Breast cancer

Facts

Breast cancer affects one in every eight American woman. If detected and treated early, it is highly curable.

Seattle Cancer Care Alliance (SCCA) offers mammography and other services to detect breast cancer early as well as comprehensive treatment from a team of breast cancer experts.

What is breast cancer?

Breast cancer develops when cells in the breast divide and grow without their normal controls. Cancer cells also don’t organize normally. Instead they grow into a tumor, which may invade nearby tissue and spread to other organs.

  • In the United States, breast cancer is the second most common cancer in women (after skin cancer). About 319,000 people are newly diagnosed with breast cancer each year. 
  • Over a woman’s lifetime, there’s a one in eight chance she will get breast cancer. For men, the lifetime risk is much lower — about one in 1,000.
  • The content in this section is mainly aimed at women, who make up 99 percent of all breast cancer patients. Most of the information applies to men as well.

Types

Breast cancers fall into these two main types:

In situ breast cancer

In situ breast cancer is only in the milk ducts and lobules (milk-producing glands). This type is also called noninvasive breast cancer.

Ductal carcinoma in situ (DCIS) is the most common noninvasive breast cancer. It is early-stage cancer confined to the milk ducts. Usually it causes no physical signs or symptoms and is detected by a screening mammogram.

Many women with DCIS can be cured by removing the tissue that contains the tumor. Left untreated, DCIS can become invasive cancer.

Invasive breast cancer

Invasive breast cancer can start in the ducts or lobules but then spreads into surrounding breast tissue. It may eventually become metastatic, meaning it spreads to other organs, like the bones or lungs. Invasive breast cancer is also called infiltrating breast cancer.

These are the most common types of invasive breast cancer.

  • Invasive ductal carcinoma: This type begins in a duct in the breast and breaks through into the surrounding fatty tissue of the breast. From there, it can spread to other parts of the body through the bloodstream or lymph. About 80 percent of invasive breast cancers are invasive ductal carcinomas, also called infiltrating ductal carcinomas.
  • Invasive lobular carcinoma: This type starts in the lobules and can spread to other parts of the body. It is also called infiltrating lobular carcinoma. This is the second most common type of invasive breast cancer.
  • Inflammatory breast cancer: Only about 1 to 3 percent of women with breast cancer have the inflammatory type. This rare cancer may begin in either the ducts or the lobules. It is aggressive and progresses rapidly. In its early stages, it can be mistaken for infection because the symptoms are similar. Most infections will respond to antibiotics, but inflammatory breast cancer will not.

Other rare types of breast cancer include Paget’s disease of the nipple and phyllodes tumors.

Breast cancer infographic

Symptoms

Early detection is key to treating and curing breast cancer. Women with smaller, early-stage cancer have more treatment options and a better chance for a cure.

If you’re concerned about a breast lump or other symptom that may result from breast cancer, ease your mind and have it evaluated at the Breast Health Clinic at SCCA or UW Medical Center–Roosevelt in the University District.

Common warning signs

Many women regularly examine their breasts to look for common warning signs. These include:

  • A painless lump in the breast
  • Abnormal thickening of the breast tissue
  • A change in the density of the breast

Less often, breast cancer can show up as:

  • A lump under the arm
  • Red or scaly skin on the breast
  • A change in the nipple (such as discharge or inversion)
  • Dimpling of the skin
Inflammatory breast cancer symptoms

Inflammatory breast cancer may make your breast red, swollen and warm to the touch, similar to the symptoms of an infection. The surface of your breast may look pitted, like the skin of an orange, because the cancer cells block lymph vessels in your skin. Typically there is no single lump in the breast.

Diagnosing

If you notice any change in the feel, appearance or texture of either of your breasts, schedule a clinical breast examination with your health care provider. Most breast lumps are not cancerous, but it’s important to have an exam — and possibly tests — to be sure.

Mammogram

A diagnostic mammogram is used to evaluate a woman with a breast problem or symptom or an abnormal finding on a screening mammogram. It usually includes additional views of one or both breasts.

SCCA was the first in the region to offer digital mammography for more accurate diagnosis. Many studies show that doctors who specialize in mammography, like they do at SCCA, are more accurate at interpreting the images when compared to doctors with less experience.

