Focus on Disability - For Disabled People, the Elderly and their Carers in the UK

Breast Cancer (Female) – A Guide

Focus on Disability - For Disabled People, the Elderly and their Carers in the UK

Breast cancer is the most common cancer in the UK. About 46,000 women get breast cancer in the UK each year.
Most of them (8 out of 10) are over 50, but younger women, and in rare cases men, can also get breast cancer.

Introduction
Symptoms of breast cancer
Causes and risk factors
Diagnosing breast cancer
Treating breast cancer
Preventing breast cancer
Breast screening
Living with breast cancer

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.

Our bodies are made up of billions of tiny cells. Normally, cells grow and multiply in an orderly way. New cells are only made when and where they are needed. In cancer, this orderly process goes wrong and cells begin to grow and multiply uncontrollably.

Breast cancer can have a number of symptoms but usually shows as a lump or thickening in the breast tissue (although most breast lumps are not cancerous). If cancer is detected at an early stage, it can be treated before it spreads to nearby parts of the body.



Types of breast cancer

There are several different types of breast cancer, which can develop in different parts of the breast. Breast cancer is often divided into non-invasive and invasive types.

Non-invasive breast cancer

Non-invasive breast cancer is also known as cancer or carcinoma in situ, or pre-cancerous cells. This cancer is found in the ducts of the breast and has not developed the ability to spread outside the breast. This form of cancer rarely shows as a lump in the breast and is usually found on a mammogram. The most common type of non-invasive cancer is ductal carcinoma in situ (DCIS).

Invasive breast cancer

Invasive cancer has the ability to spread outside the breast, although this does not mean it necessarily has spread. The most common form of breast cancer is invasive ductal breast cancer, which develops in the cells that line the breast ducts. Invasive ductal breast cancer accounts for about 80% of all cases of breast cancer and is sometimes called ‘no special type’.

Other types of breast cancer

Other less common types of breast cancer include invasive 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, usually through the lymph nodes (small glands that filter bacteria from the body) or the bloodstream. If this happens, it is known as secondary or metastatic breast cancer.

Breast screening

The exact cause of breast cancer is not fully understood, but many factors increase the likelihood of developing it, including age and family history of breast cancer.

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 aged 50-70 are invited for breast cancer screening every three years. Women over 70 are also entitled to screening and can arrange an appointment through their GP or local screening unit.

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 it is detected in its early stages. For this reason, it is vital that women check their breasts regularly for any changes 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, you can use Macmillan’s online interactive assessment tool, which is called OPERA.

The tool is based on the National Institute for Health and Clinical Excellence (NICE) guideline for the classification and care of women at risk of familial breast cancer. It is designed to be used by patients and health professionals to assess a person’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 of breast cancer

So that you can pick up any changes as soon as possible, it is important to be breast aware. Get to know what is normal for you. For instance, your breasts may look or feel different at different times of your life. This will make it much easier to spot any potential problems.

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The first symptom of breast cancer that most women notice is a lump or an area of thickened tissue in their breast. Most lumps (90%) are not cancerous, but it is always best to have them checked by your doctor.

See your GP if you notice any of the following:

  • a lump or area of thickened 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 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
  • pain in either of your breasts or armpits that is not related to your period



Causes and risk factors

The causes of breast cancer are not fully understood. This means that it is difficult to say why one woman may develop breast cancer and another may not.

Some things, known as risk factors, can change the likelihood that someone may develop breast cancer. There are some factors that you cannot do anything about, although there are others that you can change.

Age

The risk of developing breast cancer increases as you get older. Breast cancer is most common among women over 50 who have been through the menopause. Eight out of 10 cases of breast cancer occur in women over 50.

All women between 50 and 70 years of age should be screened for breast cancer every three years as part of the NHS Breast Screening Programme. Women over the age of 70 are still eligible to be screened and can arrange this through their GP or local screening unit. Currently, there are ongoing pilot studies looking at widening the screening age range to 47-73.

Family history

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

Most breast cancer cases are not hereditary (they do not run in families). However, particular genes, known as BRCA1 and BRCA2, can increase your risk of developing both breast and ovarian cancer. It is possible for these genes to be passed on from a parent to their child. A third gene (TP53) is also associated with increased risk of breast cancer.

If you have, for example, two or more close relatives from the same side of your family (such as your mother, sister or daughter) who have had breast cancer under the age of 50, you may be eligible for surveillance for breast cancer or for genetic screening to look for the genes that make developing breast cancer more likely. If you are worried about your family history of breast cancer, discuss it with your GP.

Previous diagnosis of breast cancer

If you have previously had breast cancer or early non-invasive cancer cell changes contained within breast ducts, you have a higher risk of developing it again, either in your other breast or in the same breast again.

