mastectomy.
• Breast-conserving surgery: Lumpectomy, partial mastectomy or segmental mastectomy.
• Breast-conserving surgery during pregnancy followed by radiation therapy after the baby is born.
• Surgery during pregnancy followed by chemotherapy after the first 3 months of pregnancy.
• Clinical trials of surgery followed by hormone therapy with or without chemotherapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

Late Stage Breast Cancer (Stage III and Stage IV)

Treatment of late stage breast cancer (stage III and stage IV) may include the following:

• Radiation therapy.
• Chemotherapy.

Radiation therapy and chemotherapy should not be given during the first 3 months of pregnancy.

Other Considerations for Pregnancy and Breast Cancer

Lactation (breast milk production) and breast-feeding should be stopped if surgery or chemotherapy is planned.

If surgery is planned, breast-feeding should be stopped to reduce blood flow in the breasts and make them smaller. Breast-feeding should also be stopped if chemotherapy is planned. Many anticancer drugs, especially cyclophosphamide and methotrexate, may occur in high levels in breast milk and may harm the nursing baby. Women receiving chemotherapy should not breast-feed. Stopping lactation does not improve survival of the mother.

Breast cancer does not appear to harm the fetus. Breast cancer cells do not seem to pass from the mother to the fetus. Pregnancy does not seem to affect the survival of women who have had breast cancer in the past.

Some doctors recommend that a woman wait 2 years after treatment for breast cancer before trying to have a baby, so that any early return of the cancer would be detected. This may affect a woman’s decision to become pregnant. The fetus does not seem to be affected if the mother has previously had breast cancer.

Effects of certain cancer treatments on later pregnancies are not known.

The effects of treatment with high-dose chemotherapy and a bone marrow transplant, with or without radiation therapy, on later pregnancies are not known.

Cancer Research

Piedmont Hospital participates in clinical trials for a variety of cancers. We are a member of the Atlanta Regional Community Clinical Oncology Program (ARCCOP), a National Cancer Institute (NCI) project, which allows community hospitals access to clinical trials. We also participate in pharmaceutical sponsored clinical trials. This enables patients to participate in cutting edge research studies without having to travel far distances to a research institution or the NCI.

For more information, please contact the Oncology Research department at:

Bonita Feinstein
Piedmont Hospital
Oncology Research
1968 Peachtree Rd. NW
Atlanta, GA 30309
404.605.2887

For a listing of current Atlanta Regional CCOP clinical trials open at Piedmont, you may access www.atlantaccop.org.
For other information related to cancer clinical trials, you may access the following web-sites:
Georgia’s Cancer Clinical Trials - www.georgiacancertrials.org
National Institutes of Health (NIH) Clinical Trials – www.clinicaltrials.gov
National Cancer Society (NCI) – www.cancer.gov

To Learn More

CALL

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.

WEB SITES AND ORGANIZATIONS

The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. There are also many other places where people can get materials and information about cancer treatment and services. Local hospitals may have information on local and regional agencies that offer information about finances, getting to and from treatment, receiving care at home, and dealing with problems associated with cancer treatment.

PUBLICATIONS

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615.

LIVEHELP

The NCI's LiveHelp service, a program available on several of the Institute's Web sites, provides Internet users with the ability to chat online with an Information Specialist. The service is available from 9:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

WRITE

For more information from the NCI, please write to this address:

NCI Public Inquiries Office

Suite 3036A

6116 Executive Boulevard, MSC8322

Bethesda, MD 20892-8322

About PDQ

PDQ IS A COMPREHENSIVE CANCER DATABASE AVAILABLE ON NCI'S WEB SITE.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ CONTAINS CANCER INFORMATION SUMMARIES.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

THE PDQ CANCER INFORMATION SUMMARIES ARE DEVELOPED BY CANCER EXPERTS AND REVIEWED REGULARLY.

Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.

PDQ ALSO CONTAINS INFORMATION ON CLINICAL TRIALS.

Before starting treatment, patients may want to think about taking part in a clinical trial. A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about new treatments, the risks involved, and how well they do or do not work. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard."

Listings of clinical trials are included in PDQ and are available online at NCI's Web site. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

Date Last Modified: 2006-01-04

If you want to know more about cancer and how it is treated, or if you wish to know about clinical trials for your type of cancer, you can call the NCI's Cancer Information Service at 1-800-422-6237, toll free. A trained information specialist can talk with you and answer your questions.