6 Misconceptions About Breast Cancer

 

What do doctors often hear from patients?

 

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 Anatomy of the Breast

 Each breast has 15 to 20 sections, or lobes, that surround the nipple, like spokes on a wheel. Inside these lobes are smaller lobes, called lobules. At the end of each lobule are tiny "bulbs" that produce milk. These structures are linked together by small tubes called ducts, which carry milk to the nipples. The nipple is in the center of a dark area of skin called the areola. The areola contains small glands that lubricate the nipple during breastfeeding. Fat fills the spaces between the lobes and ducts. There are no muscles in the breasts, but muscles lie under each breast and cover the ribs.

 

Each breast also contains blood vessels and vessels that transport lymph. Lymph is a fluid that travels through the lymphatic system and carries cells that help the body fight infections. The lymph vessels lead to the lymph nodes (small, bean-shaped glands that are part of the infection-fighting lymphatic system). A group of lymph nodes are located in the armpits, above the collarbone, and in the chest. If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body.

 

Lymph nodes are also found in many other parts of the body.

Breast development and function depend on the hormones estrogen and progesterone, which are produced in the ovaries. Estrogen elongates the ducts and causes them to create side branches. Progesterone increases the number and size of the lobules in order to prepare the breast for nourishing a baby. After ovulation, progesterone makes the breast cells grow, and blood vessels enlarge and fill with blood. At this time, the breasts often become engorged with fluid and may be tender and swollen.

What are the types of breast cancer?


The most common types of breast cancer are:

Infiltrating (invasive) ductal carcinoma. This cancer starts in the milk ducts of the breast. It then breaks through the wall of the duct and invades the surrounding tissue in the breast. This is the most common form of breast cancer, accounting for 80% of cases.

Ductal carcinoma in situ is ductal carcinoma in its earliest stage (stage 0). In situ refers to the fact that the cancer hasn't spread beyond its point of origin. In this case, the disease is confined to the milk ducts and has not invaded nearby breast tissue. If untreated, ductal carcinoma in situ may become invasive cancer. It is almost always curable.

Infiltrating (invasive) lobular carcinoma. This cancer begins in the lobules of the breast where breast milk is produced, but has spread to surrounding tissues or the rest of the body. It accounts for 10% to 15% of breast cancers. This cancer can be more difficult to diagnose with mammograms.

Lobular carcinoma in situ is a marker for cancer that is only in the lobules of the breast. It isn't a true cancer, but serves as a marker for the increased risk of developing breast cancer later, possibly in both or either breasts. Thus, it is important for women with lobular carcinoma in situ to have regular clinical breast exams and mammograms.

Cancers can also form in other parts of the breast but are less common.


 

How is breast cancer diagnosed?


During your regular physical examination, your doctor will take a thorough personal and family medical history. He or she will also perform and/or order one or more of the following:

Breast examination: During the breast exam, the doctor will carefully feel the lump and the tissue around it. Breast cancer usually feels different (in size, texture, and movement) than benign lumps.

Mammography: An X-ray test of the breast can give important information about a breast lump.

Digital mammography: A technique in which an X-ray image of the breast is digitally recorded into a computer rather than on a film. This may be better for women with dense breasts.

Ultrasonography: This test uses sound waves to detect the character of a breast lump -- whether it is a fluid-filled cyst (not cancerous) or a solid mass (which may or may not be cancerous). This may be performed along with the mammogram.

Based on the results of these tests, your doctor may or may not request a biopsy test to get a sample of the breast mass cells or tissue. Biopsies are performed using surgery or needles.

After the sample is removed, it is sent to a lab for testing. A pathologist -- a doctor who specializes in diagnosing abnormal tissue changes -- views the sample under a microscope and looks for abnormal cell shapes or growth patterns. When cancer is present, the pathologist can tell what kind of cancer it is (ductal or lobular carcinoma) and whether it has spread beyond the ducts or lobules (invasive).

Laboratory tests, such as hormone receptor tests (estrogen and progesterone) and human epidermal growth factor receptor (HER2/neu), can show whether hormones or growth factors are helping the cancer grow. If the test results show that they are (a positive test), the cancer is likely to respond to hormonal treatment or antibody treatment. These therapies deprive the cancer of the estrogen hormone or use a monoclonal antibody known as herceptin to treat the cancer.


