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Cancerbackup Factsheet

BREAST CANCER
This factsheet gives information about the diagnosis and treatment of breast cancer.
Breast cancer can affect both women and men. This factsheet is aimed mainly at
women, as very few cases of breast cancer occur in men. However, the treatments
used are the same.

The breasts

The breasts are made up of fat, connective tissue and glandular tissue, and are
divided into lobes. The lobes are where breast milk is produced. A network of ducts
(fine tubes) connect the lobes to the nipple. When a woman has had a baby the
breasts produce milk which then passes down the ducts and out of the nipple to feed
the baby.

A woman’s breasts are rarely the same size as each other. They may feel different at
different times of the menstrual cycle. Sometimes the breast can become lumpy just
before a period.

Under the skin, some of breast tissue extends into the armpit. The armpits also
contain a collection of lymph glands or nodes which make up part of the lymphatic
system. The lymphatic system is a network of lymph glands connected throughout
the body by tiny vessels called lymph vessels. Flowing through the lymphatic system
is lymph fluid. It contains cells called lymphocytes, which are designed to fight
disease.
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What is breast cancer?

The organs and tissues of the body are made up of tiny building blocks called cells.
Cancer is a disease of these cells. Although cells in different parts of the body may
look and work differently, most repair and reproduce themselves in the same way.
Normally, this division of cells takes place in an orderly and controlled manner. If, for
some reason, the process gets out of control, the cells will continue to divide,
developing into a lump which is called a tumour. Tumours of the breast are usually
caused by overgrowth of the cells lining the breast ducts. They can be either benign
or malignant.

In a benign tumour, the cells grow abnormally and form a lump. But they do not
spread to other parts of the body and so are not cancerous. The commonest type of
benign breast tumour is called a ‘fibroadenoma’. These often need to be surgically
removed to confirm the diagnosis. No other treatment is necessary.

A malignant tumour consists of cancer cells which have the ability to spread beyond
the breast if they are left untreated. If a malignant tumour in the breast is not treated
it may grow into the muscles which lie under the breast. It can also grow into the skin
covering the breast. Sometimes cells break away from the original (primary) cancer
and spread to other organs in the body. They can spread through the bloodstream or
lymphatic system (see page 00). When these cells reach a new area they may form a
new tumour. The new tumour is often called a secondary or metastasis.

Breast cancer occurs when cells within the breast ducts and lobules become
cancerous. If caught at an early stage, breast cancer can often be cured. However if
the cancer has spread to other areas of the body it cannot usually be cured, but
treatment can often still be given to control the cancer for months or years.

What causes breast cancer?

The causes of breast cancer are not yet completely understood. Some women do
seem to be at a higher risk of developing the disease. The risk of developing breast
cancer increases as women get older. More than half of breast cancers occur in
women over the age of 65.

A very small number (less than 5 in 100) of breast cancers are caused by an
inherited faulty gene. The abnormal genes that can lead to an increased chance of

2
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3
developing breast cancer include BRCA1 and BRCA2. The following factors might
indicate the possible presence of an inherited faulty gene within a family:

• breast cancer in two or more close members of the same family

• other cancers, especially cancer of the ovary and colon, as well as breast cancer,
in members of the same family
• breast cancer in a close relative when under the age of 40
• a relative with breast cancer affecting both breasts.

Women who either have no children or had children late in life have a slightly
increased risk of developing breast cancer. Women whose periods started when they
were very young or whose menopause occurred late also seem to have an increased
risk.

Some research studies have suggested that women who take the contraceptive pill
have a very slightly increased chance of developing breast cancer compared with
women who have never taken the pill. However taking the pill has no effect
whatsoever on most women’s chances of getting breast cancer.

Taking hormone replacement therapy (HRT) slightly increases the risk of developing
breast cancer. Women taking combinations of oestrogen and progesterone seem to
have a greater increase in risk than women taking oestrogen alone. However, HRT
has many benefits. These include reduction of heart disease and the thinning of the
bones that can lead to fractures in later life. For this reason it is considered that for
the first 10 years of use the benefits of taking HRT outweigh the slightly increased
risk of developing breast cancer.

There is no evidence that damage to a breast (such as a knock) causes cancer.

Breast cancer is not infectious and cannot be passed on to other people.

What are the symptoms?

In most women, breast cancer is first noticed as a painless lump in the breast. There
are, however, other signs to be aware of:

• a change in the size or shape of the breast

• dimpling of the skin of the breast
• a lump or thickening in the breast
• a change in the nipple (it turns in) or develops a lump
• a bloodstained discharge from the nipple (very rare)
• a rash on the nipple or surrounding area (also very rare)
• swelling in the lymph nodes in the armpit.