Ultrasound

If your mammogram turns up anything suspicious, you may be asked to have an additional mammogram or an ultrasound. Breast ultrasound is used to evaluate lumps that are hard to see on a mammogram. Because of the ways different substances interact with sound waves, ultrasound can often reveal whether a lump is a solid mass or a fluid-filled, non-cancerous cyst.

Magnetic resonance imaging (MRI)

Breast MRI is an important test for some women. It can help detect breast cancers that are harder to see on a mammogram. SCCA radiologists are experts at obtaining high-quality breast MRI images and identifying which women will benefit the most from MRIs. We also conduct breast MRI research and clinical trials that examine how to best use this technology.

Biopsy

In a biopsy, a doctor removes a sample of cells from a suspicious area. Then a pathologist examines the sample under a microscope.

A biopsy is the only way to tell if cancer is really present. A biopsy can also reveal details about the cancer that influence treatment decisions.

You may have one of these types of biopsy:

  • Fine-needle biopsy — using a needle to extract fluid or cells from a lump that can be felt or seen with ultrasound or on a mammogram. 
  • Core biopsy — nearly the same as a fine-needle biopsy but with a larger needle to remove a small cylinder of breast tissue.
  • Stereotactic needle biopsy — done when the lump is so small that the doctor cannot insert the biopsy needle accurately. You lie face down on a special table with an opening that lets your breast hang down. A mammogram shows the location of the lump and a computer guides the needle.
  • Surgical biopsy — surgery to remove all or part of a breast lump. 

During surgery for breast cancer, you may also have one or more lymph nodes removed and biopsied to check whether cancer cells have spread into your lymph system.

Grades of breast cancer

The grade of an invasive breast cancer refers to how closely the cancer cells resemble normal breast cells under a microscope. Determining the grade is part of your biopsy.

  • A lower number usually means a slower-growing cancer that is less likely to spread.
  • A higher number usually means a faster-growing cancer that is more likely to spread.

There are three grades.

  • Grade 1 (well differentiated): The cells in these cancers are relatively less abnormal looking. They do not appear to be growing rapidly.
  • Grade 2 (moderately differentiated): The cancer cells are somewhat more abnormal.
  • Grade 3 (poorly differentiated): These cancer cells look the most abnormal. They tend to grow and spread more aggressively. 

Hormone-receptor and HER2/neu status

Your care team will try to determine other traits of your breast cancer when they check the sample of tissue removed during your biopsy or a sample taken when your entire tumor is removed surgically. Specifically, they will be looking for your hormone-receptor status and HER2/neu status.

Hormone-receptor positive breast cancer

Most women with breast cancer have hormone-receptor positive (HR+) disease. This means their cancer cells have one or both of these:

  • Receptors where estrogen can attach (estrogen-receptor positive, or ER+, disease)
  • Receptors where progesterone can attach (progesterone-receptor positive, or PR+, disease)

Most women have both types of receptors. If your cancer is HR+, this helps doctors predict that your cancer will respond to hormonal therapy. 

HER2-positive breast cancer

Some women with breast cancer have HER2-positive disease. This means their cancer cells make too much of a protein called HER2/neu, which indicates that the cancer may be more aggressive.

If your cancer is HER2 positive, this helps doctors predict that your cancer will respond to certain targeted biological therapies.

Triple-negative breast cancer

This term refers to breast cancers that are:

  • Not estrogen-receptor positive
  • Not progesterone-receptor positive
  • Not HER2 positive

Stages

Doctors use your cancer’s stage to help plan the best treatment for you. Stage refers to the extent of your cancer, such as the size of the tumor and if it has spread.

There are two main systems for determining the stage of breast cancer:

TNM staging

TNM stands for tumor, nodes and metastasis. Your TNM stage will consist of:

  • The letter T followed by a number from 0 to 4. A higher T number means the tumor is larger, has spread more widely into nearby tissues or both.
  • The letter N followed by a number from 0 to 3. A higher N number means greater spread of cancer cells to lymph nodes near the breast, such as in the armpit (axilla) or under the collarbone (clavicle).
  • The letter M followed by a 0 or 1. M0 means a physical exam and imaging studies, such as X-rays, have not found cancer in lymph nodes away from the breast or in distant organs; M1 means distant spread was found.
Overall stage grouping

Once your doctor determines your TNM, they will assign a stage using overall stage grouping, also known as Roman-numeral staging.