Breast cancer diagnosis and treatment are best accomplished by a team of experts working together with the patient. Each patient needs to evaluate the advantages and limitations of each type of treatment and work with her team of physicians to develop the best approach.

 "It's back to the drawing board," he said. "We all had such hope this would make some difference."

How is breast cancer treated?


If the tests find cancer, you and your doctor will develop a treatment plan to eradicate the breast cancer, to reduce the chance of cancer returning in the breast, as well as to reduce the chance of the cancer traveling to a location outside of the breast. Treatment generally follows within a few weeks after the diagnosis.

The type of treatment recommended will depend on the size and location of the tumor in the breast, the results of lab tests done on the cancer cells, and the stage, or extent, of the disease. Your doctor will usually consider your age and general health as well as your feelings about the treatment options.

Breast cancer treatments are local or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area, such as the breast. Surgery and radiation treatment are local treatments. Systemic treatments are used to destroy or control cancer cells all over the body. Chemotherapy and hormone therapy are systemic treatments. A patient may have just one form of treatment or a combination, depending on her needs.


Surgery: Breast conservation surgery involves removing the cancerous portion of the breast and an area of normal tissue surrounding the cancer, while striving to preserve the normal appearance of the breast. This procedure has often been called a lumpectomy, which is a partial mastectomy. Some of the lymph nodes under the arm are also removed. Usually, six weeks of radiation therapy is then used to treat the remaining breast tissue. Most women who have a small, early-stage tumor are excellent candidates for this approach.

Mastectomy (removal of the entire breast) is another option. The mastectomy procedures performed today are not the same as the older, radical mastectomies. Radical mastectomies were extensive procedures that involved removing the breast tissue, skin, and chest-wall muscles. Today, mastectomy procedures do not ordinarily remove muscles and, for many women, mastectomies are accompanied by either immediate or delayed breast reconstruction.

How can I protect myself from breast cancer?


Follow these three steps for early detection:

Get a mammogram. The American Cancer Society recommends having a baseline mammogram at age 35, and a screening mammogram every year after age 40. Mammograms are an important part of your health history. Recently, the US Preventive Services Task Force (USPTF) came out with new recommendations regarding when and how often one should have mammograms. These include starting at age 50 and having them every two years. We do not agree with this, but we are in agreement with the American Cancer Society and have not changed our guidelines, which recommend yearly mammograms starting at age 40.

Examine your breasts each month after age 20. You will become familiar with the contours and feel of your breasts and will be more alert to changes.

Have your breast examined by a healthcare provider at least once every three years after age 20, and every year after age 40. Clinical breast exams can detect lumps that may not be detected by mammogram.

How to Do a Great Self-Breast Exam


 

While most of my patients have heard they should perform a self-breast exam (SBE), many say they have never heard all the tips I’d like to share with you. The key is to remember: “When, Look, Feel and Write!”


Tip #1: Do your breast exam at the same time each month


Think: “When”


You should perform a SBE only once a month. Why? It’s like watching children grow up on a daily basis versus seeing a picture of them once a year; you are more likely to notice their changes over the time interval between pictures. Perform SBE the week after each period. For postmenopausal women, pick a day each month and stick to it.


Tip #2: Stand in the mirror and examine your breasts


Think: “Look”


Stand in front of a mirror and note the size and shape of your breasts. It’s normal for one breast to be larger or smaller than the other. However, do note a change over time as well as the position and size of your nipples and areolas (the darker pigmented skin around the nipple).


Next, lift your arms above your head, put your hands on your hips and tighten your pectoralis muscles (the ones between your breasts and your ribs) by shrugging your shoulders forward. Note any dimples, skin puckering or visible lumps during these maneuvers. Cancers can tug at the skin, nipples, and muscles. If you notice anything different or asymmetric (only on one side but not the other), see your doctor.


Tip #3: Check for changes or lumps in your breasts


Think: “Feel”

Now, lie on your back and lift one arm above your head. Lying down flattens and thins out your breast tissue, allowing for easier examination.