Previous benign breast lump

A benign breast lump does not mean that you have breast cancer, but certain types of lump may slightly increase your risk of developing it. Certain benign changes in your breast tissue, such as atypical ductal hyperplasia (cells growing abnormally in ducts) or lobular carcinoma in situ (abnormal cells inside your breast lobes), can make getting breast cancer more likely.

Breast density

Your breasts are made up of thousands of tiny glands (lobules), which produce milk. This glandular tissue contains a higher concentration of breast cells than other breast tissue, making it denser. Women with more dense breast tissue may have a higher 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. Younger women tend to have denser breasts. As you get older, the amount of glandular tissue in your breasts decreases and is replaced by fat, so your breasts become less dense.

Exposure to oestrogen

In some cases, breast cancer cells can be stimulated to grow by the female hormone oestrogen. Your ovaries, where your eggs are stored, begin to produce oestrogen when you start 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 have been through the menopause and 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 after the menopause causes more oestrogen to be produced.

Being tall

If you are taller than average, you are more likely to develop breast cancer than someone who is shorter than average. This may be due to interactions between genes, nutrition and hormones, but the reason is not fully understood.

Alcohol

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

Radiation

Certain medical procedures that use radiation, such as X-rays and CT scans, may slightly increase your risk of developing breast cancer. If you had radiotherapy to your chest area 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 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 if you take combined HRT.

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 10 years. The risk continues to increase slightly the longer you take HRT, but returns to normal once you stop taking it.

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Diagnosing breast cancer

You may be diagnosed with breast cancer following routine breast cancer screening or you may have symptoms which you have seen your GP about.

Seeing your GP

If you notice any of the symptoms of breast cancer, such as an unusual lump in your breast or any change in the appearance, feel or shape of your breasts, it is important to speak to your GP as soon as possible.

Your GP will examine you and, if they think your symptoms need further assessment, refer you to a specialist breast cancer clinic.

The National Institute for Health and Clinical Excellence (NICE) has issued guidance for GPs about referring patients with cancer to specialist services, including a list of symptoms which may require an urgent referral. If you need to be referred urgently, you will usually be seen within two weeks.

Tests at the breast cancer clinic

If you have suspected breast cancer, either due to your symptoms or because your mammogram has shown an abnormality, you will be referred to a specialist breast cancer clinic for further tests.

Mammogram and breast ultrasound

If you have symptoms and have been referred by your GP, you will have a mammogram to produce an X-ray of the breasts. You may also need an ultrasound scan. If your cancer was detected through the NHS Screening Programme, you may need to have another mammogram or ultrasound scan.

If you are under 35, your doctor may suggest that you have a breast ultrasound scan only. Younger women have denser breasts, which means a mammogram is not as effective as detecting cancer.

Ultrasound uses high-frequency sound waves to produce an image of the inside of your breasts. The image produced will show any lumps or abnormalities that are present in your breasts. Your doctor may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid or contains liquid.

Biopsy

A biopsy involves taking a sample of tissue cells from your breast and testing them to see if they are cancerous. You may also need to have a scan and a needle test on the lymph nodes in your armpit (axilla) to see if these are also affected. Biopsies can be taken in different ways and the type you have will depend on what your doctor knows about your condition. The different methods of carrying out a biopsy are outlined below.

  • Needle aspiration may be used to test a sample of your breast cells for cancer or to drain a benign cyst (a small fluid-filled lump). Your doctor will use a small needle to extract a sample of cells, without removing any tissue.
  • Needle biopsy is the most common type of biopsy. 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 guided needle biopsy (usually this is guided by ultrasound or X-ray but sometimes MRI is used) to obtain a more precise and reliable diagnosis of cancer and to distinguish it from any non-invasive change, in particular ductal carcinoma in situ (DCIS).

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Treating breast cancer

What is good care for breast cancer?

People with cancer should be cared for by a multidisciplinary team (MDT). This is a team of specialists who work together to provide the best treatment and care.

The team often consists of a specialist cancer surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a radiologist, pathologist, radiographer, reconstructive surgeon and a specialist nurse. Other members may include a physiotherapist, dietitian and occupational therapist, and you may have access to clinical psychology support.

When deciding what treatment is best for you, your doctors will consider:

  • the stage and grade of your cancer (how big it is and how far it has spread)
  • your general health
  • whether you have been through the menopause

You can discuss your treatment with your care team at any time and ask any questions.

