Breast | Chris O'Brien Lifehouse

This information has been prepared to help you understand more about breast cancer.

Many people feel understandably shocked and upset when they are told they have breast cancer. This information is intended to help you understand the diagnosis and treatment of this type of cancer.

We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.

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.

breast

 

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 and the most common type is called ductal carcinoma in-situ (DCIS).

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. If you are diagnosed with invasive cancer, it is most likely to be invasive ductal cancer (IDC) or invasive lobular cancer (ILC).

There are several categories of invasive breast cancer.

  • Early breast cancer – cancer cells are contained in the breast but may have spread to one or more lymph nodes in the armpit.
  • Locally advanced breast cancer – the 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. If you would like any additional facts and statistics about breast cancer, please refer to the Cancer Institute NSW website.

What are the causes?

The exact cause of breast cancer is not known, but some factors will increase your risk:

  • getting older
  • having several close relatives, like a mother, father, 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 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 relatives with cancer of the ovary or colon
  • 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

You inherit a set of genes from each of your parents. Occasionally, you may inherit a fault (or mutation) in one copy of a gene which causes it to stop working properly. A small number of breast cancers (about 5% or 1 in 20) may be caused by an inherited faulty gene. The two most common breast cancer genes are known as BRCA1 and BRCA2. Women in families with an inherited faulty gene could be at an increased risk of breast or ovarian cancer. Men in these families may also be at an increased risk of breast and prostate cancer.

People with a strong family history of breast and associated cancers can be tested to work out whether or not they inherited a faulty gene. If you would like to discuss your family history or find out more about genetic testing, talk to your doctor.

You may notice a change in your breast or your doctor may find an unusual breast change during a physical examination. Signs to look for include:

  • a lump, lumpiness or thickening
  • changes to the nipple – such as a change in shape, crusting, a sore or an ulcer, redness, unusual discharge or a nipple that turns in (inverted) when it used to stick out
  • changes to the skin of the breast – such as dimpling of the skin, unusual redness or other colour changes
  • change in the shape or size of the breast – this might be either an increase or decrease in size
  • swelling or discomfort in the armpit
  • persistent, unusual pain that is not related to your normal monthly menstrual cycle, remains after a period and occurs in one breast only.

These changes don’t necessarily mean you have breast cancer. However, if you have any of these symptoms you should have them checked by your doctor without delay. Some women have no symptoms and their breast cancer may be found on a screening mammogram. Men’s symptoms are similar to women’s.

Types of tests

Several tests are usually used to find out if your breast change is due to breast cancer.

Physical examination

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

A mammogram 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.

For more information about mammograms, visit the BreastScreen NSW website:http://www.bsnsw.org.au/

Ultrasound

An 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 so that your breast is numb. 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.

Further tests

If the tests described above show you have breast cancer, some more tests may be done to see if the cancer has spread to other parts of your body. You may have one or more of these tests.

Blood tests

A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick.

Chest x-ray

An X-ray of the structures inside the chest. An X-ray is a type of high-energy radiation that can go through the body and onto film, making pictures of areas inside the chest, which can be used to diagnose disease.

CT scan

A series of detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an X-ray machine. Also called CAT scan, computed tomography scan, computerised axial tomography scan, and computerised tomography.

Bone scan

A technique to create images of bones on a computer screen or on film. A small amount of radioactive material is injected into a blood vessel and travels through the bloodstream; it collects in the bones and is detected by a scanner.

PET scan

A technique to create images of bones on a computer screen or on film. A small amount of radioactive material is injected into a blood vessel and travels through the bloodstream; it collects in the bones and is detected by a scanner.

MRI scan

A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or X-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones. Also called magnetic resonance imaging, NMRI, and nuclear magnetic resonance imaging.

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 referred to as hormone receptor negative. 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. A tumour that is oestrogen receptor negative (ER-) is unlikely to benefit from hormonal treatment but other suitable treatments are available.

Human epidermal-growth-factor receptor 2 (HER2) is a protein found on the surface of some cancer cells. Tumours that have high levels of these receptors are known as HER2-postive (HER2+). These tend to divide and grow more rapidly than other types of breast cancer. This receptor test can help determine whether specific drugs, such as Herceptin, will be effective as part of your treatment. About one in five women have HER2+ cancer cells.

Staging breast cancer

The additional tests described above 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), Stage III and Stage IV all refer to advanced breast cancer.

Your cancer will also be graded according to how fast the cancer is growing. The grading of breast cancer is described below:

  • 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.