How is breast cancer diagnosed?

Most people begin by seeing their family doctor (GP) or nurse. They will examine you
and arrange for you to have any tests or x-rays that may be necessary. Your GP will
refer you to hospital for specialist advice or treatment.

At the hospital the doctor will take your medical history before carrying out a physical
examination. The doctor will examine your breasts and feel for any enlarged lymph

3
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glands under your arms and at the base of your neck. A chest x-ray and blood tests
may also be taken to check your general health.

If you would prefer you can ask to see a woman doctor.

The following tests may be used in the diagnosis of cancer of the breast. You may
have one or two of those listed, or a combination

Mammography This is an x-ray of the breast. It is especially useful for detecting

early changes in the breast when it may be difficult to feel a lump. It is usually used
for women over the age of 40. Younger women’s breast tissue is more dense and
this can make mammograms less able to detect any changes. Some women find
mammography uncomfortable or even painful because pressure is put on the
breasts. The discomfort should last only a few seconds and is not harmful to the
breasts.

Ultrasound Ultrasound is used to see if a lump is solid or contains fluid. If the lump
contains fluid it is known as a cyst. A special gel is spread onto the breasts and a
small device is passed over the area. This device is like a microphone and produces
sound waves. The echoes are converted into a picture of the breast tissue by a
computer. This test is painless and takes a few minutes.

Colour Doppler Certain types of ultrasound machine show the blood supply to the
lump. This may help to distinguish between a cancer and a benign lump. The blood
supply shows up as patches of red or blue colour on the scan.

Fine-needle aspiration This is a quick, simple procedure done in the outpatient

clinic. Using a fine needle and syringe, the doctor takes a sample of cells from the
breast lump. The sample is sent to the laboratory to see if it contains any cancer
cells. This technique may also be used to drain a benign cyst. As the breast is
sensitive the needle aspiration can be quite uncomfortable.

Sometimes (especially if the lump is small) a needle aspiration may be carried out in
the x-ray department. The doctor uses x-ray or ultrasound guidance to make sure
that the exact area of the breast is sampled with a special needle. Your doctor will
discuss with you which type of needle aspiration you may have.

Needle (core) biopsy) This test uses a slightly larger needle than the one used for
needle aspiration. It is done under a local anaesthetic which numbs the area and
allows the doctor to take a biopsy (a small piece of tissue from the lump). The sample
is examined in the laboratory to check for signs of cancer.

Blood tests Samples of your blood will be taken to check your general health. The
blood samples show the number of cells in your blood (blood count). Other blood
tests will show how well your kidneys and liver are working. Your blood may also be
tested to see whether it contains particular proteins (called markers) which are
sometimes produced by cancer cells.

Excision biopsy) In this biopsy the whole lump is removed under a general or local
anaesthetic and sent to a laboratory for examination. This may mean an overnight
stay in hospital but in some hospitals this is not necessary. If a lump is too small to
be felt but has shown up on mammography or ultrasound, it may be necessary for
the radiologist to mark the area for the surgeon. This is done by inserting a very small
wire under local anaesthetic, using x-ray or ultrasound guidance.

4
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5
Many hospitals have a special ‘one-stop’ breast cancer clinic. This means you will
have all the necessary tests and some of the laboratory results on the same day. It
may take longer in general hospitals for the results to come through. This waiting
period can be an anxious time for you and it may help to talk about your worries with
a partner, close friend, relative or counsellor. You can also call Cancerbackup to
speak to one of the nurses.

Further tests

If the tests show that you have breast cancer your doctor may want to do some
further tests to see if there has been any spread of the cancer. These help the doctor
to decide on the best type of treatment for you. The tests will usually consist of a
chest x-ray and some of the following:

Liver ultrasound scan) You may be asked to have a liver ultrasound scan to check
your liver. This is a painless test and only takes a few minutes. It will probably be
done in the hospital scanning department. You will be asked to lie on a couch. A gel
will be spread on your abdomen and a small device like a microphone will be passed
over the area. The echoes are converted into a picture by a computer.

Bone scan) A very small amount of a mildly radioactive liquid is injected into a vein,
usually in your arm. After about three hours a scan is taken. Abnormal bone shows
up on the scan as highlighted areas. This happens because it absorbs more of the
radioactive substance than normal bone.

MRI scan (magnetic resonance imaging) This test uses magnetism to build up a
three dimensional picture of your body.

Staging and grading of breast cancer

Staging of breast cancer The stage of a cancer is a term used to describe its size
and whether it has spread beyond its original site. Knowing the extent of the cancer
and the grade helps the doctors to decide on the most appropriate treatment.

