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Breast cancer (female)

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In the UK, breast cancer is the most common type of cancer among women. Approximately 45,000 cases of breast cancer are diagnosed every year, usually in women who are over 50 years of age and who have reached menopause. However, it is possible for women of any age to be affected by breast cancer and, in rare cases, the condition can also affect men.
Brought to you by NHS Choices

Overview

Introduction

Anatomy of the breast

A woman's breasts are made up of fat, connective tissue, and thousands of tiny glands (known as lobules), which produce milk. If a woman has a baby, the milk is delivered to the nipple through tiny tubes called ducts, which allow her to breastfeed. Breast cancer usually shows as a lump or thickening in the breast tissue, although most breast lumps are not cancerous.

Types of breast cancer

There are several different types of breast cancer, which can develop in different parts of the breast. The most common is known as ductal breast cancer, which develops in the cells that line the breast ducts. Ductal breast cancer accounts for about 80% of all cases of breast cancer.

Other less common types of breast cancer include lobular breast cancer, which develops in the cells that line the milk-producing lobules; inflammatory breast cancer; and Paget's disease of the breast. It is possible for breast cancer to spread to other parts of the body, such as the liver, bones or lymph nodes (small glands that filter bacteria from the body).

Breast screening

The exact cause of breast cancer is not fully understood, although there are many factors that increase the likelihood of developing the condition, such as age and family history.

Women who have a higher than average risk of developing breast cancer may be offered screening and genetic testing for the condition. As the risk of breast cancer increases with age, all women between 50-70 years of age of should be screened once every three years as part of the NHS Breast Screening Programme.

Breast cancer can be treated using a combination of surgery, chemotherapy, and radiotherapy. Some cases of breast cancer may also be treated using biological or hormone treatments.

One in nine women are affected by breast cancer during their lifetime. There is a good chance of recovery if the condition is detected in its early stages. For these reasons, it is vital that women check their breasts regularly for anything unusual, and always get any changes examined by their GP.

Online Personal Education and Risk Assessment (OPERA)

If you are concerned about your risk of developing inherited breast cancer, an online interactive assessment tool called OPERA is currently available.

The tool is based on the National Institute for Clinical Excellence (NICE) guideline for the classification and care of women at risk of familial breast cancer. It is designed for use by patients and health professionals in order to assess a patient's risk of developing the condition based on their family history of both breast cancer and ovarian cancer. This is because the genes that are mainly responsible for breast cancer are also linked to ovarian cancer.

Symptoms

The main symptom of breast cancer is usually a lump, or thickened area of tissue, in your breast. The majority of breast lumps are found by the women who have them, and it is very important that you are aware of any lumps, or changes in the appearance, feel, or shape of your breasts. This is important because the sooner a cancerous lump is detected, the better the chances are that it will be treated successfully.

Changes to look out for

You should see your GP if you notice any of the following:

  • a lump, or thickened area of tissue, in either breast,
  • discharge from either of your nipples (which may be streaked with blood),
  • a lump or swelling in either of your armpits,a change in the size, or shape, of one, or both, of your breasts,
  • dimpling on the skin of your breasts,
  • a rash on, or around, your nipple,a change in the appearance of your nipple, such as becoming sunken into your breast, or
  • pain in either of your breasts or armpits which is not related to your period.

If you have a lump in your breast, it is important to remember that it may not be the result of breast cancer. In fact, 90% of breast lumps are benign (non-cancerous). For example, a breast lump may be caused by a harmless cyst (a small fluid-filled lump), or fibroadenoma (benign growths that are very common). You may also find that your breasts feel lumpy just before your period.

However, if you notice any changes to one, or both, of your breasts, as listed above, you should always get it checked by your GP.

Breast awareness

It is important that you are breast aware and, if you find a lump on your breast, that you inform your GP as soon as possible.

Get to know the way that your breasts normally look and feel because this will make any changes easier to spot.

You can check your breasts in the shower or bath, or before dressing. It is best to do this after your monthly period because your breasts can feel lumpy before your period is due.

Causes

Cancer is caused by the cells in a certain area of your body dividing and multiplying too rapidly. It is not fully understood why breast cancer occurs, but research into the causes of breast cancer is continuing.

So far, several likely causes of breast cancer have been identified, as well as risk factors that may make developing the condition more likely. The various causes and risk factors are outlined below.

Causes and risk factors of breast cancer

Age

Your risk of developing breast cancer increases as you get older. Breast cancer is most common among postmenopausal women who are over the age of 50.

All women between 50-70 years of age should be screened for breast cancer every three years, as part of the NHS Breast Screening Programme. See the 'prevention' section for further information about breast cancer screening.

Family history

The majority of breast cancer cases are not hereditary (run in families), although having breast cancer in your family can increase your chances of developing the condition. Particular genes, known as BRCA1 and BRCA2, can increase your risk of developing both breast and ovarian cancer, and it is possible for them to be passed on from one family member to another. There is also a third gene associated with an increased risk of breast cancer, which is known as TP53.

Therefore, you have a higher than average risk of developing breast cancer if you have close relatives who have had cancer of the breast, or ovary. However, as breast cancer is the most common form of cancer in women, it is also possible for it to occur more than once in the same family by chance.

If you have two, or more, close relatives from the same side of your family, such as your mother, sister, or daughter, who have had breast cancer, you should be eligible to be screened for breast cancer, or for the genes that may make developing it more likely. See the 'prevention section' for further information about breast screening.

Previous diagnosis of breast cancer

If you have had breast cancer before, you are more at risk of developing the condition in your other breast. If this is the case, you should be closely monitored by your treatment team, such as your oncologist (specialist in cancer) and your breast nurse, so that any recurring cancer can be detected as soon as possible.