Treatment

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 (known as your hormone receptor status), 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.

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, so depending on the extent of your breast cancer you will either undergo breast conservingsurgery (where part of the breast is removed) or amastectomy (where the whole breast or breasts are removed). Surgery is also undertaken to find out whether the cancer has spread to the lymph nodes. The various types of surgery are outlined below:

Lumpectomy

This breast conserving surgery is offered if the cancer is small compared to the size of your breast. Lumpectomy removes only the breast lump and some of the normal tissue surrounding it. Radiotherapy is usually given after this type of surgery to kill any cancer cells that may be left in the breast or armpit. If, after examination by a pathologist, cancerous cells are found in the edge (the margin) of the tissue surrounding the tumour the surgeon may need to remove some more tissue (re-excision) or conduct a mastectomy.

Mastectomy

An X-ray of the structures inside the chest. An X-ray is a type of high-energy radiation that can go through the body and onto film, making pictures of areas inside the chest, which can be used to diagnose disease.

Sentinel lymph node biopsy

A technique to create images of bones on a computer screen or on film. A small amount of radioactive material is injected into a blood vessel and travels through the bloodstream; it collects in the bones and is detected by a scanner.

Axillary (lymph node) surgery

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. The pathologist will provide a report that shows how many nodes were removed and how many contain cancer cells. This information assists your doctor in making decisions about further treatment. Potential physical side effects include seroma and lymphedema.

We are treating out-patients at Lifehouse and will offer in-patient care once the second phase of the Lifehouse facility opens in 2014/15.

Radiotherapy

Radiotherapy treats cancer by using high-energy X-rays to destroy the cancer cells while doing as little harm as possible to normal cells. Radiotherapy is often used after breast conserving surgery to help destroy any cancer cells left in the breast and reduce the risk of cancer returning.

Radiotherapy treatment that aims to cure the cancer will often mean that you need to go to the hospital every weekday for 5-6 weeks. Each treatment only takes about 1-5 minutes, although you may be in the treatment room for 10-30 minutes while the treatment machine is put into position. Some people manage to continue to work during radiotherapy treatment, but may need to reduce their hours to make up for travel time and time spent waiting for and receiving treatment. Other people stop working completely while they’re having radiotherapy and for a few weeks afterwards.

Side effects
Radiotherapy is a local treatment, treating a particular part of the body so other side effects will depend on the area of the body being treated. Radiotherapy to the breast does not cause hair loss but it may make you feel tired or fatigued. Some women also experience red and/or dry skin near the treatment site or, less commonly, inflammation or blistering.

Side effects tend to begin a couple of days to a couple of weeks after the treatment starts and may slowly worsen as treatment goes on. The effects may continue for several weeks after the treatment has ended and then usually improve gradually. However, the tiredness can take longer to disappear and some people find it is many months before they regain their energy.

Chemotherapy

Cytotoxic drugs (or chemotherapy) interfere with the process of cell division and are therefore able to kill or slow the growth of cancer cells. Importantly, all of the cells in our body divide to produce new cells so that the tissues and organs in our body can grow and repair. As a result, normal cells as well as cancer cells are affected and women treated with chemotherapy will experience side effects. Nevertheless, your doctor may recommend treatment with chemotherapy if:

  • the risk of the cancer returning is high, to try to prevent the breast cancer coming back or spreading to other parts of the body
  • when cancer returns after surgery or radiotherapy, to gain control of the cancer and relieve symptoms if the cancer doesn’t respond to hormone therapy.

Several different types of chemotherapy drugs are available to women with breast cancer. The most appropriate drug, or combination of drugs, for you will depend on the type of breast cancer you have and what other treatments you are having. Chemotherapy is usually given as a liquid through a drip into a vein (intravenously), so that the drugs can circulate in the bloodstream and reach the cancer cells wherever they are in the body. Some types are taken as tablets or capsules.

Chemotherapy is usually given in cycles of treatment so that your body is given time to recover. Usually you will have about 4-6 chemotherapy sessions every 2-3 weeks. You will often be treated as a day patient, but you may occasionally need to stay overnight. Chemotherapy will usually last several months. Some treatments for particular types of cancer last much longer than this, others may be shorter. The duration of your chemotherapy will be determined, among other things, by the reason for chemotherapy.

