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National Cancer Institute

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Breast cancer


Table of Contents

OVERVIEW OF PDQ
What is PDQ?
How to use PDQ
DESCRIPTION
What is breast cancer?
STAGE EXPLANATION
Stages of breast cancer
Carcinoma in situ
Stage I
Stage II
Stage III
Stage IV
Inflammatory breast cancer
Recurrent
TREATMENT OPTION OVERVIEW
How breast cancer is treated
Treatment by stage
CARCINOMA IN SITU
STAGE I BREAST CANCER
STAGE II BREAST CANCER
STAGE III BREAST CANCER
STAGE IV BREAST CANCER
INFLAMMATORY BREAST CANCER
RECURRENT BREAST CANCER
TO LEARN MORE

OVERVIEW OF PDQ


What is PDQ?

PDQ is a computer system that gives up-to-date information on cancer and its prevention, detection, treatment, and supportive care. It is a service of the National Cancer Institute (NCI) for people with cancer and their families and for doctors, nurses, and other health care professionals.

To ensure that it remains current, the information in PDQ is reviewed and updated each month by experts in the fields of cancer treatment, prevention, screening, and supportive care. PDQ also provides information about research on new treatments (clinical trials), doctors who treat cancer, and hospitals with cancer programs. The treatment information in this summary is based on information in the PDQ summary for health professionals on this cancer.


How to use PDQ

PDQ can be used to learn more about current treatment of different kinds of cancer. You may find it helpful to discuss this information with your doctor, who knows you and has the facts about your disease. PDQ can also provide the names of additional health care professionals who specialize in treating patients with cancer.

Before you start treatment, you also may want to think about taking part in a clinical trial. PDQ can be used to learn more about these trials. A clinical trial is a research study that attempts to improve current treatments or finds information on new treatments for patients with cancer. Clinical trials are based on past studies and information discovered in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help patients with cancer. Information is collected about new treatments, their risks, and how well they do or do not work. When clinical trials show that a new treatment is better than the treatment currently used as "standard" treatment, the new treatment may become the standard treatment. Listings of current clinical trials are available on PDQ. Many cancer doctors who take part in clinical trials are listed in PDQ.

To learn more about cancer and how it is treated, or to learn more about clinical trials for your kind of cancer, call the National Cancer Institute's Cancer Information Service. The number is 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. The call is free and a trained information specialist will be available to answer cancer-related questions.

PDQ is updated whenever there is new information. Check with the Cancer Information Service to be sure that you have the most up-to-date information.


DESCRIPTION


What is breast cancer?

This summary discusses the treatment of breast cancer. PDQ also contains summaries of information on screening for and prevention of breast cancer.

Breast cancer, a common cancer in women, is a disease in which cancer (malignant) cells are found in the tissues of the breast. Each breast has 15- 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts. The most common type of breast cancer is ductal cancer. It is found in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular cancer. Lobular cancer is more often found in both breasts than other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer. In this disease, the breast is warm, red, and swollen.

Hereditary breast cancer makes up approximately 5% to 10% of all breast cancer cases. The genes in cells carry the hereditary information that is received from a person's parents. Several genes have been found to be defective in some breast cancer patients. Relatives of breast cancer patients who carry these defective genes may be more likely to develop breast or ovarian cancer. Some defective genes are more common in certain ethnic groups. Tests are being developed to determine who has the genetic defect long before any cancer appears. Refer to the PDQ summaries on screening for breast cancer and prevention of breast cancer for more information.

Hormonal contraceptives may be another factor to consider. Research findings suggest a link between contraceptive use and a slightly increased risk of developing breast cancer.

A doctor should be seen if changes in the breasts are noticed. The doctor may suggest that you have a mammogram. A mammogram is a special x-ray of the breast that may find tumors that are too small to feel. If a lump in the breast is found, the doctor may need to cut out a small piece of the lump and look at it under the microscope to see if there are any cancer cells. This procedure is called a biopsy. Sometimes the biopsy is done by inserting a needle into the breast and drawing out some of the tissue. If the biopsy shows that there is cancer, it is important that certain tests (called estrogen and progesterone receptor tests) be done on the cancer cells.

Estrogen and progesterone receptor tests may tell whether hormones affect the way the cancer grows. They may also give information about the chances of the tumor coming back (recurring). The results help a doctor decide whether to use hormone therapy to stop the cancer from growing. Tissue from the tumor needs to be taken to the laboratory for estrogen and progesterone tests at the time of biopsy because it may be hard to get enough cancer cells later, although newer techniques can be used on tissue that is not fresh.