Using your other hand, reach across your chest and use the fat pads of your index and middle fingers (not the tips, but the part of the finger you use to type on a keyboard) to gently press your breast tissue against your rib cage. Don’t pinch the tissue between your finger tips. Just press down onto your ribs. There may be some mild discomfort in areas, but you don’t need to push so hard that it hurts.


Now, gently slide your fingers in circles, working your way outward from your nipple, or use the clock (12 o’clock, 1 o’clock, etc) method to cover your entire breast tissue from the nipples outward. Cover the entire area up to your collarbone, across to your breastbone, and then laterally up into your armpit. Many women will feel thickening at the bottom part of their breasts (where an underwire would sit on a bra), which is frequently normal. However, if you’re not sure, check with your doctor.


This should take about 10 minutes for each breast – which would make it hard to miss a particular area. You could even use a timer. Also, note any nipple discharge that you have never seen before. This is usually normal, but if it is something new, talk to your doctor.


Tip #4: Track your results


Think: “Write”


My patients often tell me they have stopped doing self exams because their breasts have always felt lumpy. Here’s the solution: write down what you feel. I advise patients to get a small notepad and keep it in their bathroom cupboard. Each month, they can keep a written record of their SBE.


You can use your own words to describe what you feel, but a good method is to say something, for example, like “a quarter-inch thickening in the right breast at 3 o’clock, 2 inches from the nipple – mobile and a little tender.” That way, the next month you can feel the same area and note whether it has changed or not.


Most importantly, if you do notice a change or are just not sure, call or see your doctor. This is certainly one area of your health where it is best to be safe and seek an early professional opinion.

Preventive Care: A Checklist for Women


A checklist for women to help maintain good health


With their crazy schedules, women often put themselves on the back burner. This is especially true for working moms. That is, until a health crisis hits.


So make time to take care of yourself. See your doctor regularly for preventive care. He or she will get to know you and your family history. And you’ll get important screenings and immunizations. Some of these you may know about; others may surprise you.


Can’t-miss screenings

Often, the earlier diseases are detected, the more easily they are treated. You won’t want to miss these screenings:

•Breast cancer screening — Get a yearly mammogram starting at age 40. (If you have breast cancer in the family, your doctor may want you to start them sooner.)

•Cervical cancer screening — Get a Pap test at age 21 and every two to five years after that, depending on your exact situation. (Paps are usually not needed after age 65.)

•Colorectal cancer screening — Get a colonoscopy every 10 years starting at age 50 — or earlier if you have a family history of colorectal cancer or polyps.

Routine screenings

Your doctor will also check your cholesterol, blood pressure and blood sugar levels to watch for early signs of cardiovascular disease, hypertension or diabetes. He or she may also order bone density and thyroid tests to check for osteoporosis and thyroid disorders.


Key immunizations

Immunization, or vaccination, against these diseases can prevent serious — sometimes life-threatening — illness.

•Tetanus booster — You need a booster every 10 years. Doctors recommend the tetanus booster Tdap, which covers tetanus along with diphtheria and whooping cough (pertussis), serious diseases that are making a comeback.

•Flu vaccine — If you’re over age 50, get a flu shot every fall to avoid the most common strains of influenza. And if you don’t like shots, don’t worry! A nasal-spray flu vaccine is available for women up through age 49.

•Pneumonia vaccine — The PneumoVax® vaccine prevents pneumonia and is recommended for women 60 years old and up. You can get one earlier if you have chronic medical problems.

•Shingles vaccine — This vaccine (Zostavax®) can prevent shingles if you’ve never had the painful condition but have had chickenpox. Caution: Insurance may not cover this pricey vaccine.


Remember your daughter, too


Doctors now recommend the HPV, or human papillomavirus, vaccine (Gardasil®) for girls before they become sexually active to prevent cervical cancer. Today, adolescent girls also receive the meningococcal vaccine (Meningovax®) to prevent meningitis, which can easily spread in high school and college.


Simple steps can be lifesavers


These quick tips may seem obvious but bear repeating:

•Buckle up. Wear a seatbelt every time you’re in the car.

•Eat right. Make sure your grocery list includes healthy, nutrient-rich food (hint: Go for color in your fruits and vegetables).

