breast cancer

Contents

Breast cancer

Breast cancer is cancer that forms in the cells of the breasts that begin to grow out of control 1). In the U.S., breast cancer is the second most common cancer in women after skin cancer. It can occur in both men and women, but it is rare in men. Each year there are about 100 times more new cases of breast cancer in women than in men.

Currently, the average risk of a woman in the United States developing breast cancer sometime in her life is about 12%. This means there is a 1 in 8 chance she will develop breast cancer. This also means there is a 7 in 8 chance she will never have the disease.

The American Cancer Society’s estimates for breast cancer in the United States for 2017 are 2):

  • About 252,710 new cases of invasive breast cancer will be diagnosed in women.
  • About 63,410 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form of breast cancer).
  • About 40,610 women will die from breast cancer.

Breast cancer is the second leading cause of cancer death in women (only lung cancer kills more women each year). The chance that a woman will die from breast cancer is about 1 in 37 (about 2.7%).

Death rates from female breast cancer dropped 39% from 1989 to 2015. Since 2007, breast cancer death rates have been steady in women younger than 50, but have continued to decrease in older women.

Breast cancer survival rate

Relative survival rates are an estimate of the percentage of patients who will survive for a given period of time after a cancer diagnosis, accounting for normal life expectancy. Survival among cancer patients is compared to survival among people of the same age and race who have not been diagnosed with cancer. Based on the most recent data, relative survival rates for women diagnosed with breast cancer are 3):

  • 89.7% at 5 years after diagnosis
  • 86% after 10 years
  • 80% after 15 years

Relative survival rates should be interpreted with caution. First, they are based on the average experience of all women and do not predict individual prognosis because many patient and tumor characteristics that influence breast cancer survival are not taken into account. Second, long-term survival rates are based on the experience of women diagnosed and treated many years ago and do not reflect the most recent improvements in early detection and treatment.

Breast cancer survival varies by stage at diagnosis

The overall 5-year relative survival rate is 98.9% for localized disease, 85.2% for regional disease, and 26.9% for distant-stage disease 4).

Survival within each stage varies by tumor size. For example, among women with regional disease, the 5-year relative survival is 95% for tumors less than or equal to 2.0 cm, 85% for tumors 2.1-5.0 cm, and 72% for tumors greater than 5.0 cm.

These decreases are believed to be the result of finding breast cancer earlier through screening and increased awareness, as well as better treatments.

Substantial support for breast cancer awareness and research funding has helped created advances in the diagnosis and treatment of breast cancer. Breast cancer survival rates have increased, and the number of deaths associated with this disease is steadily declining, largely due to factors such as earlier detection, a new personalized approach to treatment and a better understanding of the disease.

Female Breast Anatomy

Within each breast is a mammary gland, a modified sudoriferous (sweat) gland that produces milk (Figure 1). A mammary gland consists of 15 to 20 lobes, or compartments, separated by a variable amount of adipose tissue. In each lobe are several smaller compartments called lobules, composed of grapelike clusters of
milk- secreting glands termed alveoli (small cavities) embedded in connective tissue. Contraction of myoepithelial cells surrounding the alveoli helps propel milk toward the nipples. When milk is being produced, it passes from the alveoli into a series of secondary tubules and then into the mammary ducts. Near the nipple, the mammary ducts expand slightly to form sinuses called lactiferous sinuses, where some milk may be stored before draining into a lactiferous duct. Each lactiferous duct typically carries milk from one of the lobes to the exterior.

The functions of the mammary glands are the synthesis, secretion, and ejection of milk; these functions, called lactation, are associated with pregnancy and childbirth. Milk production is stimulated largely by the hormone prolactin from the anterior pituitary, with contributions from progesterone and estrogens. The ejection of milk is stimulated by oxytocin, which is released from the posterior pituitary in response to the sucking of an infant on the mother’s nipple (suckling).

Strands of connective tissue called the suspensory ligaments of the breast (Cooper’s ligaments) run between the skin and fascia and support the breast. These ligaments become looser with age or with the excessive strain that can occur in longterm jogging or high-impact aerobics.

