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DISEASE INFORMATION | Breast Cancer Breast cancer is the most common cancer in women in the United States. According to the American Cancer Society, it's estimated that About 178,480 women in the United States will be found to have invasive breast cancer in 2007. About 40,460 women will die from the disease this year. Right now there are slightly over 2 million women living in the United States who have been treated for breast cancer. If you're worried about developing breast cancer, or if you know someone who has been diagnosed with the disease, one way to deal with your concerns is to get as much information as possible. In this section you'll find important background information about what breast cancer is and how it develops. Breast cancer is a malignant tumor that grows in one or both of the breasts. Breast cancer usually develops in the ducts or lobules, also known as the milk-producing areas of the breast. Breast cancer is the second leading cause of cancer death in women (after lung cancer). Although African-American women have a slightly lower incidence of breast cancer after age 40 than Caucasian women, they have a slightly higher incidence rate of breast cancer before age 40. However, African-American women are more likely to die from breast cancer at every age. Breast cancer is much less common in males; by comparison, the disease is about 100 times more common among women. The American Cancer Society estimates that in 2007 some 2,030 new cases of invasive breast cancer will be diagnosed among men in the United States. Types of breast cancer There are several different types of breast cancer that can be divided into two main categories - noninvasive cancers and invasive cancers. Noninvasive cancer may also be called "carcinoma in situ." Noninvasive breast cancers are confined to the ducts or lobules and they do not spread to surrounding tissues. The two types of noninvasive breast cancers are ductal carcinoma in situ (referred to as DCIS) and lobular carcinoma in situ (referred to as LCIS). It is known that hormones in a woman's body, such as estrogen and progesterone, can play a role in the development of breast cancer. In breast cancer, estrogen causes a doubling of cancer cells every 36 hours. The growing tumor needs to increase its blood supply to provide food and oxygen. Progesterone seems to cause stromal cells (the woman's own cells to send out signals for more blood supply to feed the tumor. (Source: Dr. V. Craig Jordan, vice president and scientific director for the medical science division at Fox Chase Cancer Center in Philadelphia as quoted in NY Times, Hormones And Cancer: By Gina Kolata, Published: December 26, 2006) Non-invasive breast cancer. The majority of non-invasive breast cancers are DCIS. In DCIS, the cancer cells are found only in the milk duct of the breast. If DCIS is not treated, it may progress to invasive cancer. In LCIS, the abnormal cells are found only in the lobules of the breast. Unlike DCIS, LCIS is not considered to be a cancer. It is more like a warning sign of increased risk of developing an invasive breast cancer in the same or opposite breast. While LCIS is a risk factor for invasive cancer, it doesn't actually develop into invasive breast cancer in many women. Invasive breast cancer. Invasive or infiltrating breast cancers penetrate through normal breast tissue (such as the ducts and lobules) and invade surrounding areas. They are more serious than noninvasive cancers because they can spread to other parts of the body, such as the bones, liver, lungs, and brain. There are several kinds of invasive breast cancers. The most common type is invasive ductal carcinoma, which appears in the ducts and accounts for about 80 percent of all breast cancer cases. There are differences in the various types of invasive breast cancer, but the treatment options are similar for all of them. Not all breast cancers are alike Not all breast cancers are alike - there are different stages of breast cancer based on the size of the tumor and whether the cancer has spread. For doctor and patient, knowing the stage of breast cancer is the most important factor in choosing among treatment options. Doctors use a physical exam, biopsy, and other tests to determine breast cancer stage. Stages of Breast Cancer The most common system used to describe the stages of breast cancer is the AJCC/TNM (American Joint Committee on Cancer/Tumor-Nodes-Metastases) system. This system takes into account the tumor size and spread, whether the cancer has spread to lymph nodes, and whether it has spread to distant organs (metastasis). All of this information is then combined in a process called stage grouping. The stage is expressed as a Roman numeral. After stage 0 (carcinoma in situ), the other stages are I through IV (1-4). Some of the stages are further sub-divided using the letters A, B, and C. In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more advanced cancer. These are the stages of breast cancer: Stage 0 - Stage 0 is carcinoma in situ, early stage cancer that is confined to the ducts or the lobules, depending on where it started. It has not gone into the tissues in the breast nor spread to other organs in the body. Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer, when abnormal cells are in the lining of a duct. DCIS is also called intraductal carcinoma. DCIS sometimes becomes invasive cancer if not treated. Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. LCIS seldom becomes invasive cancer; however, having LCIS in one breast increases the risk of cancer for both breasts. Stage I - Stage I is an early stage of invasive breast cancer. In Stage I, cancer cells have not spread beyond the breast and the tumor is no more than 2 centimeters (three-quarters of an inch) across. Stage II - Stage II is one of the following: The tumor in the breast is no more than 2 centimeters (three-quarters of an inch) across. The cancer has spread to the lymph nodes under the arm. The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches). The cancer may have spread to the lymph nodes under the arm. The tumor is larger than 5 centimeters (2 inches). The cancer has not spread to the lymph nodes under the arm. Stage III - Stage III may be a large tumor, but the cancer has not spread beyond the breast and nearby lymph nodes. It is locally advanced cancer. Stage IIIA - Stage IIIA is one of the following: The tumor in the breast is smaller than 5 centimeters (2 inches). The cancer has spread to underarm lymph nodes that are attached to each other or to other structures. The tumor is more than 5 centimeters across. The cancer has spread to the underarm lymph nodes. Stage IIIB - Stage IIIB is one of the following: The tumor has grown into the chest wall or the skin of the breast. The cancer has spread to lymph nodes behind the breastbone. Inflammatory breast cancer [insert link to page on inflammatory breast cancer] is a rare type of Stage IIIB breast cancer. The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast. Stage IIIC - Stage IIIC is a tumor of any size. It has spread in one of the following ways: The cancer has spread to the lymph nodes behind the breastbone and under the arm. The cancer has spread to the lymph nodes under or above the collarbone. Stage IV - Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body. Recurrent cancer - Recurrent cancer is cancer that has come back (recurred) after a period of time when it could not be detected. It may recur locally in the breast or chest wall as another primary cancer, or it may recur in any other part of the body, such as the bone, liver, or lungs, which is generally referred to as metastatic cancer. Resources: American Cancer Society Centers for Disease Control and Prevention National Cancer Institute How is breast cancer treated? When breast cancer is detected at an early stage of development, a number of effective treatment options are available. A woman and her physician will choose the treatment that is right for her, based on the location and extent of the cancer, her age and preferences, and the risks and benefits of each treatment. The basic treatment choices for breast cancer are surgery, radiation, chemotherapy, and hormonal therapy. Local treatments such as breast surgery and radiation therapy are focused on the breast itself to remove or destroy the cancer cells confined to the breast. Systemic treatments such as chemotherapy and hormonal therapy aim to destroy the cancer cells that may have spread throughout the body. Breast cancer cells can be estrogen receptor positive or estrogen receptor negative. Estrogen receptor positive cells are those that have a protein to which the hormone estrogen will bind. Cancer cells that are ER+ need estrogen to grow, and may stop growing when treated with hormones that block estrogen from binding. Estrogen receptor negative refers to cells that do not have a protein to which the hormone estrogen will bind. Cancer cells that are ER- do not need estrogen to grow, and usually do not stop growing when treated with hormones that block estrogen from binding. Surgery has an important role in breast cancer treatment. Most women have the option to choose between breast-conserving surgery (lumpectomy, plus radiation) or removal of the breast (mastectomy). Clinical trials have proven that both options provide the same long-term survival rates for most types of early stage breast cancer. Lumpectomy removes a small tumor and a margin of normal tissue around the tumor` The surgeon also removes some of the lymph nodes under the arm to find out if the cancer has spread. Lumpectomy followed by radiation therapy to destroy any remaining cancer cells is the standard care. A clinical trial on lumpectomy and radiation is currently underway. Modified radical mastectomy is surgery to remove the entire breast, some of the lymph nodes under the arm, and the lining over the chest muscles. It may be appropriate when the breast tumor is large or if cancer is found in more than one part of the breast. Radical mastectomy involves removal of the breast, chest muscles, and all lymph nodes under the arm. It was the standard treatment many years ago, but it is used now only when a tumor has spread to the chest muscles. Radiation therapy uses high-energy x-rays to destroy cancer cells. It is usually used after lumpectomy to destroy any cancer cells that still may remain in the breast after surgery. It is sometimes used to shrink tumors before surgery. Chemotherapy uses drugs, usually a combination of drugs, that travel through the body to slow the growth of cancer cells or to kill them. Hormonal therapy prevents cancer cells from getting the hormones they need to grow. If a breast tumor relies on the body's