Previous benign breast lump

While having a benign breast lump does not mean that you have breast cancer, it can slightly increase your risk of developing it. Certain changes in your breast tissue, such as atypical hyperplasia (cells growing abnormally), or lobular carcinoma in situ (benign cell changes inside your breast lobes) can also make getting breast cancer more likely.

Research shows that having atypical hyperplasia can increase your risk of developing breast cancer by 2-5 times. If you have either of these conditions, your GP should monitor the health of your breasts with regular check ups.

You should always visit your GP if you notice any lumps, or changes, in the appearance of your breasts.

Breast density

Your breasts are made up of thousands of tiny glands, or lobules, which produce milk, as well as fat and connective tissue. The glandular tissue contains a higher concentration of breast cells than the fat, or connective tissue, which makes it denser. Therefore, having dense breast tissue can increase your risk of developing breast cancer because there are more cells that can become cancerous.

Dense breast tissue can also make a breast scan (mammogram) harder to read because it makes any lumps, or areas of abnormal tissue, harder to spot.

Despite the fact that the risk of breast cancer increases with age, it is younger women who tend to have denser breasts. As you get older, the amount of glandular tissue in your breasts decreases and is replaced by fat, and your breasts become less dense.

Exposure to oestrogen

In some cases, breast cancer cells can be stimulated by the female hormone oestrogen. Your ovaries (where your eggs are stored) begin to produce oestrogen when you enter puberty in order to regulate your periods.

Your risk of developing breast cancer may rise slightly with the amount of oestrogen that your body is exposed to. For example, if you started your periods at a young age, and entered menopause at a late age, you will have been exposed to oestrogen over a longer period of time. In the same way, not having children, or having children later in life, may slightly increase your risk of developing breast cancer because your exposure to oestrogen is uninterrupted by pregnancy.

Being overweight or obese

If you are postmenopausal, and you are overweight, or obese, you may be more at risk of developing breast cancer. This is thought to be linked to the amount of oestrogen in your body, as being overweight, or obese, causes more oestrogen to be produced.

You can find out if you are overweight, or obese, by using the body mass index (BMI) calculator. See the 'related articles' section for a link to the BMI calculator.

Being tall

If you are taller than average height, you are more likely to develop breast cancer than those who are shorter than average. The reason for this is not fully understood, although it may be because taller women tend to have more breast tissue than women who are of average height, or less.

Alcohol

Your risk of developing breast cancer can increase with the amount of alcohol that you drink. Research shows that there will be three extra women diagnosed with breast cancer for every 200 women who regularly have two alcoholic drinks a day, when compared with women who do not drink at all.

Radiation

Certain medical procedures which use radiation, such as X-rays and CT scans, may slightly increase your risk of developing breast cancer. However, the amount of radiation that is used during these procedures is always the lowest possible, and they are only carried out when they are medically necessary.

If you had radiotherapy for Hodgkin's lymphoma when you were a child, you should have already received a written invitation from the Department of Health for a consultation with a specialist to discuss your increased risk of developing breast cancer. See your GP about this if you were not contacted, or you did not attend a consultation. If you currently need radiotherapy for Hodgkin's lymphoma, your specialist should discuss the risk of breast cancer before your treatment begins.

Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT) is associated with a slightly increased risk of developing breast cancer. Both combined HRT and oestrogen-only HRT can increase your risk of developing breast cancer, although the risk is slightly higher again if you take combined HRT.

The research behind this is still in its early stages, but it is estimated that there will be an extra 19 cases of breast cancer for every 1,000 women who are taking combined HRT for ten years. The risk continues to increase slightly the longer you take HRT, but returns to normal once you stop taking it.

Diagnosis

See your GP if you notice a lump in your breast, or any change in the appearance, feel, or shape of your breasts. Your GP will examine your breasts, and if they think that you may have breast cancer, they will be able to refer you to a specialist breast clinic for tests.

At the breast clinic, a specialist, or specialist breast nurse, will carry out tests to determine whether or not you have breast cancer. If you have breast cancer, the tests will also show what type of breast cancer you have. Your specialist, or nurse, will be able to determine the best way to treat you. They may also take photographs of your breasts in order to keep a record of their current appearance, and any further changes which may occur.

If you are diagnosed with breast cancer, the tests can also help to identify the stage and grade of your condition, which your oncologist (specialist in cancer) will discuss with you thoroughly. The stage is used to describe the spread of the cancer at the time of diagnosis, and the grade indicates how aggressively it is spreading.

Determining the stage and grade of your breast cancer will help your doctors to decide on the best kind of treatment for your condition. However, it is important to remember that the stage and grade of your breast cancer alone cannot predict how your condition will progress. The way in which your condition will progress also depends on factors such as the type of breast cancer that you have and your overall health.

The various tests that you may have to diagnose breast cancer, and those which determine specific types of treatment, are outlined below.

Tests to diagnose breast cancer

Blood test

A sample of your blood will be taken so that your doctor can assess your overall health, as well as how well your liver and kidneys are working.

Mammogram

A mammogram is a simple procedure which uses X-rays to create an image of the inside of your breasts. This can help to identify early changes in your breast tissue when it may be difficult to feel a lump. However, as younger women tend to have denser breasts in which changes are more difficult to identify, a mammogram is not as effective if you are under the age of 35. If this is the case, your doctor may suggest that you have a breast ultrasound instead.

If you need to have a mammogram, your radiographer (X-ray specialist) will position one of your breasts on a flat X-ray plate. A second X-ray plate will press down on your breast from above, so that it is temporarily compressed and flattened between the two plates. An X-ray will then be taken which will give the clearest possible image of the inside of your breast. The procedure will then be carried out on your other breast.

A mammogram only takes a few minutes and you may find it a bit uncomfortable, or even a little painful. Your doctor will examine the mammography for indications of cancer, such as calcification (areas of calcium within your breast tissue) that show up on an X-ray. However, if you have calcification, it does not mean that you have cancer, and you will need further tests to confirm a diagnosis.