Figure 1. Normal breast (female)

Breast

Where breast cancer starts

Breast cancers can start from different parts of the breast. The most common type of breast cancer is ductal carcinoma, which begins in the cells of the lactiferous ducts that carry milk to the nipple (ductal cancers). Some start in the glands (the cells of the lobules) that make breast milk (lobular cancers). There are also other types of breast cancer that are less common.

Ductal carcinoma in situ is a condition in which abnormal cells are found in the lining of the lactiferous ducts but they haven’t spread outside the lactiferous duct. Breast cancer that has spread from where it began in the ducts or lobules to surrounding tissue is called invasive breast cancer. In inflammatory breast cancer, the breast looks red and swollen and feels warm because the cancer cells block the lymph vessels in the skin.

A small number of cancers start in other tissues in the breast. These cancers are called sarcomas and lymphomas and are not really thought of as breast cancers.

Although many types of breast cancer can cause a lump in the breast, not all do. Many breast cancers are found on screening mammograms which can detect cancers at an earlier stage, often before they can be felt, and before symptoms develop. There are other symptoms of breast cancer you should watch for and report to a health care provider.

It’s also important to understand that most breast lumps are benign and not cancer (malignant). Non-cancerous breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman’s risk of getting breast cancer. Any breast lump or change needs to be checked by a health care professional to determine if it is benign or malignant (cancer) and if it might affect your future cancer risk.

How breast cancer spreads

Breast cancer can spread when the cancer cells get into the blood or lymph system (see Figure 2) and are carried to other parts of the body.

The lymph system is a network of lymph (or lymphatic) vessels found throughout the body that connects lymph nodes (small bean-shaped collections of immune system cells). The clear fluid inside the lymph vessels, called lymph, contains tissue by-products and waste material, as well as immune system cells. The lymph vessels carry lymph fluid away from the breast. In the case of breast cancer, cancer cells can enter those lymph vessels and start to grow in lymph nodes. Most of the lymph vessels of the breast drain into:

  • Lymph nodes under the arm (axillary nodes)
  • Lymph nodes around the collar bone (supraclavicular [above the collar bone] and infraclavicular [below the collar bone] lymph nodes)
  • Lymph nodes inside the chest near the breast bone (internal mammary lymph nodes)

If cancer cells have spread to your lymph nodes, there is a higher chance that the cells could have traveled through the lymph system and spread (metastasized) to other parts of your body. The more lymph nodes with breast cancer cells, the more likely it is that the cancer may be found in other organs. Because of this, finding cancer in one or more lymph nodes often affects your treatment plan. Usually, you will need surgery to remove one or more lymph nodes to know whether the cancer has spread.

Still, not all women with cancer cells in their lymph nodes develop metastases, and some women with no cancer cells in their lymph nodes develop metastases later.

Figure 2. Lymph nodes associated with breast cancer spread

Lymph nodes of breastWhat Causes Breast Cancer

Changes or mutations in DNA can cause normal breast cells to become cancer. Certain DNA changes are passed on from parents (inherited) and can greatly increase your risk for breast cancer. Other lifestyle-related risk factors, such as what you eat and how much you exercise, can increase your chance of developing breast cancer, but it’s not yet known exactly how some of these risk factors cause normal cells to become cancer. Hormones seem to play a role in many cases of breast cancer, but just how this happens is not fully understood.

Inherited versus acquired DNA mutations

Normal breast cells become cancer because of changes (mutations) in DNA. DNA is the chemical in our cells that makes up our genes. Genes have the instructions for how our cells function. Some DNA mutations are inherited or passed to you from your parents. This means the mutations are in your cells when you are born and some mutations can greatly increase the risk of certain cancers. They cause many of the cancers that run in some families and often cause cancer when people are younger.

But most DNA changes linked to breast cancer are acquired. This means the change takes place in breast cells during a person’s life rather than having been inherited or born with them. Acquired DNA changes take place over time and are only in the breast cancer cells.

Mutated DNA can lead to mutated genes. Some genes control when our cells grow, divide into new cells, and die. Changes in these genes can cause the cells to lose normal control and are linked to cancer.

Proto-oncogenes

Proto-oncogenes are genes that help cells grow normally. When a proto-oncogene mutates (changes) or there are too many copies of it, it becomes a “bad” gene that can stay turned on or activated when it’s not supposed to be. When this happens, the cell grows out of control and makes more cells that grow out of control. This can lead to cancer. This bad gene is called an oncogene.

