UPMC Cancer Centers Administration

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UPMC Cancer Centers Administration
5150 Centre Avenue
Pittsburgh, PA 15232
Phone:412-647-2811

E-mail: PCI-INFO@upmc.edu


General Information About Breast Cancer

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. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.

Anatomy of the breast, showing lymph nodes and lymph vessels. | View a Larger Version

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

The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.

See the PDQ summary on Unusual Cancers of Childhood for information about childhood breast cancer.



Age and health history can affect the risk of developing breast cancer.

Anything that increases your chance of getting a disease is called a risk factor. Risk factors for breast cancer include the following:


Older age.
Menstruating at an early age.
Older age at first birth or never having given birth.
A personal history of breast cancer or benign (noncancer) breast disease.
A mother or sister with breast cancer.
Treatment with radiation therapy to the breast/chest.
Breast tissue that is dense on a mammogram.
Taking hormones such as estrogen and progesterone.
Drinking alcoholic beverages.
Being white.



Breast cancer is sometimes caused by inherited gene mutations (changes).

The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up approximately 5% to 10% of all breast cancer. Some altered genes related to breast cancer are more common in certain ethnic groups.

Women who have an altered gene related to breast cancer and who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of developing ovarian cancer, and may have an increased risk of developing other cancers. Men who have an altered gene related to breast cancer also have an increased risk of developing this disease. For more information, see the PDQ summary on Male Breast Cancer Treatment.

Tests have been developed that can detect altered genes. These genetic tests are sometimes done for members of families with a high risk of cancer. See the following PDQ summaries: for more information:


Breast Cancer Screening
Breast Cancer Prevention
Genetics of Breast and Ovarian Cancer



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

A doctor should be seen if changes in the breast are noticed. The following tests and procedures may be used:


Mammogram: An x-ray of the breast. Mammography of the right breast. | View a Larger Version
Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, the doctor may need to remove a small piece of the lump. Four types of biopsies are as follows:

Excisional biopsy: The removal of an entire lump of tissue.
Incisional biopsy: The removal of part of a lump or a sample of tissue.
Core biopsy: The removal of tissue using a wide needle.
Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.

Estrogen and progesterone receptor test: A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If cancer is found in the breast, tissue from the tumor is checked in the laboratory to find out whether estrogen and progesterone could affect the way cancer grows. The test results show whether hormone therapy may stop the cancer from growing.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).



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 (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
The type of breast cancer.
Estrogen-receptor and progesterone-receptor levels in the tumor tissue.
Whether the cells have high levels of human epidermal growth factor type 2 receptors (HER2/neu).
How fast the tumor is growing.
A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
Whether the cancer has just been diagnosed or has recurred (come back).




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 whether 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.



There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:


Through tissue. Cancer invades the surrounding normal tissue.
Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.



The following stages are used for breast cancer:


Stage 0 (carcinoma in situ)

There are 2 types of breast carcinoma in situ:


Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.
Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.


Pea, peanut, walnut, and lime show tumor sizes. | View a Larger Version

Stage I

In stage I, cancer has formed. The tumor is 2 centimeters or smaller and has not spread outside the breast.



Stage IIA

In stage IIA:


no tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
the tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.



Stage IIB

In stage IIB, the tumor is either:


larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
larger than 5 centimeters but has not spread to the axillary lymph nodes.



Stage IIIA

In stage IIIA:


no tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
the tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
the tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.



Stage IIIB

In stage IIIB, the tumor may be any size and cancer:


has spread to the chest wall and/or the skin of the breast; and
may have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.



Stage IIIC

In stage IIIC, there may be no sign of cancer in the breast or the tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:


has spread to lymph nodes above or below the collarbone; and
may have spread to axillary lymph nodes or to lymph nodes near the breastbone.

Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

Stage IIIC breast cancer is divided into operable and inoperable stage IIIC.

In operable stage IIIC, the cancer:


is found in ten or more axillary lymph nodes; or
is found in lymph nodes below the collarbone; or
is found in axillary lymph nodes and in lymph nodes near the breastbone.

In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone.



Stage IV

In stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.





Inflammatory Breast Cancer
In inflammatory breast cancer, cancer has spread to the skin of the breast and the breast looks red and swollen and feels warm. The redness and warmth occur because the cancer cells block the lymph vessels in the skin. The skin of the breast may also show the pitted appearance called peau d’orange (like the skin of an orange). There may not be any lumps in the breast that can be felt. Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.


Inflammatory breast cancer of the left breast showing peau d’orange and inverted nipple. | View a Larger Version



Recurrent Breast Cancer
Recurrent breast cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the breast, in the chest wall, or in other parts of the body.



Treatment Option Overview

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. 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. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.



Four types of standard treatment are used:


Surgery

Most patients with breast cancer have surgery to remove the cancer from 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.

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


Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.

Breast-conserving surgery. Dotted lines show the area containing the tumor that is removed and some of the lymph nodes that may be removed. | View a Larger Version
Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy. This procedure is called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after. Lymph node dissection is done through a separate incision.

Other types of surgery include the following:


Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision. Total (simple) mastectomy. The dotted line shows where the entire breast is removed. Some lymph nodes under the arm may also be removed. | View a Larger Version
Modified radical mastectomy: Surgery 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. The dotted line shows where the entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed. | View a Larger Version
Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy.