The chance of recovery (prognosis) and choice of treatment depend on the stage of the cancer (whether it is just in the breast or has spread to other places in the body), the type of breast cancer, certain characteristics of the cancer cells, and whether the cancer is found in the other breast. A woman's age, weight, menopausal status (whether or not a woman is still having menstrual periods), and general health can also affect the prognosis and choice of treatment.


STAGE EXPLANATION


Stages of breast cancer

Once breast cancer has been found, more tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, a doctor needs to know the stage of the disease. The following stages are used for breast cancer.


Carcinoma in situ

About 15% to 20% of breast cancers are very early cancers. They are sometimes called carcinoma in situ. There are two types of breast cancer in situ. One type is ductal carcinoma in situ (DCIS; also known as intraductal carcinoma); the other type is lobular carcinoma in situ (LCIS). LCIS is not cancer, but for the purpose of classifying the disease, it is called breast cancer in situ, carcinoma in situ, or stage 0 breast cancer. Sometimes LCIS is found when a biopsy is done for another lump or abnormality found on the mammogram. Patients with this condition have a 25% chance of developing breast cancer in either breast in the next 25 years.


Stage I

The cancer is no larger than 2 centimeters (about 1 inch) and has not spread outside the breast.


Stage II

Any of the following may be true:

The cancer is no larger than 2 centimeters but has spread to the lymph
nodes under the arm (the axillary lymph nodes).

The cancer is between 2 and 5 centimeters (from 1 to 2 inches). The cancer
may or may not have spread to the lymph nodes under the arm.

The cancer is larger than 5 centimeters (larger than 2 inches) but has
not spread to the lymph nodes under the arm.


Stage III

Stage III is divided into stages IIIA and IIIB.

Stage IIIA is defined by either of the following:

The cancer is smaller than 5 centimeters and has spread to the lymph nodes
under the arm, and the lymph nodes are attached to each other or to
other structures.

The cancer is larger than 5 centimeters and has spread to the lymph
nodes under the arm.

Stage IIIB is defined by either of the following:

The cancer has spread to tissues near the breast (skin or chest wall,
including the ribs and the muscles in the chest).

The cancer has spread to lymph nodes inside the chest wall along the breast
bone.


Stage IV

The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. Or, tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone.


Inflammatory breast cancer

Inflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it is inflamed because of its red appearance and warmth. The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory breast cancer tends to spread quickly.


Recurrent

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of the body.


TREATMENT OPTION OVERVIEW


How breast cancer is treated

There are treatments for all patients with breast cancer. Four types of treatment are used:

Biological therapy (using the body's immune system to fight cancer), bone marrow transplantation, and peripheral blood stem cell transplantation are being tested in clinical trials.

Most patients with breast cancer have surgery to remove the cancer from the breast. Usually, some of the lymph nodes under the arm are also taken out and looked at under a microscope to see if there are any cancer cells.

Different types of operations used:

Surgery to conserve the breast:

Lumpectomy (sometimes called excisional biopsy or wide excision) is the
removal of the lump in the breast and some of the tissue around it. It is
usually followed by radiation therapy to the part of the breast that
remains. Most doctors also take out some of the lymph nodes under the arm.

Partial or segmental mastectomy is the removal of the cancer as well as some
of the breast tissue around the tumor and the lining over the chest muscles
below the tumor. Usually some of the lymph nodes under the arm are taken
out. In most cases, radiation therapy follows.

Other types of surgery:

Total or simple mastectomy is the removal of the whole breast. Sometimes
lymph nodes under the arm are also taken out.

Modified radical mastectomy is the removal of the breast, many of the lymph
nodes under the arm, the lining over the chest muscles, and sometimes part
of the chest wall muscles. This is the most common operation for breast
cancer.

Radical mastectomy (also called the Halsted radical mastectomy) is the
removal of the breast, chest muscles, and all of the lymph nodes under the
arm. For many years, this was the operation most used, but it is used now
only when the tumor has spread to the chest muscles.

Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by mouth or it may be put into the body by inserting a needle into a vein or muscle. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the breast area.

If tests show that the breast cancer cells have estrogen receptors and progesterone receptors, hormone therapy may be given. Hormone therapy is used to change the way hormones in the body help cancers grow. This may be done by using drugs that change the way hormones work or by surgery to take out organs that make hormones, such as the ovaries. Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer. Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of getting cancer of the uterus. A doctor should be seen for a pelvic examination every year. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible.

