Breast Cancer

Condition Basics

What is breast cancer?

Breast cancer occurs when abnormal cells grow out of control in one or both breasts. These cancer cells can spread (metastasize) to nearby tissues and form a mass, called a tumour. The cells can spread within the breast, to nearby lymph nodes and other tissues, and to other parts of the body.

The most common type of breast cancer starts in the ducts of the breast. It's called ductal carcinoma. The second most common type is lobular carcinoma. It starts in the lobes of the breast.

Some breast cancer is a mix of both ductal and lobular carcinoma.

When abnormal cells in the ducts or lobes of the breast haven't spread, they are said to be non-invasive, or "in situ" (say "in-SY-too"). These include:

Breast cancer can occur in people who don't identify as female but have breasts. And it can occur even if they had a breast reduction or a mastectomy. There are also some less common types of invasive breast cancer, such as inflammatory breast cancer and male breast cancer.

What causes it?

Doctors don't know exactly what causes breast cancer. But some things are known to increase the chance that you will get it, such as your age and health history.

What are the symptoms?

The most common symptom is a painless lump or thickening in the breast or underarm. But early breast cancer is often found on a mammogram before a lump can be felt. The size, shape, or appearance of the breast may also change. Or the nipple may turn in, look scaly, or leak fluid.

How is it diagnosed?

Depending on your age and risk factors, the doctor may recommend that you have a mammogram. A mammogram can often find a lump that is too small to feel.

During a regular physical examination, your doctor can check your breasts for lumps or changes. You also may find a lump during a breast self-examination.

If there are concerns, the doctor will check to see if there is cancer by examining a sample of cells (biopsy). The results of the biopsy help your doctor know if you have cancer and what type of cancer it is.

You may have other tests to find out the stage of the cancer. The stage is a way for doctors to describe how far the cancer has spread.

How is breast cancer treated?

Treatment for breast cancer is based on the type and stage of the cancer and other things, such as your overall health. The main treatment is surgery to remove the cancer. Other treatment options may include radiation therapy, chemotherapy, endocrine therapy, or targeted therapy.

What Increases Your Risk

The top risk factors for breast cancer are:

Aging.

Your risk increases as you get older.

Being female.

Male breast cancer is rare.

Other risks include:

Health history.

Having dense breasts, a breast disease that isn't cancer, or previous breast cancer increases your risk.

Family history.

Your risk increases if you have a history of breast cancer in your family.

Breast changes.

Conditions such as atypical hyperplasia, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS) increase the risk.

Race.

White people have a higher risk than Black, Hispanic, or Asian people.

Radiation therapy.

Exposure to large amounts of radiation treatment at a young age increases the risk.

Not breastfeeding.

Those who don't breastfeed have a higher risk than those who breastfeed.

Alcohol.

Your risk goes up the more you drink.

Hormones.

Female hormones play a part in some types of breast cancer.

BRCA gene change and risk for breast cancer

BRCA1 and BRCA2 are genes that normally help control cell growth. But a rare, inherited change (mutation) in one of these genes makes you much more likely to get breast, ovarian, and some other cancers. Genetic testing can show if you have gene changes that increase your risk for these cancers.

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Lowering Your Risk

Your risk for breast cancer increases as you get older. There is no known way to prevent breast cancer. But with some cancers, finding them early can increase your chances of successful treatment.

Here are some steps you can take to help reduce your risk:

• Get familiar with the look and feel of your breasts. This will help you notice any changes. Call your doctor or nurse advice line if you notice a change.
• Have regular breast examinations by your doctor or nurse. Ask your doctor how often you should get them.
• Have regular mammograms. A mammogram is a picture of your breast tissue. It can find changes in your breast before you can feel them. Talk to your doctor about when to get this test.

You can also help take care of yourself and reduce your risk of cancer if you:

• Stay at a healthy weight.
• Eat a healthy, low-fat diet.
• Get some exercise every day. If you don't usually exercise, walking is a good way to start.
• Don't smoke. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
• If you drink alcohol, limit it to less than 1 drink a day if you are a woman and less than 2 drinks a day if you are a man. Any amount of alcohol may increase your risk for some types of cancer.
• Breastfeed. There is some evidence that breastfeeding may lower the risk of breast cancer. The benefit seems to be greatest in those who have breastfed for longer than 12 months or who breastfed several children.