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

If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline or silicone gel. Before the decision to get an implant is made, patients can call the Food and Drug Administration's (FDA) Center for Devices and Radiologic Health at 1-888-INFO-FDA 1-888-INFO-FDA ( 1-888-463-6332 1-888-463-6332) or visit the FDA's Web site for more information on breast implants.



Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. 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.



Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them 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.



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 hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for any signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible.

Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone-dependent breast cancer. Hormone-dependent breast cancer needs the hormone estrogen to grow. Aromatase inhibitors decrease the body's estrogen by blocking an enzyme called aromatase from turning androgen into estrogen.

For the treatment of early stage breast cancer, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen. For the treatment of metastatic breast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen.




New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site.


Sentinel lymph node biopsy followed by surgery

Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. After the sentinel lymph node biopsy, the surgeon removes the tumor (breast-conserving surgery or mastectomy).




Sentinel lymph node biopsy. Radioactive substance and/or blue dye is injected near the tumor (first panel), the injected material is followed visually or with a probe (middle panel), and the first lymph nodes to take up the material are removed and checked for cancer cells (last panel).


High-dose chemotherapy with stem cell transplant

High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body’s blood cells.

Studies have shown that high-dose chemotherapy followed by stem cell transplant does not work better than standard chemotherapy in the treatment of breast cancer. Doctors have decided that, for now, high-dose chemotherapy should be tested only in clinical trials. Before taking part in such a trial, women should talk with their doctors about the serious side effects, including death, that may be caused by high-dose chemotherapy.



Monoclonal antibodies as adjuvant therapy

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies are also used in combination with chemotherapy as adjuvant therapy.

Trastuzumab (Herceptin) is a monoclonal antibody that blocks the effects of the growth factor protein HER2, which transmits growth signals to breast cancer cells. About one-fourth of patients with breast cancer have tumors that may be treated with trastuzumab combined with chemotherapy.



Tyrosine kinase inhibitors as adjuvant therapy

Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may be used in combination with other anticancer drugs as adjuvant therapy.

Lapatinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins inside tumor cells. It may be used to treat patients with HER2-positive breast cancer that has progressed following treatment with trastuzumab.




Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.



Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's clinical trials database.



Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.




Treatment Options by Stage
A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.


Ductal Carcinoma In Situ (DCIS)
Treatment of ductal carcinoma in situ (DCIS) may include the following:


Breast-conserving surgery and radiation therapy with or without tamoxifen.
Total mastectomy with or without tamoxifen.
Breast-conserving surgery without radiation therapy.
Clinical trials testing breast-conserving surgery and tamoxifen with or without radiation therapy.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with ductal breast carcinoma in situ.



Lobular Carcinoma In Situ (LCIS)
Treatment of lobular carcinoma in situ (LCIS) may include the following:


Biopsy to diagnose the LCIS followed by regular examinations and regular mammograms to find any changes as early as possible. This is referred to as observation.
Tamoxifen to reduce the risk of developing breast cancer.
Bilateral prophylactic mastectomy. This treatment choice is sometimes used in women who have a high risk of getting breast cancer. Most surgeons believe that this is a more aggressive treatment than is needed.
Clinical trials testing cancer prevention drugs.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with lobular breast carcinoma in situ.



Stage I, Stage II, Stage IIIA, and Operable Stage IIIC Breast Cancer
Treatment of stage I, stage II, stage IIIA , and operable stage IIIC breast cancer may include the following:


Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
Modified radical mastectomy with or without breast reconstruction surgery.
A clinical trial evaluating sentinel lymph node biopsy followed by surgery.

Adjuvant therapy (treatment given after surgery to increase the chances of a cure) may include the following:


Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
Systemic chemotherapy with or without hormone therapy.
Hormone therapy.
A clinical trial of trastuzumab (Herceptin) combined with systemic chemotherapy.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I breast cancer, stage II breast cancer, stage IIIA breast cancer and stage IIIC breast cancer.



Stage IIIB, Inoperable Stage IIIC, Stage IV, and Metastatic Breast Cancer

Stage IIIB and inoperable stage IIIC breast cancer
Treatment of stage IIIB and inoperable stage IIIC breast cancer may include the following:


Systemic chemotherapy.
Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.
Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment.



Stage IV and metastatic breast cancer
Treatment of stage IV or metastatic breast cancer may include the following:


Hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin).
Tyrosine kinase inhibitor therapy with lapatinib combined with capecitabine.
Radiation therapy and/or surgery for relief of pain and other symptoms.
Clinical trials testing new systemic chemotherapy and/or hormone therapy.
Clinical trials of new combinations of trastuzumab (Herceptin) with anticancer drugs.
Clinical trials of new combinations of lapatinib with anticancer drugs.
Clinical trials testing other approaches, including high-dose chemotherapy with stem cell transplant.
Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.


Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IIIB breast cancer, stage IIIC breast cancer and stage IV breast cancer.




Treatment Options for Inflammatory Breast Cancer
Treatment of inflammatory breast cancer may include the following:


Systemic chemotherapy.
Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.
Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with inflammatory breast cancer.



Treatment Options for Recurrent Breast Cancer
Treatment of recurrent breast cancer (cancer that has come back after treatment) in the breast or chest wall may include the following:


Surgery (radical or modified radical mastectomy), radiation therapy, or both.
Systemic chemotherapy or hormone therapy.
A clinical trial of trastuzumab (Herceptin) combined with systemic chemotherapy.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent breast cancer
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