  • Stage 0: Noninvasive cancers (ductal carcinoma in situ, or DCIS, and lobular carcinoma in situ, or LCIS) are considered stage O.
  • Stage I: The tumor is smaller than 1 inch, and the cancer has not spread to the lymph nodes under your arm or to other sites beyond your breast.
  • Stage II: The tumor is 1 to 2 inches in size, or the cancer has spread to the lymph nodes under your arm. Stage I or II cancers may be called early-stage cancers.
  • Stage III: This is a more advanced cancer, but it is still confined to your breast, surrounding tissues and lymph nodes. Stage III cancers may be considered early-stage or advanced cancers.
  • Stage IV: Cancer has spread or metastasized to distant sites, such as your lungs, liver, bones and brain, or to lymph nodes beyond your underarm area.

Frequently asked questions

Risk and Prevention

Is hormone replacement therapy safe?

Approach hormone replacement therapy (HRT) with caution. Taking postmenopausal estrogen replacement increases your risk of breast cancer. Women who have had breast cancer or who are at high risk of developing it should probably avoid HRT. Talk with your doctor about HRT options and the risks and benefits for you.

Should I take soy estrogens—or eat tofu—to help prevent breast cancer?

Soybeans and soy products (including tofu, soy milk, and miso) contain phytoestrogens, or plant estrogens. These substances are similar to but much weaker than human estrogen. They are used by many women to control symptoms of menopause, such as hot flashes. It is also believed that the phytoestrogens found in soy-based foods may help prevent breast cancer.

Do regular mammograms save lives? What about breast self-exams?

Yes, screening mammograms save lives. Because mammograms do not detect every cancer, a complete breast health program also includes annual clinical breast examinations.

Breast self-examination (BSE) is also a component of a complete breast health program. Used in conjunction with mammography and clinical breast examination, BSE can facilitate early detection of some of the more elusive cancers. It is very helpful for a woman to be familiar with her own breast anatomy so that she can provide information as to whether lumps or thickenings are new or have been present for a long time. BSE is the best way for a woman to become familiar with how her breasts normally feel.

My sister had breast cancer. What’s my risk?

The answer depends on the specifics of your situation. If your sister was diagnosed with breast cancer when she was 65 years old and no one else in your family has had breast or ovarian cancer, your risk is probably not much higher than average. If your sister was diagnosed when she was 35 years old and there are other women in your family with breast or ovarian cancer, your risk may be a lot higher than average. The specialists at the Cancer Genetics Clinic can help you figure out your risk. Call (206) 616-2135 for more information.

Can I have an ultrasound instead of a mammogram to check for breast cancer?

A mammogram is the most effective way to screen for breast cancer. Ultrasound is not used for routine breast cancer screening because it does not consistently detect early signs of cancer such as microcalcifications.

Are women who have had an abortion at higher risk for breast cancer?

No, according to the National Cancer Institute. NCI reported that neither induced abortion nor spontaneous abortion (miscarriage) is associated with an increase in breast cancer risk.

Current-Patient Questions

How can I receive financial assistance for breast cancer treatment?

Financial assistance for the treatment of breast cancer can come from several places. The U.S. government has several programs that help patients pay for medical treatment, including Aid to Families with Dependent Children, Medicare, Medicaid and the Hill-Burton Program. Also, local affiliates of the Komen Foundation, the American Cancer Society and other cancer support organizations may be able to help. If you are an SCCA patient, please call our social work department at (206) 606-1076, or e-mail socialw@seattlecca.org for more information.

After a mastectomy, can I have my breast reconstructed?

Yes, today most mastectomy patients can have breast reconstruction. Age is not a factor in determining whether a woman can have reconstructive surgery, nor is the type of mastectomy or the placement of the mastectomy scar. Women who have had radical mastectomies (removal of the breast and chest wall muscles) or modified radical mastectomies (removal of the breast with the chest muscles left intact) can have breast reconstruction.

Also, it does not matter how much time has elapsed since a woman’s original cancer surgery. Breast reconstruction, depending on the procedure, can be performed at the same time as the mastectomy surgery or years later. 

Support Questions

Where can I find a breast cancer support group?

Ask your doctor, oncology nurse or an SCCA social worker (e-mail socialw@seattlecca.org) about breast cancer support groups. Or check the times and meeting places of SCCA support groups. The local chapter of the American Cancer Society (ACS) will also have information about support groups in your area.