Breast ultrasound

You may need to have a breast ultrasound if you are under the age of 35 because your breasts may be too dense for a mammogram. Your doctor may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid, or contains liquid.

Ultrasound uses high frequency sound waves to produce an image of the inside your breasts, in the same way that an unborn baby can be seen in the womb. An ultrasound probe, or sensor, will be placed over your breasts in order to create an image on a screen. The image produced will show any lumps, or abnormalities, that may be present in your breasts.

Biopsy

A biopsy involves taking a sample of tissue cells from your breast and testing them to see if they are cancerous. Biopsies can be taken in different ways, and the type you will have will depend on what your doctor knows about your condition so far. The different methods of performing a biopsy are outlined below.

  • Needle aspiration - this type of biopsy may be used to test a sample of your breast cells for cancer, or to drain a benign cyst (small fluid-filled lump). Your doctor will use a small needle to extract a sample of cells, without removing any tissue.
  • Needle biopsy - this is the most common type of biopsy, in which a sample of tissue is taken from a lump in your breast using a large needle. You will have a local anaesthetic, which means that you will be awake but your breast will be numb. Your doctor may suggest that you have a needle biopsy if they need to know whether or not the cancer has spread, as it allows them to examine it within your tissue, rather than after it has been extracted from it.
  • Surgical or excision biopsy - this type of biopsy is carried out under general anaesthetic, which means that you will be asleep during the procedure. Your doctor will surgically remove all, or part, of a lump from your breast in order to test it for cancer.

CT scan or MRI scan

CT and MRI scans produce detailed pictures of the inside of your body and, if necessary, they can be used to highlight the locations in your body where cancer has spread. They can also show in detail the exact size and shape of a lump inside your breast.

A CT scan uses a series of X-rays to form a 3-D image. An MRI scan uses a strong magnetic field and radio waves, and your doctor may suggest it if your mammogram, or breast ultrasound, does not show a lump in your breast in enough detail.

Chest X-ray

You may need to have a chest X-ray if your doctor thinks that your breast cancer may have spread to your lungs.

Bone scan

You may need to have a bone scan if your doctor thinks that the cancer may have spread to your bones. Before a bone scan, a substance containing a small amount of radiation, known as an isotope, will be injected into a vein in your arm, which will be absorbed into your bone if it has been affected by cancer. The affected areas of bone will show up as highlighted areas on the bone scan, which is carried out using a special camera.

The radioactive substance will disappear from your body after a few hours and will not make you radioactive. The amount of radiation used is very small and has no harmful effects. However, as with any form of radiation there is a small risk of it affecting an unborn child, so it is best to avoid contact with pregnant women for the rest of the day, if possible.

Tests to determine specific types of treatment

If you are diagnosed with breast cancer, you will need to have further tests which can show whether or not the cancer will respond to specific types of treatment. Whatever the result of your tests, they can give your doctors a more complete picture of the type of cancer that you have, and how best to treat you.

Hormone receptor test

In some cases, breast cancer cells are stimulated to grow by hormones which occur naturally in your body, such as oestrogen and progesterone. If this is the case, the cancer may be treated by stopping the effects of the hormones, or lowering their levels in your body. This is known as hormone therapy.

A sample of cancer cells will be taken from your breast and tested to see if they respond to either oestrogen or progesterone. The cancer cells are said to respond if they have areas that let either hormone attach itself to them, which are known as hormone receptors.

If you have cancer cells that respond to oestrogen, the type of breast cancer that you have is said to be oestrogen receptor positive. If you have cancer cells that respond to progesterone, the type of cancer that you have is said to be progesterone receptor positive. Hormone therapy is most effective on cancers that are oestrogen receptor positive, but it is only one of the ways in which breast cancer can be treated.

HER2 test

In the same way that hormones can encourage the growth of some types of breast cancer, other types are stimulated by a protein called HER2. These types of cancer may be treated by blocking the effects of HER2, which is known as biological therapy.

If the test shows that the cancer cells in your breast respond to HER2, it means that they have HER2 receptors, which are areas that let HER2 attach itself to them. The type of cancer that you have is said to be HER2 positive.

Biological therapy can be used on breast cancers that are HER2 positive, but as is the case with hormone therapy, biological therapy is only one of the ways in which breast cancer can be treated.

Treatment for breast cancer is usually carried out using a combination of surgery, chemotherapy, radiotherapy and, in some cases, hormone, or biological therapies. The amount and type of treatment that you receive will depend on the type of breast cancer that you have, as well as its stage and grade, and your overall health.

You will receive treatment from a team of healthcare professionals headed by an oncologist (a specialist in cancer). Do not be afraid to discuss any fears and concerns that you have with your oncologist; they will be able to explain each phase of your treatment.

Surgery

Most women who have breast cancer will need surgery and this is often the first form of treatment that you will receive. There are two types of surgery for breast cancer; surgery to remove just the cancerous lump (tumour), which is known as breast-conserving surgery, and surgery to remove a whole breast, which is called a mastectomy. In many cases, a mastectomy can be followed by reconstructive surgery to recreate the removed breast.

In some cases, particularly if the cancer is detected in its early stages, you may be able to choose which type of surgery you would prefer. This is a big decision, and you should be able to discuss your options fully with your surgeon and oncologist (specialist in cancer). Some women may decide that they want to keep their breast if at all possible, while others may feel more comfortable having their breast removed.

The two different types of surgery are outlined in more detail below.

Breast-conserving surgery

The aim of breast-conserving surgery is to save as much of your breast as possible, while removing as much of the cancer as possible in order to prevent it from recurring. You may be able to have breast-conserving surgery if the cancer is in its early stages, or has not spread beyond your breast.

Breast-conserving surgery ranges from a lumpectomy, or wide local excision, in which just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy, or quadrantectomy, in which up to a quarter of your whole breast is removed.