The main treatments for breast cancer are:

  • surgery
  • radiotherapy
  • chemotherapy
  • hormone therapy
  • biological therapy (targeted therapy)

You may have one of these treatments or a combination. The type of treatment or the combination of treatments will depend on how the cancer was diagnosed and the stage it is at. Breast cancer that has been diagnosed at screening may be at an early stage, but breast cancer diagnosed when you have symptoms may be at a later stage and require a different treatment. Your healthcare team will discuss with you which treatments are most suitable.

Treatment overview

The first type of treatment for breast cancer is usually surgery. The type of surgery depends on the type of breast cancer you have. Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments. Again, the treatment you will have depends on the type of breast cancer. Your doctor will discuss the best treatment plan with you. Sometimes, chemotherapy or hormone therapy will be the first treatment.

Secondary breast cancer

Most breast cancers are discovered in the early stages of the disease. However, a small proportion of women discover that they have breast cancer after it has spread to other parts of the body (metastasis). If this is the case, the type of treatment you have may be different. Secondary cancer, also called advanced or metastatic cancer, is not curable and treatment aims to achieve a remission, where the cancer shrinks or disappears, making you feel normal and able to enjoy life to the full.

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Preventing breast cancer

Diet and lifestyle

Regular exercise and a healthy diet are recommended for all women as they can help prevent many conditions, including heart disease, diabetes and many forms of cancer.

Studies have looked at the link between breast cancer and diet and, although there are no definite conclusions at the moment, there are benefits for women who maintain a healthy weight, do regular exercise and who have a low intake of saturated fat and alcohol.

It has also been suggested that regular exercise can reduce your risk of breast cancer by as much as a third. If you have been through the menopause, it is particularly important that you are not overweight or obese. This is because these conditions cause more oestrogen to be produced, which can increase the risk of breast cancer.

Breastfeeding

Studies have shown that women who breastfeed are statistically less likely to develop breast cancer than those who do not. The reasons are not fully understood, but it could be because women do not ovulate as regularly while they are breastfeeding and oestrogen levels remain stable.

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Breast screening

The NHS Breast Screening Programme screens around 1.6 million women a year. Women aged 50 to 70, who are registered with a GP, are automatically invited for screening every three years. You will first be invited for screening between your 50th and 53rd birthday. Women over the age of 70 are still eligible to be screened and can arrange this through their GP or local screening unit. The NHS is extending the breast screening age range in England so that by the end of 2012, all women aged 47 to 73 will be invited.

Screening takes place at a special clinic or mobile breast screening unit. A mammogram (X-ray of the breast) is taken by a female health professional. The mammogram is then studied to look for any abnormalities. The aim is to find breast cancer at an early stage, when any changes in the breast would be too small to feel and when there is a good chance of successful treatment and full recovery. It is estimated that screening saves 1,400 lives a year.

Not all cancers are found during breast screening. Breast cancer can develop between screening appointments. Even if you go to breast screening, it is important to get to know your breasts so that you can spot any unusual changes early on and report them to your GP.

What happens at the screening unit?

Screening is carried out by female staff, who take mammograms 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 the compression uncomfortable and occasionally it may be painful. However, the compression is necessary to ensure the mammogram is clear. Any discomfort will be over quickly.

The results of the mammogram will be sent to you and your GP. About one woman in 20 will be called back for further assessment. Being called back does not mean you definitely have cancer. The first mammogram may have been unclear. About one in six women who are called back for further assessment are diagnosed with breast cancer.

Screening for women at high risk of breast cancer

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

  • Two or more close relatives (at least one of whom is your mother or sister) on the same side of your family have or have had breast cancer.
  • Three of your close relatives were diagnosed with breast cancer at any age.
  • One close relative has breast cancer and one has ovarian cancer (one of them being your mother, sister or daughter).
  • Your mother or sister were diagnosed with breast cancer before the age of 40.
  • Your father or brother were diagnosed with breast cancer at any age.
  • Your mother or sister were diagnosed with breast cancer in both breasts and were diagnosed for the first time under the age of 50.

If any of the above applies to you, 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 40, you should be offered screening with a mammogram once a year. If you are under 40, you are entitled to screening using MRI scans instead of mammograms because your breasts may be too dense to produce a clear mammogram.

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 make breast cancer more likely runs in your family. You may be able to have screening for these genes, which are known as BRCA1, BRCA2 and TP53.

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 carry any of the breast cancer genes.

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

Living with breast cancer

Breast cancer can affect your daily life in different ways, depending on what stage it is at and what treatment you are having.

How women cope with the diagnosis and with their treatment varies from person to person. There are several forms of support if you need it. Not all of them work for everybody, but one or more of them should help:

  • Talk to your friends and family. They can be a powerful support system.
  • Communicate with other people who are in the same situation.
  • Know as much as possible about your condition.
  • Do not try to do too much or overexert yourself.
  • Make time for yourself.

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