How can I help a friend or family member who has cancer?

Helping a friend or family member who has cancer can be as easy as writing a letter of support, cooking a meal, or offering to drive the person to the doctor. Let the friend or family member know that you are ready and willing to help by asking how they would like you to help. 

Survivor Questions

As a breast cancer survivor, should I take tamoxifen?

Tamoxifen (Nolvadex) is a drug that interferes with the activity of estrogen. Some breast cancer cells are “estrogen sensitive,” meaning estrogen binds to receptors on these cells and stimulates the cells to grow and divide. (Such cancer is called hormone-receptor positive.) Tamoxifen prevents estrogen from binding and stops the cancer cells from growing. So it can prevent or delay a recurrence of breast cancer for some women.

However, large randomized trials in postmenopausal women found that aromatase inhibitors, (such as anastrozole (Arimidex) or exemestane (Aromasin)) was better than tamoxifen in terms of recurrence-free survival.

Are there alternatives to tamoxifen?

Tamoxifen (Nolvadex) has been found to be effective in preventing a recurrence of breast cancer. However, several randomized trials in postmenopausal women found that aromatase inhibitors (such as anastrozole (Arimidex) or exemestane (Aromasin)) are better than tamoxifen in terms of recurrence-free survival. 

What is Herceptin?

Trastuzumab (trade name Herceptin) is an engineered antibody that targets cancer cells that over-express (make too much of) a protein called HER2/neu. (Such cancer is called HER2 positive.) Herceptin is used to treat early-stage and metastatic (spread to other parts of the body) breast cancers.

Herceptin is effective only for women whose breast cancer is HER2 positive. Because it is a targeted treatment that just attacks cancer cells, the side effects are milder than those of chemotherapy, which damages all fast-growing cells.

What is Avastin?

Bevacizumab (Avastin) is a drug that inhibits the growth of blood vessels to tumors. It has been approved by the U.S. Food and Drug Administration to treat some types of cancer but is no longer approved to treat breast cancer. Nonetheless, there is ongoing clinical research at SCCA testing Avastin in certain forms of breast cancer.

I am a breast cancer survivor. Can I take soy estrogens to help with menopause symptoms? Are they safe for me?

Researchers are looking at these questions now. Until more is known, women who have or have had estrogen-positive breast cancer should minimize their intake of phytoestrogens. (Estrogen-positive breast cancer is cancer that is stimulated by estrogen to grow and divide.) Ask your doctor about the latest research and how it applies to you. Women who are taking tamoxifen should also minimize their intake of phytoestrogens.

Should I receive breast imaging surveillance after my breast cancer treatment?

Yes, breast imaging surveillance is used for early detection of second breast cancers in people who have been treated for breast cancer. Learn more about breast imaging surveillance after breast cancer treatment in this handout.

Screening Questions

What’s the difference between mammography and MRI?

Mammography uses X-rays. MRI, short for magnetic resonance imaging, uses radio waves and a powerful magnet linked to a computer to create detailed pictures of areas inside the body.

Mammography is an excellent tool for screening women at average risk for breast cancer. It is easily accessible and less expensive than MRI.
 
Recent studies show that MRI is a great complement to mammography, especially in women who have been diagnosed with breast cancer. MRIs are now used most often as adjuncts to screening mammography in women who are at very high lifetime risk for breast cancer. But breast MRI is not considered a replacement for screening mammography.

The American Cancer Society recommends that a small number of women (less than 2 percent of women in the U.S.) be screened with MRI in addition to mammograms because these women have a family history of or a genetic tendency for cancer or because they have certain other risk factors. Ask your health-care provider whether you should have an MRI or other screening tests or start screenings earlier in life.

MRI is also used to evaluate the extent of breast cancer in patients whose disease is newly diagnosed, and it can help guide treatment options. Breast MRI also detects unsuspected cancer in the other breast in 3 to 4 percent of women with newly diagnosed breast cancer.

What about the radiation from a mammogram? Is it safe?

If you read much, you’re bound to run into articles that say radiation increases cancer risk. So it stands to reason that mammography would increase risk as well because it uses X-rays (radiation) to take images of the breast. Doctors have been looking at this assumption for years. That’s how the guidelines came about for the age when mammograms should begin. The younger a person is, the more sensitive they are to radiation damage, especially in soft tissue like breast tissue. Therefore, it’s not recommended that women 25 to 39 get mammograms, unless there is a strong reason to do so, which your doctor will help you determine.