Think of a cell as a car. For the car to work properly, there need to be ways to control how fast it goes. A proto-oncogene normally functions in a way that’s much like a gas pedal. It helps control how and when the cell grows and divides. An oncogene is like a gas pedal that’s stuck down, which causes the cell to divide out of control.

Tumor suppression genes

Tumor suppressor genes are normal genes that slow down cell division (cell growth), repair DNA mistakes, or tell cells when to die (a process known as apoptosis or programmed cell death). When tumor suppressor genes don’t work properly, cells can grow out of control, make more cells that grow out of control, and don’t die when they should, which can lead to cancer.

A tumor suppressor gene is like the brake pedal on a car. It normally keeps the cell from dividing too quickly, just as a brake keeps a car from going too fast. When something goes wrong with the gene, such as a mutation, the “brakes” don’t work and cell division can get out of control.

Inherited gene changes

Doctors estimate that about 5 to 10 percent of breast cancers are linked to gene mutations passed through generations of a family. Certain inherited DNA mutations (changes) can dramatically increase the risk for developing certain cancers and are linked to many of the cancers that run in some families. For instance, the breast cancer genes or BRCA genes (breast cancer gene 1 = BRCA1 and breast cancer gene 2 = BRCA2) are tumor suppressor genes. When one of these breast cancer (BRCA) genes changes, it no longer suppresses abnormal cell growth, and cancer is more likely to develop. A change in one of these genes can be passed from a parent to a child.

  • If you have a strong family history of breast cancer or other cancers, your doctor may recommend a blood test to help identify specific mutations in BRCA or other genes that are being passed through your family.
  • Consider asking your doctor for a referral to a genetic counselor, who can review your family health history. A genetic counselor can also discuss the benefits, risks and limitations of genetic testing to assist you with shared decision-making.

Women have already begun to benefit from advances in understanding the genetic basis of breast cancer. Genetic testing can identify some women who have inherited mutations in the BRCA1 or BRCA2 tumor suppressor genes (or less commonly in other genes such as PALB2, ATM or CHEK2). These women can then take steps to reduce their risk of breast cancer and make plans to look for changes in their breasts to help find cancer at an earlier, more treatable stage. Since these mutations in BRCA 1 and BRCA 2 genes are also associated with other cancers (besides breast), women with these mutations can also consider early screening and preventive actions for other cancers.

Mutations in tumor suppressor genes like the BRCA genes are considered “high penetrance” because they often lead to cancer. Although many women with high penetrance mutations develop cancer, most cases of cancer (including breast cancer) are not caused by this kind of mutation.

More often, low-penetrance mutations or gene variations are a factor in cancer development. Each of these may have a small effect on cancer occurring in any one person, but the overall effect on the population can be large because the mutations are common, and people often have more than one at the same time. The genes involved can affect things like hormone levels, metabolism, or other things that impact risk factors for breast cancer. These genes may cause much of the risk of breast cancer that runs in families.

Acquired gene changes

Most DNA mutations related to breast cancer take place in breast cells during a woman’s life rather than having been inherited. These acquired mutations of oncogenes and/or tumor suppressor genes may result from other factors, like radiation or cancer-causing chemicals. But so far, the causes of most acquired mutations that could lead to breast cancer are still unknown. Most breast cancers have several acquired gene mutations.

Tests to spot acquired gene changes may help doctors more accurately predict the outlook (prognosis) for some women with breast cancer. For example, tests can identify women whose breast cancer cells have too many copies of the HER2 oncogene. These cancers tend to grow and spread faster. There are drugs that target these cancer cell changes and improve outcomes for patients.

Risk factors for breast cancer

A breast cancer risk factor is anything that makes it more likely you’ll get breast cancer. But having one or even several breast cancer risk factors doesn’t necessarily mean you’ll develop breast cancer. Many women who develop breast cancer have no known risk factors other than simply being women.