BRCA gene changes

People who do a gene test and find out that they have a BRCA gene change have some options to manage their cancer risk.

• For female breast cancer: If you haven't yet had cancer, you may want to think about starting breast cancer screening at a younger age, taking medicine, and having preventive surgery.
• For male breast cancer: You may want to think about doing breast self-examinations and having clinical breast examinations. (And it's a good idea to have prostate cancer screenings too.)

If you have a BRCA gene change, talk with your doctor about how you can manage your cancer risk.

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Symptoms

The first sign of breast cancer is often a painless lump. But early breast cancer is often found on a mammogram before a lump can be felt.

Other symptoms of breast cancer may not appear until the cancer is more advanced. These include:

• A thickening in the breast or armpit.
• A change in the size or shape of the breast.
• Changes in the skin of the breast, such as a dimple or skin that looks like an orange peel.
• A change in the nipple, such as scaling of the skin or a nipple that turns in.
• A green or bloody fluid that comes from the nipple.
• A change in the colour or feel of the skin around the nipple (areola).

Symptoms such as changes in the skin of the breast or the nipple may be a sign of inflammatory breast cancer.

What Happens

Often breast cancer is found in an early stage, and the cancer can be removed with surgery. In some cases, breast cancer may grow and spread to nearby tissues and lymph nodes. Advanced breast cancer can spread to the bones, liver, and brain.

Your doctor will look at the stage of the cancer to see how far it has spread. Your doctor may also do tests on tissues removed during surgery to look for hormone receptors and gene changes. These test results, and whether your cancer has spread, will help guide your treatment options.

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When to Call a Doctor

Call your doctor if you have:

• A painless lump in your breast or armpit.
• A change in the size or shape of the breast.
• Changes in the skin of the breast, such as a dimple or skin that looks like an orange peel.
• A change in the nipple, such as scaling of the skin, a nipple that turns in, or discharge or bleeding.
• A change in the colour or feel of the skin around the nipple.

If you have been diagnosed with cancer, be sure to follow your doctor's instructions about calling when you have problems, new symptoms, or symptoms that get worse.

Examinations and Tests

Depending on your age and risk factors, the doctor may recommend that you have a mammogram. This test can often find a lump that is too small to feel. The earlier breast cancer is found, the more easily and successfully it can be treated.

During a regular physical examination, your doctor can check your breasts for lumps or changes. You also may find a lump during a breast self-examination.

If there are concerns, the doctor will check to see if there is cancer by examining a sample of cells (biopsy). The results of the biopsy help your doctor know if you have cancer and what type of cancer it is.

Diagnostic tests

If your doctor thinks that you have breast cancer, you may have other tests. They include:

Another mammogram.

You may get more detailed mammograms.

An ultrasound.

You may have an ultrasound of the breast if a lump is found during a clinical breast examination or on a mammogram.

An MRI of the breast.

This is sometimes used to get more information about a breast lump or to check for problems in people who have breast implants.

A complete blood count (CBC).

This provides important information about the kinds and numbers of cells in your blood.

A chemistry screen.

This test measures the levels of several substances (such as those involved in liver functions) in your blood.

A chest X-ray.

It provides a picture of organs and structures within your chest, including your heart and lungs, your blood vessels, and the thin sheet of muscle just below your lungs (diaphragm).

Screening tests for breast cancer

Knowing your personal risk for breast cancer can help you decide about screening. Your doctor can help you make a plan for when and how often to have mammograms based on your risk.

The tests used to screen for breast cancer include mammogram, 3-D mammogram (digital breast tomosynthesis), and clinical breast examination (CBE). MRI of the breast may be used as a screening test if you have a high risk of breast cancer.

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Treatment Overview

Treatment for breast cancer is based on the type and stage of the cancer and other things, such as your overall health. The main treatment is surgery to remove the cancer. Other treatment options may include radiation therapy, chemotherapy, endocrine therapy, targeted therapy, or immunotherapy.