If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:

  • the type of cancer you have,
  • the size of the tumour and where it is in your breast,
  • the amount of surrounding tissue which needs to be removed, and
  • the size of your breasts.

Your surgeon will always remove an area of healthy breast tissue around the cancer, which will then be tested for traces of cancer. If there is no cancer present in the healthy tissue, there is less chance that the cancer will recur. However, if cancer cells are found in the surrounding tissue, you may need to have more tissue surgically removed from your breast.

After breast-conserving surgery, you will need to have radiotherapy in order to destroy any remaining cancer cells.

Mastectomy

A mastectomy removes all of your breast tissue, including your nipple. You may need to have a mastectomy if the tumour is large or very central in your breast, or if the cancer has spread beyond your breast to other parts of your body.

The type of mastectomy that you have will depend on whether or not the cancer has spread to your lymph nodes (small glands under your breast and in your armpit that filter bacteria from the body), or to your chest wall muscles.

If the cancer has not spread to your lymph nodes, you may have a simple mastectomy, in which only your breast will be removed. However, if the cancer has spread to your lymph nodes, you may need to have a modified or radical mastectomy, in which your breast will be removed, along with lymph nodes under your arm or your chest wall muscles.

If you have lymph nodes removed from your armpit during a mastectomy, it is possible for the scarring to block the filtering action of the lymph nodes. This is known as lymphoedema, and can cause excess fluid to build up in your arm. Lymphoedema can also be caused by radiotherapy.

If it occurs, lymphoedema can be treated through exercise, massage, and using compression sleeves (tightly fitting bandages which push excess fluid out of your arm), but it is a long-term (chronic) condition. Lymphoedema can develop months, or sometimes even years, after surgery, so you should see your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your operation.

Breast reconstruction and prostheses

If you have a mastectomy, you may be able to have reconstructive surgery at the same time, or later, in order to recreate your breast. This may be done either by inserting a breast implant, or by using tissue from another part of your body to create a new breast.

It is your decision as to whether or not you have reconstructive surgery following a mastectomy, and when you wish to have it, as long as there is no medical reason for delaying the surgery. It is a good idea to discuss your options fully with your surgeon and breast nurse before making a decision.

Women who decide against breast reconstruction can wear a false breast, or breast prosthesis, which are available free on the NHS. After having a mastectomy, you may have both a temporary fibre-filled prosthesis and a permanent prosthesis made from silicone, which can be replaced every two years.

See the 'selected links' section for more information about breast cancer surgery, breast reconstruction, and breast prostheses.

Chemotherapy

Chemotherapy is a specialist treatment for cancer which uses medicines that can stop the growth of cancer cells. These medicines are known as cytotoxic, which means that they target rapidly growing cancer cells, stopping them from dividing and multiplying.

Chemotherapy is usually used before radiotherapy to destroy any cancer cells that cannot be removed by surgery, although in some cases, you may have it before surgery to shrink a large tumour. It can also be used to treat breast cancer that has recurred (come back).

If you need to have chemotherapy, it is likely that you will be given the medicine intravenously (by injection through a vein, directly into your bloodstream). However, in some cases, you may need to take tablets. There are many different cytotoxic medicines for breast cancer, and it is likely that you will be given a combination of three at the same time. As it circulates through your blood, the medicine targets cancer cells in your breast, as well as any that may have spread elsewhere in your body.

Chemotherapy for breast cancer also works in another way. If you have not yet been through the menopause, chemotherapy can stop the production of oestrogen in your body, which can encourage the growth of some breast cancers. Your ovaries should start producing oestrogen again once your chemotherapy is over, but unfortunately in a small number of cases, this does not happen and it is possible for chemotherapy to make you enter early menopause.

It is not possible to predict whether or not this will happen, but it is more likely to occur in women who are over the age of 40 because they are closer to menopausal age. If you do enter menopause as a result of chemotherapy, you will no longer be able to conceive.

You may receive chemotherapy sessions 3-4 times a week, over a period of 4-8 months. Your sessions will be 3-4 weeks apart to give your body a rest in between treatments. The medicine is usually injected over a period of three hours, although in some cases, this may be extended to 24 hours. If this is the case, you will need to stay in hospital overnight.

Side effects of chemotherapy

Chemotherapy works by preventing cells, such as those that are cancerous, from growing rapidly. However, there are other cells that occur naturally in your body which also divide and multiply rapidly, including hair follicles, and red and white blood cells. As a result, chemotherapy also destroys these non-cancerous cells, which can cause many different side effects including:

  • hair loss,
  • nausea and vomiting,
  • diarrhoea or constipation,
  • rashes on the skin of your hands and feet,
  • loss of appetite,
  • sores around your mouth,
  • anaemia (tiredness and breathlessness brought on by a lack of red blood cells), and
  • leukopenia (infection brought on by a lack of white blood cells).

If you need to have chemotherapy, the side effects that you experience will depend on the type of cytotoxic medicine that you take, the number of treatment sessions you need to have, and your individual reaction to the treatment.

If you experience nausea and vomiting as a result of chemotherapy, you may be able to take anti-sickness medication to counter it. This may be given intravenously (by injection directly into your bloodstream) at the same time as your chemotherapy.

The side effects of chemotherapy will only last for as long as your course of treatment lasts. Once your treatment is over, the rapidly growing cells that occur naturally in your body will repair themselves. This means that your hair will grow back, although it might look or feel different to how it did before your chemotherapy. For example, it may be a slightly different colour, or be softer, or curlier, than before.

Radiotherapy

Radiotherapy uses high energy X-rays and, like chemotherapy, works by targeting rapidly growing cancer cells. Radiotherapy is usually given after chemotherapy in order to minimise the risk of the cancer recurring after breast-conserving surgery, or to destroy any remaining cancer cells in your lymph nodes under your arm after a mastectomy. It may also be given without chemotherapy if the cancer is detected in its early stages.