Generally breast cancer is divided into four stages. These are from small and
localised (stage 1) to spread to other parts of the body (stage 4). If the cancer has
spread to distant parts of the body this is known as secondary or metastatic cancer.

A commonly used staging system is described below:

Ductal carcinoma in situ (DCIS) At this stage the breast cancer cells are completely
contained within the breast ducts (the channels in the breast that carry milk to the
nipple). They have not spread into the surrounding breast tissue or into any other
part of the body. This may be referred to as non-invasive or intraductal cancer
(translation in brackets). DCIS is almost always completely cured.

Lobular carcinoma in situ (LCIS) means that cell changes are found in the lining of
the lobes of the breast. It can be present in both breasts. It is also referred to as non-
invasive cancer as it has not spread into the surrounding breast tissue.

Stage 1 tumours measure less than 2cm. The lymph glands in the armpit are not
affected. There are no signs that the cancer has spread elsewhere in the body.

5
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6
Stage 2 tumours measure between 2 to 5cm, or the lymph glands in the armpit are
affected, or both. However, there are no signs that the cancer has spread further.

Stage 3 tumours are larger than 5cm and may be attached to surrounding structures
such as the muscle or skin. The lymph glands are usually affected. There are no
signs that the cancer has spread beyond the breast or the lymph glands in the
armpit.

Stage 4 tumours are of any size. The lymph glands are usually affected and the
cancer has spread to other parts of the body. This is secondary breast cancer.

Grading of breast cancer refers to the appearance of the cancer cells under the
microscope. The grade gives an idea of how quickly the cancer may develop. There
are three grades. These are grade 1 (low grade), grade 2 (moderate grade) and
grade 3 (high grade). Low-grade means that the cancer cells look very like the
normal cells of the breast. They are usually slow-growing and are less likely to
spread. In high-grade tumours the cells look very abnormal. They are likely to grow
more quickly and are more likely to spread to other parts of the body.

Types of treatment

The treatment of breast cancer depends on many factors. These include the stage of
the cancer; your age; whether or not you have had the menopause (change of life);
and the grade of the cancer. Whether the cancer cells have receptors for certain
hormones on their surface is also important. Receptors are proteins which particular
hormones attach to, in order to enter the cancer cell.

Surgery, radiotherapy, hormonal therapy and chemotherapy may be used to treat

cancer of the breast. Usually, more than one type of treatment is used.

It is important to discuss any treatment fully with your doctor, so that you understand
what it involves. It is a good idea to take some one with you who can speak English
as well as your language. You can also ask for an interpreter to be present when you
speak to the doctor to help you understand. Remember, no treatment will be given
without your consent. You will be asked to sign a consent form to show that you
understand and agree to the treatment. Consent forms should be available written in
your language.

Surgery
Surgery is used to remove the cancer and an area of healthy cells all around the
cancer. Sometimes the whole breast may need to be removed (mastectomy) and
sometimes just the cancer may be removed (lumpectomy).

If you have a lumpectomy, you will usually be advised to have radiotherapy to the
remaining breast tissue afterwards. If you have a mastectomy you will sometimes not
need to have radiotherapy.

Research has shown that in early breast cancer a lumpectomy followed by

radiotherapy is as effective at curing the cancer as mastectomy. You may be offered
the opportunity to choose which of these treatments suits you best. The different
treatments have different benefits and side effects and this can be a difficult decision
to make. To help you make the decision you may want to discuss both options fully
with your doctor, breast care nurse, or the nurses at Cancerbackup. This can help
you to feel confident that you have made the choice that is right for you.

6
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7
It is often possible for women who have had a mastectomy to have their breast
reconstructed. This involves making a new breast using either an implant, or fat and
muscle from another part of your body. Sometimes this is done at the same time as
the mastectomy. It can also be done some months, or even years, after the original
operation. There are several different methods of breast reconstruction and your
surgeon can discuss the different options that may be suitable for you. If you would
like to consider breast reconstruction, discuss it with your doctor at the beginning of
your treatment so that they can tell you about the different methods available.

As well as removing the breast cancer, the surgeon will usually take out some, or all,
of the lymph glands from under your arm on the same side of the body. This is known
as lymph gland sampling. There are approximately 20 lymph glands in the armpit
(axilla), although the exact number varies from person to person. The lymph glands
are examined to check whether any cancer cells have spread into them from the
breast. This helps doctors decide what other treatment is needed. Removing the
lymph glands can sometimes lead to the development of swelling of the arm on the
affected side. This is called lymphoedema.