Even if the doctor removes all the cancer that can be seen at the time of the operation, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Therapy given after an operation when there are no cancer cells that can be seen is called adjuvant therapy.

Biological therapy tries to get the body to fight cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. This treatment is currently only being given in clinical trials.

Bone marrow transplantation is a newer type of treatment that is being studied in clinical trials. Sometimes breast cancer becomes resistant to treatment with radiation therapy or chemotherapy. Very high doses of chemotherapy may then be used to treat the cancer. Because the high doses of chemotherapy can destroy the bone marrow, marrow is taken from the bones before treatment. The marrow is then frozen and the patient is given high-dose chemotherapy with or without radiation therapy to treat the cancer. The marrow that was taken out is then thawed and given back to the patient through a needle inserted into a vein to replace the marrow that was destroyed. This type of transplant is called an autologous transplant. If the marrow that is given is taken from another person, the transplant is called an allogeneic transplant.

Another type of autologous transplant is called a peripheral blood stem cell transplant. The patient's blood is passed through a machine that removes the stem cells (immature cells from which all blood cells develop) and then returns the blood back to the patient. This procedure is called leukapheresis and usually takes 3 or 4 hours to complete. The stem cells are treated with drugs to kill any cancer cells and then frozen until they are transplanted back to the patient. This procedure may be done alone or with an autologous bone marrow transplant.

A greater chance for recovery occurs if the doctor chooses a hospital that does more than five bone marrow transplantations per year.


Treatment by stage

Treatment of breast cancer depends on the type and stage of the disease, and the patient's age, menopausal status, and overall health.

Standard treatment may be considered because of its effectiveness in patients in past studies, or participation in a clinical trial may be considered. Not all patients are cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are ongoing in most parts of the country for all stages of breast cancer. To learn more about clinical trials, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.


CARCINOMA IN SITU

The treatment depends on whether the patient has ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). Since it is difficult to distinguish between these two types, it may be helpful to have a second opinion by having the patient's biopsy preparations (slides) studied by pathologists at another hospital.

If the patient has DCIS, treatment may be one of the following:

1. Surgery to remove the whole breast (total mastectomy).

2. Breast-conserving surgery with radiation therapy.

3. Clinical trial of surgery to remove only the cancer (lumpectomy) followed by radiation therapy with or without hormone therapy.

Rarely, some of the lymph nodes under the arm may also be removed during the above surgeries.

If a patient has LCIS, the patient may have a higher risk of developing invasive cancer in both breasts: about a 25% chance over 25 years. LCIS is not breast cancer, and many women with LCIS never develop breast cancer. The treatment options for LCIS are varied and quite controversial. Treatment may be one of the following:

1. Biopsy to diagnose the LCIS followed by regular examinations and yearly mammograms to find any changes as early as possible.

2. A large clinical trial is testing hormone therapy with the drug tamoxifen to see whether it can prevent cancer from occurring. The Cancer Information Service can be called for more information (1-800-4-CANCER).

3. Surgery to remove both breasts (total mastectomy).

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA's Center for Devices and Radiologic Health at 1-888-INFO-FDA (1-888-463- 6332) to obtain additional information. Additional questions can then be discussed with a doctor.


STAGE I BREAST CANCER

Treatment may be one of the following:

1. Breast-conserving surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove part of the breast (partial or segmental mastectomy); both are followed by radiation therapy. Some of the lymph nodes under the arm are also removed. This treatment provides identical long-term cure rates as those from mastectomy. A doctor's recommendation on which procedure to have is based on tumor size and location and its appearance on mammogram.

2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles (modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (given in addition to the treatments listed above):
1. Chemotherapy.

2. Hormone therapy.

3. A clinical trial of adjuvant chemotherapy in certain patients.

4. A clinical trial of no adjuvant therapy for patients with a good chance of recovery (prognosis).

5. A clinical trial of treatment to keep the ovaries from working.

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA (1-800-532-4440) to obtain additional information. Additional questions can then be discussed with a doctor.


STAGE II BREAST CANCER

Treatment may be one of the following:

1. Breast-conserving surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove part of the breast (partial or segmental mastectomy); both are followed by radiation therapy. Some of the lymph nodes under the arm are also removed. This treatment provides identical long-term cure rates as those from mastectomy. A doctor's recommendation on which procedure to have is based on tumor size and location and its appearance on mammogram.

2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles (modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (given in addition to the treatments listed above):
1. Chemotherapy with or without hormonal therapy.