If you need to have radiotherapy, your treatment will begin about a month after your surgery or chemotherapy in order to give your body a chance to recover. It is a painless procedure in which you lie under a radiotherapy machine while it directs radiation at your affected breast. You will be positioned by your radiographer (a specialist in radiotherapy) so that the machine targets only the cancer cells and avoids as much of your healthy tissue as possible.

It is likely that you will have radiotherapy sessions five days a week, for 3-6 weeks. Each session will only last a few minutes. The radiation does not stay in your system afterwards, and it is perfectly safe to be around others in between your treatments.

Side effects of radiotherapy

As radiotherapy works by targeting rapidly growing cancer cells, like chemotherapy, it can have several side effects. Other rapidly growing cells that occur naturally in your body are also damaged by radiotherapy, including the skin cells and the cells that line your digestive system. The side effects of radiotherapy may include:

  • irritation and darkening of the skin on your breast,
  • fatigue (extreme tiredness), and
  • lymphoedema (excess fluid build up in your arm caused by blockage of the lymph nodes under your arm).

It is possible for lymphoedema to develop months, or years, after radiotherapy, so you should see your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your treatment.

Hormone therapy

If your breast cancer was found to be hormone receptor positive at the time of diagnosis, you may be able to have hormone therapy to further minimise the risk of your breast cancer recurring. For more information about hormone receptor testing, see the 'diagnosis' section.

Breast cancers which are hormone receptor positive are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body. Hormone therapy works by lowering the levels of hormones in your body, or by stopping their effects. It may be used as the only treatment for breast cancer if your general health prevents you from having surgery, chemotherapy, or radiotherapy.

If hormone therapy is suitable for you, it is likely that your treatment will be given after surgery or chemotherapy although, in some cases, it may be given before surgery to help shrink a large tumour. There are several different hormone therapy medicines, including tamoxifen, aromatase inhibitors, and pituitary downregulators. In most cases, you will need to take hormone therapy for up to five years after your breast cancer surgery.

Tamoxifen

Tamoxifen is the most common type of hormone therapy. It is most effective for treating cancers that are oestrogen receptor positive, although you may still be prescribed tamoxifen if you have cancer that is progesterone receptor positive. If you are prescribed taximofen, you will need to take it every day by mouth (orally) as either a tablet or a liquid. Tamoxifen can cause several side effects including:

  • tiredness,
  • changes to your periods,
  • nausea and vomiting,
  • hot flushes,
  • aching joints,
  • headaches, and
  • weight gain.

Aromatase inhibitors

Aromatase inhibitors come in brands called Arimidex, Aromasin, and Femara. They are only suitable for women who have been through the menopause because they block the oestrogen that is made after menopause by the adrenal glands. If you are prescribed an aromatase inhibitor, you will need to take it as a tablet once a day. Aromatase inhibitors can cause side effects, including:

  • hot flushes and sweats,
  • loss of interest in sex,
  • nausea and vomiting,
  • tiredness,
  • aching joints,
  • headaches, and
  • skin rashes.

Pituitary downregulators

Pituitary downregulators are most commonly available in a brand called Zoladex. They are prescribed for women who are still having periods, as they prevent the ovaries from producing hormones.

If you are prescribed a pituitary downregulator, your periods will stop while you are taking it, although they should start again once your treatment is complete. However, if you are close to approaching menopause (around the age of 50), you may find that your periods do not start again once you stop taking the pituitary downregulator.

This type of hormone therapy is taken as an injection once a month, and can cause menopausal side effects, including:

  • hot flushes and sweats,
  • mood swings, and
  • trouble sleeping.

Biological therapy

If your breast cancer was found to be HER2 positive at the time of diagnosis, you may be able to have biological therapy to further minimise the risk of your breast cancer recurring. Biological therapy can also increase the effects of chemotherapy on breast cancer cells. For more information about HER2 testing, see the 'diagnosis' section.

Breast cancers which are HER2 positive are stimulated to grow by the protein HER2. Biological therapy works by stopping the effects of HER2, and by helping your immune system to fight off cancer cells.

If you are able to have biological therapy, it is likely that you will be prescribed a medicine called Herceptin. Herceptin is usually used following chemotherapy.

Herceptin

Herceptin is a type of biological therapy known as a monoclonal antibody. Antibodies are molecules that occur naturally in your body, and are made by your immune system to destroy harmful cells, such as viruses and bacteria. Herceptin works by targeting and destroying cancer cells that are HER2 positive.

If you are prescribed Herceptin, you will need to have your treatment in hospital, as it is given intravenously (an injection directly into your vein). Each treatment session takes up to one hour, and the number of sessions that you need will depend on whether you have early breast cancer, or cancer that is more advanced. On average, you will need a session once every three weeks for early breast cancer, and weekly sessions if your cancer is more advanced.

Herceptin can cause side effects, including heart problems. This means that it is not suitable if you have existing heart problems, such as angina, uncontrolled high blood pressure (hypertension), or heart valve disease. If you need to take Herceptin, you will need to have regular tests on your heart to make sure it is not causing any problems. Other side effects of Herceptin may include:

  • an initial allergic reaction that can cause nausea, wheezing, chills, and fever,
  • diarrhoea,
  • tiredness, and
  • aches and pains.

Prevention

As the causes of breast cancer are not fully understood, it is not possible to know if there is anything which can prevent it altogether. However, a number of factors have been identified which may make the chances of developing breast cancer less likely.

There are also methods of screening for breast cancer. All women between 50-70 years of age are eligible for breast cancer screening once every three years as part of the NHS Breast Screening Programme. Women who have two, or more, close relatives with breast cancer may be eligible to be screened for breast cancer, or for the genes that may make developing it more likely.

The possible preventative factors of breast cancer, and details about the screening methods, are outlined below.