There are many different reasons that you may undergo chemotherapy:

  • Cure – some cancers can be cured by chemotherapy alone or combined with other treatments, such as surgery and radiotherapy
  • Adjuvant – chemotherapy can be given either before or after other treatments. When given before, the drugs are used to make the cancer small so other treatment can be more effective. When given after the other treatment, chemotherapy is used to kill any leftover cancer cells that may cause problems later.
  • Palliative – this treatment aims for relief of symptoms. It is particularly important for people who cannot be cured but want to maintain their quality of life. For example chemotherapy may be used to relieve pain caused by cancer or to stop the spread of cancer into an organ.

Cytotoxic chemotherapy affects people in different ways. Some people find that they can’t work at all. Others find they can keep working or that they just need to take a few days off after their treatment and can then work until their next treatment.

Side effects
Chemotherapy can cause unpleasant side effects. It can temporarily stop the bone marrow from making new blood cells. This means your immunity is reduced and you’re more prone to infections. You may also become anaemic (when the number of red blood cells in your blood is low) or have bleeding problems, such as nose bleeds or bruise easily. If the bone marrow is not working properly you may need to take antibiotics to treat infection, or have a blood transfusion if you are anaemic. You will have regular blood tests between courses of treatment to monitor the effects.

Other common side effects include tiredness and weakness, feeling sick, a sore mouth or mouth ulcers, diarrhoea or constipation, and numbness and tingling of the hands and feet. In addition, most people who have chemotherapy lose their head and body hair. Some women also find that their period become irregular during treatment and then return to normal; for others, chemotherapy may cause their period to stop permanently (menopause).

Your side effects will be closely monitored whilst you are on treatment. Medicines can be given to control some of these effects. The side effects will gradually disappear once the treatment has finished.

Hormone therapy

Hormone therapy, also called endocrine therapy, is a treatment option in some women who have ER+ hormone receptors on their breast cancer cells. Hormone therapy aims to stop or slow the growth of hormone receptor positive cells, change the level of a particular hormone in the body, or prevent the hormone affecting the cancer cells.

Tamoxifen
Tamoxifen is known as an anti-oestrogen drug. It works by preventing cancer cells from responding to oestrogen. Tamoxifen is usually, but not solely, given to premenopausal women and is often started after surgery or following radiotherapy or chemotherapy. It is taken as a daily tablet over five years.

Tamoxifen does not cause menopause but may cause hot flushes, headaches, a skin rash, trouble sleeping, vaginal dryness or discharge, weight gain and irregular periods. Importantly, tamoxifen has also been linked to a higher risk of blood clots and you should see you doctor immediately if you have new swelling, soreness or a warm spot in your arm or leg.

Ovarian treatments
If you are premenopausal, your doctor may recommend a treatment to stop your ovaries from producing oestrogen, either temporarily or permanently. The drug goserelin (Zoladex) can be injected into the body to stop oestrogen production and bring on a temporary menopause. It may cause side effects such as low sex drive, hot flushes, mood swings, trouble sleeping, vaginal dryness and headaches.

Ovarian ablation is a treatment that stops oestrogen production permanently. The ovaries will either be surgically removed (oophorectomy) or will undergo radiotherapy. Ovarian ablation will bring on menopause, meaning that you will no longer be able to become pregnant. You may have some menopausal symptoms such as hot flushes and a dry vagina. You will also be at higher risk of osteoporosis.

Aromatase inhibitors
If you have reached menopause you may be treated with an aromatase inhibitor. Aromatase inhibitors help prevent the growth of oestrogen-dependent cancer cells by reducing the amount of oestrogen made in the body. Side effects may include osteoporosis, vaginal dryness, hot flushes and weight gain.

Herceptin
Trastuzumab (commonly known as Herceptin) is a common type of targeted therapy for breast cancer. It attaches itself to HER2+ breast cancer cell receptors and destroys the cells and their ability to divide and grow. Herceptin also encourages the body’s own immune cells to help destroy the cancer cells.

Herceptin is given through a drip (injection or infusion into your vein) approximately every three weeks and you may receive Herceptin for a few years. The first treatment may take up to 90 minutes. Many women experience side effects when they take Herceptin, the most common of which include fever, runny nose, nausea and vomiting, diarrhoea, headache and a rash.

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:

  • General practitioner (GP) – explains information provided by specialists, helps you with treatment decisions and assists you in obtaining practical and emotional support
  • 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 – prescribes and coordinates chemotherapy, hormone therapy and targeted drug therapies
  • 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 educate patients about lymphedema management
  • Social worker – links you to support services and helps you with any emotional, physical or practical problems
  • Reconstructive (plastic) 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.

Cancer Council Australia

A guide for people with breast cancer.

Useful websites

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