2. Hormone therapy.

3. A clinical trial of chemotherapy before surgery (neoadjuvant therapy).

4. A clinical trial of high-dose chemotherapy with bone marrow transplantation for patients with cancer in more than three lymph nodes.

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA (1-800-532-4440) to obtain additional information. Additional questions can then be discussed with a doctor.


STAGE III BREAST CANCER

Stage III breast cancer is further divided into stage IIIA (can be operated on) and IIIB (biopsy is usually the only surgery performed).

Stage IIIA cancer:
Treatment may be one of the following surgeries:

1. Surgery to remove the whole breast, the lining over the chest muscles, and many of the lymph nodes (modified radical mastectomy) or the whole breast, the chest muscles, and all of the lymph nodes (radical mastectomy).

2. Radiation therapy given after surgery.

3. Chemotherapy with or without hormone therapy given with surgery and radiation therapy.

4. A clinical trial testing new chemotherapy with or without hormonal drugs; they are also testing chemotherapy before surgery (neoadjuvant therapy).

5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

Stage IIIB cancer:
The patient will probably have a biopsy then be given one or more of the following:
1. Surgery (radical or modified radical mastectomy) and/or radiation therapy to the breast and the lymph nodes.

2. Chemotherapy with or without hormones to shrink the tumor, followed by surgery and/or radiation therapy.

3. Hormonal therapy followed by additional therapy.

4. A clinical trial testing new chemotherapy drugs and biological therapy, new drug combinations, and new ways of giving chemotherapy.

5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.


STAGE IV BREAST CANCER

The patient will probably have a biopsy and then be given one or more of the following:

1. Radiation therapy or, in some cases, a mastectomy to reduce the symptoms.

2. Hormonal therapy with or without surgery to remove the ovaries.

3. Combination chemotherapy.

4. A clinical trial testing new chemotherapy and hormonal drugs and new combinations of drugs and biological therapy.

5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.


INFLAMMATORY BREAST CANCER

Treatment will probably be a combination of chemotherapy, hormonal therapy, and radiation therapy, which may be combined with surgery to remove the breast. The treatment is usually similar to that for stage IIIB or IV breast cancer.


RECURRENT BREAST CANCER

Breast cancer that comes back (recurs) can often be treated, but usually cannot be cured when it recurs in another part of the body. Some patients with recurrence in the breast can be cured, however. The choice of treatment depends on hormone receptor levels, the kind of treatment the patient had before, the length of time from first treatment to when the cancer came back, where the cancer recurred, whether the patient still has menstrual periods, and other factors.

Treatment may be one of the following:

1. Hormonal therapy with or without surgery to remove the ovaries.

2. Surgery and/or radiation therapy (for the small group of patients whose cancer has come back only in one place).

3. Other types of hormone therapy.

4. Combination chemotherapy.

5. Retreatment with previously used therapies.

6. A clinical trial of newly developed chemotherapy or biologic therapy.


TO LEARN MORE

TO LEARN MORE..... CALL 1-800-4-CANCER

To learn more about breast cancer, call the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. By dialing this toll-free number, you can speak with a trained information specialist who can answer your questions.

The Cancer Information Service also has booklets about cancer that are available to the public and can be sent on request. The following booklet about breast cancer may be helpful:

What You Need To Know About Breast Cancer

The following general booklets on questions related to cancer may also be helpful:

What You Need To Know About Cancer
Chemotherapy and You: A Guide to Self-Help During Treatment
Radiation Therapy and You: A Guide to Self-Help During Treatment
Eating Hints for Cancer Patients
Taking Time: Support for People with Cancer and the People Who Care About
Them
What Are Clinical Trials All About?
Advanced Cancer: Living Each Day
When Cancer Recurs: Meeting the Challenge Again
Research Report: Bone Marrow Transplantation

There are many other places where people can get material and information about cancer treatment and services. The social service office at a hospital can be checked for local and national agencies that can help with getting information about finances, getting to and from treatment, getting care at home, and dealing with problems.

For more information from the National Cancer Institute, please write to this address:

National Cancer Institute
Office of Cancer Communications
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580

For more information on breast implants, please write to the FDA at this address:

Breast Implants
Food and Drug Administration
HFE-88
Rockville, MD 20857

The FDA also has a hotline number to answer questions about silicone gel-filled breast implants. To learn more, call 1-800-532-4440, Monday through Friday, 9 a.m. to 7 p.m. Eastern standard time.

Date Last Modified: 10/1999


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.


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