Cancerbackup can send you a factsheet about surgery in your

language

After a mastectomy you will be given an artificial breast made of lightweight foam
which you can put inside your bra. This is sometimes called a cumfie. It is specially
designed to be worn immediately after the operation when the area will be feeling
tender. When your wound has fully healed you will be fitted with a permanent
prosthesis (false breast). Several types of prosthesis are available on the NHS.

Radiotherapy Radiotherapy treats cancer by using high-energy rays that destroy the
cancer cells, while doing as little harm as possible to normal cells. In breast cancer,
radiotherapy is usually given to the remaining breast tissue after lumpectomy.

If the cancer has spread to the bones, radiotherapy may also be very effective in
relieving symptoms, such as pain.

Radiotherapy is usually given as a series of short daily treatments in the hospital

radiotherapy department. The treatments are normally given from Monday to Friday
with a rest at the weekend. The number of treatments will depend on the size and
position of the cancer, but the whole course of treatment will generally last from three
to six weeks. Each treatment takes from 10 to 15 minutes. Your doctor will discuss
the possible side effects with you. Possible side effects include soreness of the skin
in the radiotherapy area, tiredness and feeling slightly sick.

It is important to get plenty of rest during your treatment. The side effects can usually
be well controlled with medicines. They should gradually get better once the
treatment has ended.

Cancerbackup has a factsheet, in your language, about radiotherapy

which gives more details about the treatment and its side effects

Chemotherapy
Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. They work by
disrupting the growth of cancer cells. Chemotherapy may be used to shrink a tumour
before surgery. It may also be used after surgery to reduce the chance of the cancer

7
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8
coming back. It can also be used if the cancer has spread to another part of the
body, or if it comes back in the future.

The drugs are sometimes given as tablets or, more usually, by injections into a vein.
Two or three chemotherapy drugs are usually given together. The drugs will be
injected, or given slowly through a drip. As well as the chemotherapy you will be
given injections to stop you feeling sick. Most patients are usually able to go home on
the same day. This is followed by a rest period of three to four weeks. This rest
allows your body to recover from any side effects of the treatment. The number of
sessions of chemotherapy can vary from four to eight.

Some people will have their chemotherapy given through a central line or a PICC
line. These are long plastic tubes that are placed into a vein either in your chest or
the crook of your arm. The lines can stay in place for the whole of your treatment. It is
important that the line is kept clean and dry to prevent infection. You will be taught
how to look after the line before you go home.

A few chemotherapy drugs may contain very small amounts of alcohol. The alcohol is
used to stabilize the drug to make it safe to give. If you are concerned about having
these drugs because of your religious or cultural beliefs, it may help to discuss this
with your religious leader, your doctor or nurse.

Chemotherapy is usually given to you as an outpatient, but occasionally it will mean

spending a few days in hospital.

Chemotherapy can cause unpleasant side effects. Many people have just a few side
effects and those that occur can often be well controlled with medicines. It is helpful
to let your doctor or chemotherapy nurse know about any side effects immediately,
so that they can find ways of controlling them. The main side effects are a lowered
resistance to infection, anaemia, tiredness, feeling sick, a sore mouth, and loss of
appetite. Some of the chemotherapy drugs can cause hair loss.

Cancerbackup’s factsheet about chemotherapy, that is written in your

language, discusses the treatment and its side effects in more detail. We
would be pleased to send you a copy

Hormonal therapies
Hormonal therapies can slow or stop the growth of breast cancer cells. They work
either by altering the levels of particular female hormones which are naturally
produced in the body, or by preventing the hormones from being taken up by the
cancer cells.

There are many different types of hormonal therapy and they work in slightly different
ways. Hormonal therapy may also be given before or after chemotherapy. Commonly
used hormonal therapies, which are given as tablets, include tamoxifen, arimidex,
artificial progesterones (megace and provera), letrozole, anastrozole, exemestane,
and formestane. Zoladex may be given to women who have not had their
menopause and is given as an injection once a month.

Hormonal therapies can cause side effects. These include hot flushes and sweats,
feeling sick, putting on weight, dryness of the vagina and an increased discharge
from the vagina. These side effects are usually mild.

Some women may be advised to have their ovaries removed to reduce the level of
oestrogen in the body. The ovaries can be removed by an operation. They can also

8
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9
be stopped from working by giving a low dose of radiotherapy to the area.
Unfortunately, this brings on an early menopause which can be distressing,
especially for a woman who was hoping to have children or complete her family. It
also causes menopausal side effects such as hot flushes, dry skin, emotional
changes and depression. However, these symptoms can be effectively treated.