Like dental X-rays, mammograms use very small amounts of radiation to take images of the breast—images that can be life saving. At this time, the risk of not getting mammograms seems to be greater than the risk of getting them. According to the National Cancer Institute, several large studies conducted around the world show that breast cancer screening with mammograms reduces the number of deaths from breast cancer for women ages 40 to 74, especially for those over age 50. 

Among women in the United States, breast cancer is the most common non-skin cancer and the second leading cause of cancer-related death. The great news is that death rates from breast cancer have been declining since 1990, and the decrease is believed to result, in part, from earlier detection and improved treatment. Early detection means getting a mammogram.

Do mammograms hurt?

In the February 2005 issue of the American Journal of Roentgenology, a study was published suggesting that most women do not experience pain or anxiety during mammography screening.

The study consisted of 150 women divided into three groups for their screening mammograms. In one group, the women listened to a relaxation tape during the mammogram. Another group listened to music during their mammogram. The third group didn’t listen to anything. After their mammograms, the women filled out questionnaires about how much pain and anxiety they experienced during the mammogram. The study found no significant differences regarding pain or stress in any of the groups. “Virtually none of the participants experienced pain or anxiety. We were quite surprised at the outcome,” the study investigator said in a prepared statement.

Some women say that their breasts are so sensitive just the idea of a mammogram is painful. This may especially be true for women with large breasts. Be sure to let the technician know if you experience pain during your mammogram so they can reposition you.

Bottom line: Mammograms should not be a painful experience.

Digital vs. film mammography: Which is best?

There are two kinds of mammograms: digital and conventional film. Both use X-ray radiation to produce an image of the breast. Conventional mammograms are read and stored on film. Digital mammograms are read and stored in a computer so the data can be enhanced, magnified or manipulated for further evaluation. There are no other differences between the two.

Studies show that in most cases, digital mammograms read by specialized radiologists are more than 20 percent more accurate at detecting breast cancer than traditional mammograms read by generalists. Breast expert radiologists read thousands of mammograms a year.

According to the National Cancer Institute, women with dense breasts who are premenopausal or perimenopausal (women who had their last menstrual period within 12 months of their mammogram) or who are younger than age 50 may benefit from having a digital rather than a film mammogram because subtle differences between normal and abnormal tissue may be easier to see. Recent studies support this, showing that digital mammography detects up to 28 percent more cancers than film mammography in the population of women mentioned above. A 28 percent increase in accuracy means earlier detection, and most importantly, a better chance of a cure.

Other advantages to digital mammography over film mammography include improved ease of image access, transmission, retrieval and storage, and lower average radiation dose without a compromise in diagnostic accuracy. (Digital mammograms require about three quarters the radiation dose of film mammography. However, the dose in film mammography is quite low and poses no significant danger to patients.) In addition, digital mammograms are less likely than film mammograms to be lost.

Why are expert radiologists important?

The more experienced a radiologist is at reading mammograms, the more accurate the results will be.

The doctors at SCCA who read mammograms are all board-certified radiologists, and the more experienced ones are likely to be fellowship-trained, which means they earned the title of breast imaging specialist. As specialists, all they do is read mammograms—thousands of them a year. Lots of studies have shown that doctors who specialize in mammography are more accurate at interpreting the images when compared to doctors with less experience.

So, what does this mean for you? When you schedule your appointment for a mammogram, ask if the radiologist reading the image is a general radiologist or a breast imaging specialist so you can be confident about the results you receive. 

How often should I have a screening mammogram?

At SCCA, we follow the American Cancer Society (ACS) screening guidelines for mammography. ACS recommends women have an annual screening mammogram starting at age 40. For women with a 20 percent or greater lifetime risk for breast cancer, ACS recommends having an annual screening breast MRI (magnetic resonance imaging) scan in addition to a mammogram. If you have questions about your risk level or which screenings you should have and when, ask your health-care provider. If you are at high risk for breast cancer or ovarian cancer, SCCA has a special program to help you know which screenings are appropriate for you and how you can decrease your cancer risk. It’s called the Breast and Ovarian Cancer Prevention Program. Call the program coordinator at (206) 606-6990 with questions or to make an appointment.