Your doctor will talk with you about your options and then make a treatment plan.

Some people use complementary therapies along with medical treatment. Therapies like acupuncture or massage may help you cope with the symptoms and stress of cancer. Talk with your doctor about any of these options you would like to try.

Surgery

Most people have surgery. The types of breast cancer surgery are:

Breast-conserving surgery.

The doctor removes just the cancer and a border of normal tissue around it (margin). This may also be called a lumpectomy. This helps reduce the risk of the cancer coming back (recurrence) while leaving as much of the breast tissue as possible.

Mastectomy.

Mastectomy is surgery to remove the breast. The types of mastectomy that are done most often are:

• Total (or simple) mastectomy. This removes the whole breast.
• Modified radical mastectomy. This removes the whole breast and the lymph nodes in the armpit area (axillary nodes).

During breast surgery, the doctor may remove one or more nearby lymph nodes to check them for cancer. This may include:

• Removing the first lymph node that the cancer may have spread to. This is a called a sentinel node biopsy.
• Removing the lymph nodes under the arm. This is called an axillary node dissection.

Your doctor will remove all the cancer that can be found. Then you may have other treatments to kill any cancer cells that may be left.

Some people choose to have breast reconstruction after cancer surgery. A surgeon can reshape or rebuild your breast using implants or your own tissue. You can talk with your doctor about your options.

Radiation

Radiation therapy uses high-dose X-rays to destroy cancer cells and shrink tumours. It is usually given after breast-conserving surgery. It may be given after mastectomy. Radiation therapy is used after surgery to help reduce the chance that the cancer will come back.

Radiation therapy can be given in different ways. It's often given by a machine outside the body (external radiation). Or it may be given by placing substances inside the body (internal radiation).

Medicines

Medicines used to treat breast cancer include:

Chemotherapy.

These medicines kill fast-growing cells, including cancer cells and some normal cells. Chemotherapy may be used before surgery to help shrink the tumour before it's removed. It may be given after surgery to help keep cancer from coming back.

Endocrine therapy.

These medicines block the natural hormones that cause certain cancers to grow. This helps slow or stop cancer growth.

Tests can show if the cancer cells have receptors for hormones such as estrogen or progesterone. This helps your doctor know which medicines will work best for you. Medicines that help block estrogen and progesterone include tamoxifen and aromatase inhibitors.

Targeted therapy.

These medicines target cancer cells and may cause less harm to normal cells. They help keep cancer from growing or spreading.

Some of these medicines target certain tumour markers (biomarkers) in the cancer cells. If the cancer has a tumour marker that can be targeted, you may be given one or more of these medicines.

Immunotherapy.

This treatment helps your immune system fight cancer. Immunotherapy medicines include pembrolizumab.

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Supportive Care

Hospice palliative care is a type of care for people who have a serious illness. It's different from care to cure your illness, called curative treatment. Hospice palliative care provides an extra layer of support that can improve your quality of life—not just in your body, but also in your mind and spirit. Sometimes hospice palliative care is combined with curative treatment.

The kind of care you get depends on what you need. Your goals guide your care. You can get both hospice palliative care and care to treat your illness. You don't have to choose one or the other.

Hospice palliative care can help you manage symptoms, pain, or side effects from treatment. It may help you and those close to you better understand your illness, talk more openly about your feelings, or decide what treatment you want or don't want. It can also help you communicate better with your doctors, nurses, family, and friends.

End-of-life care

It can be hard to live with an illness that cannot be cured. But if your health is getting worse, you may want to make decisions about end-of-life care. Planning for the end of your life does not mean that you are giving up. It is a way to make sure that your wishes are met. Clearly stating your wishes can make it easier for your loved ones. Making plans while you are still able may also ease your mind and make your final days less stressful and more meaningful.