Factors which may help to prevent breast cancer

Diet and lifestyle

Research into breast cancer has suggested that eating a healthy, balanced diet may help to prevent it. For example, the rates of breast cancer among Japanese women, who eat a largely low fat diet that is rich in fruit and vegetables, are far lower than those of American women, whose diet is similar to ours and high in fat.

It has also been suggested that regular exercise can minimise your risk of breast cancer by as much as a third. If you are postmenopausal, it is particularly important that you are not overweight, or obese, because it causes more oestrogen to be produced which, in some cases, can stimulate the growth of cancer cells.

Aside from this, it is known that regular exercise and a healthy, low fat diet are extremely beneficial to your overall health, and can help to prevent all forms of cancer and heart disease.

Breastfeeding

Women who breastfeed are statistically less likely to develop breast cancer than those who do not. Research into this has found women who breastfeed may reduce their risk of developing breast cancer before they reach menopause by half. Younger mothers in particular can reduce their risk of breast cancer by breastfeeding, and the risk is reduced further the longer you continue to breastfeed your baby.

The reasons for this are not fully understood, but it could be due to the fact that you do not ovulate as regularly while you are breastfeeding, and your oestrogen levels remain stable.

Screening methods for breast cancer

The NHS Breast Screening Programme

If you are a woman between 50 -70 years of age, you are eligible to be regularly screened for breast cancer as part of the NHS Breast Screening Programme. You should receive your first invitation for screening by the time you are 54 years of age.

Women between 50-70 years of age are considered to be the most at risk, although as your risk of breast cancer increases with age, you may wish to continue being screened after the age of 70. If this is the case, you should see your GP. For more information about the NHS Breast Screening Programme, see the 'selected links' section.

The screening method for the Breast Screening Programme is a mammogram once every three years. You should always attend every appointment, even if you cannot see or feel any changes in your breasts. For more information about mammograms, see the 'diagnosis' section.

Screening for women at high risk of breast cancer

You may be eligible for screening for breast cancer before the age of 50 if the condition runs in your family. Your risk of developing breast cancer is considered to be higher than average if:

  • you have two or more close relatives - such as your mother, sister, or daughter - on the same side of your family who have, or have had, breast cancer (at least one should be your mother or your sister),
  • you have three close relatives who were diagnosed with breast cancer at any age,
  • you have one close relative with breast cancer, and one with ovarian cancer, one of them being your mother, sister, or daughter,
  • your mother, or sister, has been diagnosed with breast cancer before the age of 40,
  • your father, or brother, has been diagnosed with breast cancer at any age, or
  • your mother, or sister, has been diagnosed with breast cancer in both breasts, and was diagnosed for the first time under the age of 50.

If any of the above applies to you, you should see your GP, who can refer you to a breast clinic for assessment based on your family history. If you have a high risk of developing breast cancer, and you are over the age of 40, you should be offered screening with a mammogram once a year. If you are under the age of 40, you may be offered screening using MRI scans instead of mammograms because your breasts may be too dense to produce a clear mammography.

Genetic screening for breast cancer

If, following an assessment at your breast clinic, it is found that you have a family history of breast cancer it may be because one of the genes that makes breast cancer more likely runs in your family. If this is the case, you may be able to have screening for these genes, which are known as BRCA1, BRCA2, and TP53.

In order to be genetically screened for breast cancer, you must have a living relative with breast cancer. You and your relative will both have a blood test to see if you both carry any of the breast cancer genes.

If a breast cancer gene is found, and you are under 49 years of age, you may be offered yearly MRI scans. If you are aged 50, or over, you may also be offered yearly mammograms

References

Breakthrough Breast Cancer. About Breast Cancer [online], Torchbox [Accessed 14th Feb 2008] (whole section).

Breast Cancer Care. (2006). Treating Breast Cancer [online], Cavendish Press Ltd [Accessed 19th Feb 2008].

Cancer Research UK. (2008). Breast cancer [online], CancerHelp UK [Accessed 14th Feb 2008]. (whole section).

Cancer Research UK. (2007). When your hair grows back [online], CancerHelp UK [Accessed 21st Feb 2008].

Mayoclinic. (2007). Breast cancer [online] [Accessed 14th Feb 2008] (Risk factors and Screening and Diagnosis sections).

National Institute for Health and Clinical Excellence. (2006). Understanding NICE guidance: Women with breast cancer in the family [online] [Accessed 14th Feb 2008].

Patient UK. (2005). Breast cancer [online] [Accessed 14th Feb 2008].

Patient UK. (2004). Radionuclide (Isotope) Scan [online] [Accessed 21st Feb 2008].

SOGC Clinical Practice Guidelines. (2002). Breast cancer, pregnancy and breastfeeding [online], Society of Obstetricians and Gynaecologists of Canada [Accessed 21st Feb 2008].

Expert view

Consultant breast surgeon Clive Griffiths on the questions to ask

Breast cancer is the most common cancer to affect women, with around 42,000 cases being diagnosed every year in the UK. It develops in the milk-producing glands of the breast (lobular cancer), or the passages that carry the milk to the nipples (ductile cancer). The lifetime risk of any woman in the country developing breast cancer is one in nine.

We asked consultant breast surgeon, Clive Griffith, what questions he would want to know about breast cancer.

What symptoms could indicate breast cancer?
If there’s any abnormality in the shape of the breast or if it doesn’t look the same as the other breast, then we advise people to come and get it checked out.

The most common symptom of any patient with breast cancer is a breast lump that doesn’t go away with the menstrual period, which increases in size, or may be associated with deformity of the breast. Nipple discharge, particularly if it’s bloodstained, is worrying.

About a third to half of all breast cancers in the UK are now picked up in the National Breast Cancer screening programme (links to external site) due to an abnormality in a mammogram. The screening age will soon be extended from 47 to 73, so we're expecting more and more women with cancer in the early stages to be picked up.