•Get moving. Exercise daily — one hour a day is best.

•Think ahead. Create a living will and medical power of attorney.

Breast Cancer: Do Your Genes Put You at Risk?



Chances are you or someone you love has been affected by breast cancer. It is the third most common cancer in the country, with 200,000-plus new cases diagnosed each year.


But did you know that many of those cases are tied to genetics?


“Ten to 15 percent of all breast cancers, which is a lot, are due to strong genetic causes that can be inherited and passed on,” says Charis Eng, MD, PhD, a geneticist and chair of Cleveland Clinic’s Genomic Medicine Institute and director of its Center for Personalized Genetic Healthcare.


The good news is that genetic counselors can help assess your risk. And it’s not future science — it’s available now.


Bigger than BRCA


“Genetic testing can tell you whether you have inherited a gene associated with increased breast cancer risk,” says oncologist Halle Moore, MD. These tests can tell if you have mutations of certain genes that cause cancer to grow faster than usual.


You may have heard of mutations in the BRCA1 and BRCA2 genes. They are the most common — and most commonly discussed — genes associated with breast cancer. But Dr. Eng points out that 10 genes are known to increase your risk of cancer. That includes PTEN, a gene she discovered that is linked to thyroid and other cancers, too.


“A PTEN mutation increases lifetime breast cancer risk to 85 percent, compared to 13 percent in the general population,” Dr. Eng says. “We were shocked to learn this. It means we have to do the same type of intensive screening as we do with BRCA1 and BRCA2.”


Red flags for genetic counseling


Dr. Eng points to seven red flags that suggest potential genetic breast cancer:


1. You have a family history of breast and/or other cancers. If cancer runs in your family, talk to your doctor about genetic counseling. Certain family factors — including the other red flags outlined below — may put you at greater risk.


2. You get breast cancer before age 50. Breast cancer is more common in women after age 55 or 60. Being diagnosed at a young age means you may have a higher risk of getting breast cancer again later in life.

3. Your breast cancer is a specific type. For example, “triple-negative” breast cancer is associated with the BRCA genes. “When we see a patient with a triple-negative breast cancer, we often recommend genetic counseling. We know those cancers have a higher likelihood of being hereditary, even if there’s not a big family history,” Dr. Moore says. A different type of breast cancer, lobular, is associated with stomach cancer and is caused by the CDH1 gene.


4. You develop cancer in both breasts. Getting cancer in one breast is common enough, but having it in both breasts is a sign of extremely high risk, Dr. Eng says.


5. You get breast cancer at any age but have one other risk factor, such as:

•Having a close relative who had breast cancer before age 50

•Having a close male relative who had breast cancer

•Having a close relative who had ovarian or other types of cancer

•Being of Ashkenazi Jewish descent


6. You have both breast and another type of cancer. For example, breast and ovarian cancers are often linked, especially in people with BRCA mutations. Dr. Eng says that having breast cancer with additional types of cancer can be a red flag, too. For example, having both breast and thyroid cancers may mean you have a PTEN mutation.


7. One of your family members has a gene mutation. If a family member has a mutation that increases cancer risk, you should be tested too. This does not mean you will inherit the family mutation. You have an equal chance that it will be negative — in which case your risk is the same as the general population.


What’s next after risks are identified?

Genetic counselors will gather your personal and family history in detail and consult your doctor. If you seem to be at risk, they may test a blood sample. If they find mutations, they will tailor a screening and prevention plan for you.


“For example, if you find out you have a BRCA1 mutation and you have had breast cancer on one side, you are at such a high risk for cancer on the other side that you may decide to do a prophylactic mastectomy,” Dr. Moore says. “If, on the other hand, testing doesn’t reveal a mutation, your risk of breast cancer on the other side is lower, and preventive mastectomy wouldn’t be necessary.”


Knowing exactly which of the 10 breast cancer genes is involved is crucial because the recommendations for each are different, Dr. Eng says.


“Genes are like encyclopedias in which we’re trying to look for very small typographical errors, and we have 35,000 encyclopedias in each cell,” she says. “Genetic counselors and genetic physicians can help choose which encyclopedia to read and find those errors.”