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Self-Care

• Take your medicines exactly as prescribed. Call your doctor or nurse advice line if you think you are having a problem with your medicine. You may get medicine for nausea and vomiting if you have these side effects.
• Follow your doctor's instructions to relieve pain. Pain from cancer and surgery can almost always be controlled. Use pain medicine when you first notice pain, before it becomes severe.
• Eat healthy food. If you do not feel like eating, try to eat food that has protein and extra calories to keep up your strength and prevent weight loss. Drink liquid meal replacements for extra calories and protein. Try to eat your main meal early.
• Get some physical activity every day, but do not get too tired. Keep doing the hobbies you enjoy as your energy allows.
• Do not smoke. Smoking can make your cancer worse. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
• Take steps to control your stress and workload. Learn relaxation techniques.
  • Share your feelings. Stress and tension affect our emotions. By expressing your feelings to others, you may be able to understand and cope with them.
  • Consider joining a support group. Talking about a problem with your spouse, a good friend, or other people with similar problems is a good way to reduce tension and stress.
  • Express yourself through art. Try writing, crafts, dance, or art to relieve stress. Some dance, writing, or art groups may be available just for people who have cancer.
  • Be kind to your body and mind. Getting enough sleep, eating a healthy diet, and taking time to do things you enjoy can contribute to an overall feeling of balance in your life and can help reduce stress.
  • Get help if you need it. Discuss your concerns with your doctor or counsellor.
• If you are vomiting or have diarrhea:
  • Drink plenty of fluids to prevent dehydration. Choose water and other clear liquids. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the amount of fluids you drink.
  • When you are able to eat, try clear soups, mild foods, and liquids until all symptoms are gone for 12 to 48 hours. Other good choices include dry toast, crackers, cooked cereal, and gelatin dessert, such as Jell-O.
• If you have not already done so, prepare an advance care plan. An advance care plan provides instructions to your doctor and family members about what kind of care you want if you become unable to speak or express yourself.

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Complementary Treatments

Some people use complementary therapies along with medical treatment. They may help relieve the symptoms and stress of cancer or the side effects of cancer treatment. Therapies that may be helpful include:

• Acupuncture to relieve pain and other symptoms.
• Meditation or yoga to relieve stress.
• Massage and biofeedback to reduce pain and tension.
• Breathing exercises to help you relax.

Talk with your doctor about any of these options you would like to try. And let your doctor know if you are already using any complementary therapies. They are not meant to take the place of standard medical treatment. But they may help you feel better and cope better with treatment.

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Getting Support

Relationships take on new importance when you're faced with cancer. Your family and friends can help support you. You may also want to look beyond those who are close to you.

• Reach out to your family and friends.

  Remember that the people around you want to support you, and asking for help isn't a sign of weakness.

• Tell them how they can help.

  Your friends and family want to help, but some of them may not know what to do. It may help to make a list. For example, you might ask them to:

  • Run errands or pick up kids.
  • Deliver meals or groceries to your home.
  • Drive you to appointments.
  • Go to doctor visits with you and take notes.
• Look for help from other sources.

  Places to turn for support include:

  Counselling.

  Counselling can help you cope with cancer and the effect cancer is having on your life. Different types of counselling include family therapy, couples therapy, group counselling, and individual counselling.

  Your health care team.

  Your team should be supportive. Be open and honest about your fears and concerns. Your doctor can help you get the right medical treatments, including counselling.

  Spiritual or religious groups.

  These groups can provide comfort and may be able to help you find counselling or other social support services.

  Social groups.

  Social groups can help you meet new people and get involved in activities you enjoy. Focus on activities that bring you comfort, such as spending time outdoors or being with children.

  A cancer support group.

  Cancer support groups offer support and practical advice. You can hear others talk about:

  • What it's like to live with cancer.
  • Practical ways to manage your cancer treatment and its side effects.
  • Ways to cope with your illness.

Adjusting to body changes after treatment

Your feelings about your body may change after treatment for breast cancer. For example, you may find it hard to adjust to how your body looks after surgery. These and other physical changes may affect your body image. Or they may affect your desire to be intimate with a partner. Everyone has their own reaction to the challenges of cancer treatment.

If you have concerns, try to talk openly with your partner, if you have one. Or discuss your feelings with your doctor or nurse. Your care team may be able to help. Or they may refer you to counselling or a support group. Talking with others who've had similar feelings can be very helpful.

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