What different types of treatment are available?
There are five treatments available:

  • Surgery: treatment almost always involves surgical removal of the primary tumour either by lumpectomy (removal of the breast lump) or mastectomy (removal of the whole breast). The best treatment for any cancer is to remove the primary tumour with a good clear margin of tissue.
  • Radiotherapy: high-energy X-rays target where the tumour was in the breast, or the armpit in cases where the lymph glands are affected.
  • Chemotherapy: anti-cancer drugs are given into the bloodstream. When we treat cancer we treat it on a local level, which is the surgery and the radiotherapy. We also treat it on what’s called a systemic level, so that the treatment actually gets into the bloodstream, the rationale being that anywhere a cancer cell could go, the treatment will go.
  • Hormone treatment: we know that most breast cancers are driven by oestrogen, and if the tumour is what we call oestrogen receptor positive, we can give the patient an anti-oestrogen agent in combination with the other treatments.
  • Herceptin: this is a monoclonal antibody (a protein produced by the immune system in response to substances that might threaten the body). It’s a specific chemical that targets a receptor on the cancer cell surface and stops the cancer cell from dividing.

It may well be that a patient will have all of these five treatments.

What are the surgical procedures?
For breast cancer it can either be a lumpectomy, where we remove the tumour with a margin of tissue and preserve the mound of breast tissue or a mastectomy. A mastectomy involves removal of the whole area of breast tissue plus the skin over the breast and the nipple, and the lymph glands that drain the breast.

There are various reasons why we still need to do mastectomies, e.g. if it’s a big tumour or if the cancer is in lots of different areas in the breast.

If you have a lumpectomy you would probably go home the day after surgery. The surgery itself will take an hour or so. If you have a mastectomy you’d probably be able to go home within three to four days.

What are the chances of recovery?
What we can say is that with a good prognosis, your breast cancer is unlikely to bother you again in your lifetime. If you have a breast cancer picked up early on the national breast cancer screening programme, you have a 98% chance of being alive 10 years after your breast cancer treatment.

If you come to a clinic with a symptomatic breast cancer, or a lump on the breast, the figure drops slightly but 80% of women who come with a lump in the breast will still be alive 10 years after the breast cancer treatment.

We know the majority of recurrences happen within the first five years. Most (90%) of ‘events’ are either a local recurrence where the tumour was in the chest wall, or a distant recurrence, i.e. in another organ such as the lung or liver, and will happen within the first five years of treatment. This is encouraging because we can tell patients at five years that the chances of the tumour coming back now are much less.

Can you give any guidelines about how to lower your risk of breast cancer?
We’ve been able to show that breast cancer is related to lifestyle. There are various things that increase the risk of breast cancer. Apart from family history, the biggest risk is being overweight; obesity will increase your chance of breast cancer by a third.

Drinking alcohol to excess increases the risk of breast cancer. This is not sociable drinking but drinking to excess.

Lifestyle

Screening

How the breast cancer screening programme works

The NHS Breast Screening Programme screens around 1.6 million women every year, and saves an estimated 1,400 lives a year in England. Screening enables breast cancer to be found at an early stage, when there is a good chance of successful treatment and full recovery. Women aged 50-70 who are registered with a GP, are automatically invited for screening every three years. Women aged over 70 don’t receive invitations, but are encouraged to make their own screening appointments every three years. Women should receive their first invitation for screening some time between their 50th and 53rd birthdays.

Mammography takes place at breast screening units in hospitals or clinics, or in mobile breast screening vans. Screening is carried out by female staff, taking X-rays of the breasts (mammography) to detect abnormalities. The breasts are X-rayed one at a time. The breast is placed on the X-ray machine and gently but firmly compressed with a clear plate. Two X-rays are taken of each breast, at different angles. Most women find this uncomfortable, and it may be painful for some. Unfortunately the compression is necessary to ensure a clear mammogram.

Results

  • Results from screening are sent to the woman and her GP in writing.
  • Around 19 out of every 20 women screened have a normal result, and will be recalled for screening in three years (or encouraged to make their own appointment if aged over 70 by that time).
  • Around one in 20 women may be called back for further assessment. This could be because the first mammogram was unclear, or because a potential abnormality was detected. For most women, further tests show that there is no problem.
  • Only around one in six women recalled for assessment are diagnosed with breast cancer, and around half of the cancers found at screening are still small enough to be removed from the breast. This means that the whole breast does not have to be removed (mastectomy).

Not all cancers are found at breast screening, and breast cancer can develop in the time between screening appointments. Because of this, women are encouraged to be ‘breast aware’, so that they can spot any unusual changes early on, and report them to their GP.

Further information
For more information on breast screening, go to the NHS Cancer Screening Programmes’ website and download the information leaflets (both link to an external site).

Breast awareness

Become breast aware

Breast awareness is an important issue for all women, and being aware of how your breasts look and feel at different times of the month can help you detect any problems early on.

Breast cancer is rare in women under 40, but the likelihood of developing breast cancer increases with age. 80% of breast cancers occur in woman aged over 50. If you are aged 50 or over, you should take advantage of the NHS Breast Screening Programme, which offers three-yearly mammography (a special x-ray of the breast). If you are registered with a GP, you will automatically be invited for screening every three years. Your first invitation will arrive some time between your 50th and 53rd birthday.

As part of being breast aware, it is important to know what is normal for you. For instance, your breasts may look or feel different at different times of the month and at different times during your life.

Before the menopause normal breasts feel different at different times of the month. The milk-producing tissue in the breast becomes active in the days before a period starts. In some women, the breast at this time feel tender and lumpy, especially near the armpits.

After a hysterectomy the breasts usually show the same monthly differences until the time when your periods would have stopped.

After the menopause activity in the milk-producing tissue stops. Normal breasts feel soft, less firm and not lumpy.

If you notice any changes to what is normal for you, tell your doctor without delay because it could be the first sign of cancer.