natural hormones to grow, it is described as estrogen receptor-positive or progesterone-positive. This means that any cancer cells that remain after surgery may continue to grow when these hormones are present in the body. Hormonal therapy can reduce the amount of the body's natural hormones or block the hormones from reaching any remaining cancer cells. Questions to Ask Your Doctor Learning about the diagnosis and treatment options available may help you to make decisions about your care. The first step in the learning process is a conversation with your physician. Every woman's breast cancer diagnosis is different. What a physician recommends for one woman may not be right for another. Developing a list of questions to ask is a good first start to addressing concerns and getting information. Here is a list of basic questions on advanced breast cancer to get the conversation started. You can easily print this page, which includes space to write down the answers your doctor gives you. ABOUT BREAST CANCER What stage is my breast cancer? What does this mean? What are my chances of responding to treatment? ADVANCED BREAST CANCER Is my breast cancer hormone receptor positive? Why has my breast cancer recurred? Does this mean my treatment will have to change? What are my chances of responding to treatment? TREATMENT OPTIONS What are the treatment options for my stage of breast cancer? Why or why not would these treatments help me? Surgery Radiation Chemotherapy Hormonal therapy Biologically targeted therapy Clinical trial participation What treatment options, oral or injectable, are available for me as an advanced breast cancer patient? What treatment do you feel will work best for me? Why are you recommending this treatment? What are the possible side effects of this treatment? Will it make me feel sick? What kinds of food will help me? Or where can I get advice on meal planning? Will this treatment allow me to continue to be involved in my normal daily activities? If not, would another treatment be better for me so I can remain active? Will the treatment affect my family? What do they need to know? Will the treatment affect my appearance? If so, are there other options that will not change the way that I look? What if my current therapy does not continue to benefit me? Are there any other options? What types of hormonal therapies are available to me? Will it be beneficial? Is there any treatment I could be prescribed that does not have to be taken daily? What are the latest advances in hormonal therapies? How often will I be able to see my health care professional? How will I know if the treatment is working? What are the side effects? How can I manage side effects? What side effects should I tell you about? Will I need follow-up care? OTHER CONSIDERATIONS What studies are currently under way for women with advanced stage breast cancer? Do you recommend a clinical trial for me? How can it help? Where can I get further information on my stage of breast cancer? Where can I find additional support? Please be sure to let your doctor know all the medications (prescription, over-the-counter, and herbal supplements) you currently take. Also, check with your doctor before starting any other medication. One in three of us will get cancer at some point in our lives. Once so feared its name was whispered, the disease is no longer an inevitable death sentence. Today, almost two-thirds of those who develop cancer will still be alive five years later, compared with just half in the 1970s. Cancer has turned out to be tougher to crack than everyone hoped when US President Richard Nixon launched the War on Cancer in 1971. But death rates are falling, thanks to earlier detection of tumours and improved use of existing treatments - mainly chemotherapy and radiotherapy. The success has been biggest for children: since the mid-1970s, death rates from cancers of childhood have halved. Of those with the most common childhood cancer, acute lymphocytic leukaemia, 85% are still alive five years later, compared with just 53% in the 1970s. Inner workings A key reason why cancer patients are living longer, is that scientists now understand more clearly what happens when cells turn cancerous. Cancer begins when genes which normally control cell division, growth and repair are damaged through mutation. These genes can then cause cells to grow and divide uncontrollably, destroying neighbouring healthy cells. For example, a gene called p53, which normally acts as a brake on cell division, turns out to be mutated or lost in about half of all tumours. Another proto-oncogene, Myc normally helps healthy cell division, but can become an oncogene if damaged, causing cells to divide unchecked. Mutations can arise by chance errors in DNA replication, and genes can also be damaged by carcinogens - such as tobacco chemicals, benzene, possibly acrylamide and some food additives - or ultraviolet light from sunshine. Certain viruses can also trigger gene mutations, such as the human papilloma virus that can cause cervical cancer. Some mutated genes are inherited: two examples are BRCA1 and BRCA2, which together account for about 5% of all breast cancer cases. Other genes such as DBC2, EMSY and FA have been implicated in ovarian, breast and lung cancer. Once a cell has turned cancerous, it divides until a mass of cells forms a tumour. Diagnostic tests can quickly distinguish