Contraception

It is generally advised that you do not get pregnant for two years after treatment for
breast cancer. As there is a risk that the hormones (oestrogen and progesterone) in
the contraceptive pill may affect breast cancer cells, women who have had breast
cancer are usually advised not to take the pill. Barrier methods of contraception such
as condoms or the cap are more suitable. Lubricating jelly (available without
prescription from the chemist) is completely safe to use with barrier contraceptives if
extra moisture is needed during sex.

Your GP, hospital doctor or breast care nurse can give you advice about
contraception. Your GP can also fit you with a cap if this is the method of
contraception you choose. Coils (IUDs) can be an effective method of contraception
and your GP can fit you with a coil if you wish. Some women choose to be sterilised
to prevent the risk of pregnancy.

The choice of an effective contraceptive is largely a personal one. Your likes and
dislikes, and those of your partner, are obviously important. Some women also have
religious and moral implications to consider. Unfortunately, the withdrawal and
rhythm methods of contraception are not safe enough to be effective as protection
against pregnancy. Some women find that talking through their situation with their
religious leader, the Family Planning Association or a trained family planning
counsellor helps them to find acceptable alternatives.

Hormone replacement therapy (HRT)

Women who have had breast cancer are usually advised not to take hormone
replacement therapy as there is a risk that the oestrogen could stimulate a
recurrence of the cancer.

However, if you have troublesome menopausal symptoms there are drugs which can
be used to treat them. If the menopausal symptoms continue despite the drugs, your
doctor may wish to prescribe a short course of low-dose HRT to deal with these.
Research trials are being carried out to find the risks and benefits of taking HRT for
menopausal symptoms. If you take HRT, it is important that you should be very
carefully monitored.

Follow-up

After your treatment has ended your doctor will want you to have regular check-ups
and mammograms. These check-ups will take place more frequently in the first year
or two. They will probably continue for at least five years, gradually become less
frequent.

Research - clinical trials

Research into new ways of treating cancer of the breast is going on all the time. No
current cancer treatment results in the cure of all the patients treated, so cancer

9
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This factsheet has been compiled using information from a number of reliable sources including The Oxford Textbook of Oncology, Cancer and

its management and The Textbook of Uncommon Cancers. Each Cancerbackup factsheet is regularly reviewed and updated by cancer doctors,

specialist nurses, other relevant health professionals and people with cancer.

© CANCERBACKUP 2006, Breast cancer.

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, electronic or mechanical,

including photocopying, recording, or any information storage and retrieval system, without permission in writing from Cancerbackup,

3 Bath Place, Rivington Street, London EC2A 3JR. Charity Registration No. 1019719. A company limited by guarantee.

Registered in England and Wales. Company No. 2803321. Registered office as above.

10
doctors are continually looking for new ways to treat the disease. They do this by
using clinical trials. Many hospitals now take part in these trials. Cancerbackup can
give you information about current trials and can advise you how to contact the
appropriate organisation or doctor.

Your feelings

You may have many different emotions about your cancer including anger,
resentment, guilt, anxiety and fear. These are all normal reactions and are part of the
process many people go through in trying to come to terms with their illness.

Support services

If you would like to talk to someone in your language, about your situation or how you
are feeling, please contact Cancerbackup’s Cancer Support Service. The nurses will
be able to talk through any concerns you have and suggest where you can get any
*other support that you may need. The freephone number is 0808 800 0140 and the
lines are open Monday to Friday, 9am until 7pm. Interpreters are also available for
over 100 other languages by ringing Cancerbackup’s main helpline number, 0808
800 1234.

You may find the following Cancerbackup booklets and factsheets helpful to you.
Please call Cancerbackup on 0808 800 0140 if you would like a copy of any of them.
They are only available in English.

Understanding cancer of the breast

Understanding breast reconstruction
Understanding chemotherapy (available in four Asian languages)
Understanding radiotherapy (available in five Asian languages)
Who can ever understand: talking about your cancer
The emotional effects of cancer
Cancer and complementary therapies
What do I tell the children?
Sexuality and cancer

Factsheets are available on individual chemotherapy drugs, or combinations of

drugs, and on individual hormonal therapy drugs.

This factsheet has been compiled using information from a number of reliable sources including The
Oxford Textbook of Oncology, Cancer and its management and The Textbook of Uncommon Cancers.
Each Cancerbackup factsheet is regularly reviewed and updated by cancer doctors, specialist nurses,
other relevant health professionals and people with cancer.

© CANCERBACKUP 2006, Breast cancer.

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from Cancerbackup, 3 Bath Place, Rivington Street, London EC2A 3JR.
Charity Registration No. 1019719. A company limited by guarantee. Registered in England and Wales.
Company No. 2803321. Registered office as above.

10