All women should follow the breast awareness five-point code:

  • Know what is normal for you.
  • Know what changes to look for.
  • Look and feel.
  • Report any changes without delay.
  • Attend for breast screening if aged 50 or over.

Changes to look out for include:

  • any change in the outline or shape of the breast or any puckering or dimpling of the skin,
  • any discomfort or pain in one breast that is different from normal,
  • any lumps, thickening or bumps in one breast or armpit that is different to normal,
  • any discharge or bleeding or moist reddish areas that will not heal easily,
  • any change in nipple position or a nipple rash.

For more information about breast awareness, please go to www.cancerscreening.nhs.uk (links to external site).

Support

Support for carers

Being a carer isn’t an easy role. When you’re busy responding to the needs of others, it can deplete your reserves of emotional and physical energy and make it easy to forget your own health and mental well-being (research on carers’ health shows that high numbers of carers suffer health effects through caring). And if you are trying to combine caring with a paid job or looking after a family, this can bring about even more stress.

But putting yourself last on the list doesn’t work in the long term. If you are caring for someone else, it’s important to look after yourself and get as much help as possible. Not only is it in your best interests – but also those of the person you are caring for.

Look after your health
Eat regularly and healthily. If you don’t have time to sit down with every meal, try to make time to sit down once a day. Instead of relying on fast food snacks, try to go for healthier options.

Look after your emotional health
It’s understandable if there are times when you feel resentful and then guilty for feeling like this. Combine that with exhaustion, isolation and worries about the person you’re caring for and it’s easy to forget about you. Don’t be hard on yourself – you’re only human.


Look for support
Friends and family may not always understand what you’re going through and it can be helpful to talk to people in the same situation.

  • Carers UK have a lot of useful information on their website and run a helpline: www.carersuk.org CarersLine 0808 808 7777
    They also have a help and information booklet ‘New To Caring’ which can be downloaded.
  • The Princess Royal Trust for Carers have a chatroom on their website and also run 129 Carers Centres nationwide which provide information and advice and emotional support. For more information visit: www.carers.org.

Find out what benefits you are entitled to:
You can find out the services available in your area by contacting your social services or local carers’ organisation or by visiting Carers UK Finding Help page

Other people to contact:
Your GP and primary care team
Social services
For details of government services and information aimed at carers, go to www.direct.gov.uk/carers.

For more on support for patients and carers:

Macmillan

Cancer Backup

Risk of breast cancer in over 70s

About one third of all breast cancers occur in women over the age of 70, making them more at risk than younger women.

If you're a 70+ woman, you're still eligible to be screened every three years even though you won’t receive invitations. You can make your own screening appointments by contacting your local screening unit direct. Your GP will have contact details for the unit, or you can phone NHS Direct on 0845 4647. Screening can detect small changes in the breast before there are any outward signs or symptoms. The earlier any changes are found the better chance there is of successful treatment and recovery.

For more information about screening if you're aged over 70, please go to www.cancerscreening.nhs.uk (links to external site).

Real stories

Emma's story

'I've had breast cancer twice'

Emma Duncan is 33, and has been diagnosed with breast cancer twice in the past four years, once in each breast. Her first treatment was a lumpectomy with chemotherapy and radiotherapy. Her second treatment included a full mastectomy, removing both breasts, followed by reconstructive plastic surgery

"I asked my GP if there was any screening programme that they could put me into when I was 25, because my mother had died from breast cancer when she was 32. They referred me to the Royal Victoria Infirmary and I used to come once a year just for a check-up.

"A few years later I was in the bath and I noticed a lump under my left armpit. I didn’t quite know what to make of it; I was quite worried at first. I went to see my GP the next day and he suspected that it might just be a cyst because I was only 28 at the time, but because of my family history, they did a referral anyway.

"At the hospital I had an ultrasound, a mammogram and a needle biopsy. When I returned a week later for the results, they confirmed that I did have breast cancer and that I would need to come in for lumpectomy surgery 10 days later.

"I had chemotherapy for six months after my first diagnosis, followed by five weeks of radiotherapy. It was really, really hard. All my hair fell out and it made me feel so ill.

"My husband Graham was great, he tried to support me as best he could throughout it, my sister-in-law was never off the phone, and my best friend Claire was lovely.

"My sister handled it in a very different way; she had watched my mum become very, very poorly and then her older sister was diagnosed. She found it hard to deal with and she just couldn’t handle coming to see me. She later admitted being terrified that it might be her next.

"The second time I was diagnosed, I had a bigger operation, a double mastectomy. The decision to have a mastectomy was quite easy to make, for me the only decision when you’ve had cancer twice.

"The reality after the event was much different. With the reconstructive surgery as well, I knew it would be a long recovery, but I don’t think anything prepared me for just how long. I cried every single day because I was so uncomfortable.

"I was referred to a psychologist who told me I wasn’t going mad. Anybody who had been through what I had would be expected to have a few tearful days. Things settled down, then it was just a case of trying to get back to normal.

"Looking back at everything I wouldn’t have changed my decision at all, it was definitely for the best.

"I now have check-ups every six months, I see my oncologist, my breast surgeons and the family clinic. I’m seen quite regularly. I see my plastic surgeon, my geneticist and have an ultrasound once a year, plus a blood test every four months as part of the ovarian screening programme. The Macmillan Breast Care nurses ring me up every once in a while to keep me up to date, and to check that I’m alright. I’m very well looked after!

"Now I just want to stay cancer-free. I’ve done as much as I possibly can to prevent it from coming back or getting a new cancer. I didn’t quite make it after my first diagnosis, but I’d like to hit my five-year point.

"My advice to other women would be to speak to your breast care nurse or go on the Cancer Research UK or Cancer Care websites, there are so many recognised sources of information. The internet is full of horror stories, so make sure you get as much information but from reputable sources."

Useful links

NHS Choices links

External links

This article was originally published by NHS Choices

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