between malignant, or cancerous, tumours and those that are benign, or harmless. As a malignant tumour progresses, cells or clumps of cells break off and spread, or metastasise, around the body via the lymphatic system and blood vessels. The latest generation of treatments exploit our knowledge of what happens within cancerous cells. These target proteins and messenger chemicals - such as growth factors or enzymes - that the errant cells need to survive and grow. Glivec (or Gleevec), for example, targets abnormal proteins that help cancerous cells to grow. Dubbed the first "magic bullet" for cancer, it is used to treat one type of leukaemia and a rare cancer of the gut. Another drug, 17AAG, targets cancer cells by suppressing Hsp90 - a protein vital for their growth. The drug is undergoing trials to treat melanoma and other cancers that affect the prostate, kidney and breast. An alternative approach is to persuade the immune system to attack tumours, using vaccines, biological therapies such as alpha interferon or interleukin 2 and genetically altered white blood cells. In the future, scientists hope to target stem-cell-like cells within cancers that may be responsible for most of the growth of some tumours, and evade existing drugs. They also plan to use nano-drugs, nano-bullets and "smart bombs" to deliver molecules with pinpoint precision to tumour cells. Even soil-living or flesh-eating bacteria, engineered viruses, weed extracts, microwaves, chemicals from Antarctic sea squirts and the immune cells of siblings have been recruited to destroy tumours. Prevalence Patterns In developed countries, the cancer most likely to afflict you is non-melanoma skin cancer, often caused by the Sun’s harmful ultraviolet rays. This is usually treated and cured. Melanoma, a deadlier skin cancer, is less common but is increasing by around 3% a year in the US. Though UV light is the cause of many skin cancers, there is some evidence that small amounts may also help prevent other cancers. In the developing world the most common cancers are linked to infectious agents, such as cervical cancer or liver cancer, caused by hepatitis B. The biggest killer in industrialised nations remains lung cancer. For men, lung cancer mortality has been falling since 1990, mirroring a peak in popularity of smoking during the 1960s. For women, who commonly took up smoking later, lung cancer mortality is still rising. Tobacco is also rapidly becoming the leading cause of cancer in Asia. Breast cancer accounts for almost one in three of all cancers diagnosed in women each year. For men, prostate cancer is just as common, with the highest rates in African American men and Caribbean men of African origin. Screening for both of these diseases has improved sharply. Early breast tumours show up on a mammogram long before they can be felt as a lump. More women now survive the disease - three-quarters of women whose breast cancer was diagnosed 10 years ago are still alive today. Similarly, a prostate-specific antigen (PSA) test has revolutionised early diagnosis for this cancer in the US. Some experts argue that screening can be harmful, however. Factoring in risk Dozens of factors affect an individual’s risk of getting cancer. Smoking is the biggest single risk factor - with tobacco linked to about a third of all cancers. Another clearly established risk factor is exposure to ionising radiation. This may be responsible for cancers in people living around Chernobyl in Ukraine, Toikamura in Japan and for people working in nuclear power plants. Radiation may also have led to a high incidence of cancer in those who witnessed early nuclear tests or have been in contact with depleted uranium munitions, though a recent study contests this risk. Risk factors for developing breast cancer include: being childless or delaying childbearing until aged over 30, starting periods early, using hormone replacement therapy, being exposed to oestrogen-like chemicals, and drinking one or more units of alcohol daily. More than one risk factor is usually needed before cancer cells develop. Risks posed by living near overhead power lines or petrol stops, or using cellphones, are less clear. Preventative steps If everyone stopped smoking, cancer deaths could be cut by one-third, researchers estimate. Moves to protect people from passive smoking, in bars for example, are gaining ground in many industrialised countries. Staying out of sunlight and using strong sunscreens could prevent hundreds of thousands of us from developing skin cancer worldwide annually. Foods rich in antioxidants and beneficial fatty acids such as omega-3 and oleic acid found in olive oil - a key ingredient of the healthy Mediterranean diet - seem to protect against some cancers, although the findings are mixed. Doctors can increasingly intervene directly to prevent cancers. For example, vaccines against hepatitis B could soon cut deaths from liver cancer. There are also preventive therapies - such as tamoxifen or the trial drug anastrazole - that interfere with the production of the hormone oestrogen, implicated in many breast cancers. Doctors believe that it could halve the rates of breast cancer in women with a family history of the disease. All this means that, while hopes of total cure for cancer are still unrealistic, the disease is increasingly under control. |
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