Factors that are associated with an increased risk of breast cancer include 5):

  • Being female. Women are much more likely than men are to develop breast cancer.
  • Increasing age. Your risk of breast cancer increases as you age.
  • A personal history of breast conditions. If you’ve had a breast biopsy that found lobular carcinoma in situ (LCIS) or atypical hyperplasia of the breast, you have an increased risk of breast cancer.
  • A personal history of breast cancer. If you’ve had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.
  • A family history of breast cancer. If your mother, sister or daughter was diagnosed with breast cancer, particularly at a young age, your risk of breast cancer is increased. Still, the majority of people diagnosed with breast cancer have no family history of the disease.
  • Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most well-known gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don’t make cancer inevitable.
  • Radiation exposure. If you received radiation treatments to your chest as a child or young adult, your risk of breast cancer is increased.
  • Obesity. Being obese increases your risk of breast cancer.
  • Beginning your period at a younger age. Beginning your period before age 12 increases your risk of breast cancer.
  • Beginning menopause at an older age. If you began menopause at an older age, you’re more likely to develop breast cancer.
  • Having your first child at an older age. Women who give birth to their first child after age 30 may have an increased risk of breast cancer.
  • Having never been pregnant. Women who have never been pregnant have a greater risk of breast cancer than do women who have had one or more pregnancies.
  • Postmenopausal hormone therapy. Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of breast cancer. The risk of breast cancer decreases when women stop taking these medications.
  • Drinking alcohol. Drinking alcohol increases the risk of breast cancer.

Prevention of breast cancer

Breast cancer risk reduction for women with an average risk

Making changes in your daily life may help reduce your risk of breast cancer. Try to:

Ask your doctor about breast cancer screening. Discuss with your doctor when to begin breast cancer screening exams and tests, such as clinical breast exams and mammograms.

Talk to your doctor about the benefits and risks of screening. Together, you can decide what breast cancer screening strategies are right for you.

Become familiar with your breasts through breast self-exam for breast awareness. Women may choose to become familiar with their breasts by occasionally inspecting their breasts during a breast self-exam for breast awareness. If there is a new change, lumps or other unusual signs in your breasts, talk to your doctor promptly.

  • Breast awareness can’t prevent breast cancer, but it may help you to better understand the normal changes that your breasts undergo and identify any unusual signs and symptoms.
  • Drink alcohol in moderation, if at all. Limit the amount of alcohol you drink to no more than one drink a day, if you choose to drink.
  • Exercise most days of the week. Aim for at least 30 minutes of exercise on most days of the week. If you haven’t been active lately, ask your doctor whether it’s OK and start slowly.
  • Limit postmenopausal hormone therapy. Combination hormone therapy may increase the risk of breast cancer. Talk with your doctor about the benefits and risks of hormone therapy.

Some women experience bothersome signs and symptoms during menopause and, for these women, the increased risk of breast cancer may be acceptable in order to relieve menopause signs and symptoms.

  • To reduce the risk of breast cancer, use the lowest dose of hormone therapy possible for the shortest amount of time.
  • Maintain a healthy weight. If your weight is healthy, work to maintain that weight. If you need to lose weight, ask your doctor about healthy strategies to accomplish this. Reduce the number of calories you eat each day and slowly increase the amount of exercise.
  • Choose a healthy diet. Women who eat a Mediterranean diet supplemented with extra-virgin olive oil and mixed nuts may have a reduced risk of breast cancer. The Mediterranean diet focuses mostly on plant-based foods, such as fruits and vegetables, whole grains, legumes, and nuts. People who follow the
  • Mediterranean diet choose healthy fats, such as olive oil, over butter and fish instead of red meat.

Breast cancer risk reduction for women with a high risk

If your doctor has assessed your family history and determined that you have other factors, such as a precancerous breast condition, that increase your risk of breast cancer, you may discuss options to reduce your risk, such as:

  • Preventive medications (chemoprevention). Estrogen-blocking medications, such as selective estrogen receptor modulators and aromatase inhibitors, reduce the risk of breast cancer in women with a high risk of the disease.

These medications carry a risk of side effects, so doctors reserve these medications for women who have a very high risk of breast cancer. Discuss the benefits and risks with your doctor.

  • Preventive surgery. Women with a very high risk of breast cancer may choose to have their healthy breasts surgically removed (prophylactic mastectomy). They may also choose to have their healthy ovaries removed (prophylactic oophorectomy) to reduce the risk of both breast cancer and ovarian cancer.

Types of breast cancer

There are many types of breast cancer. The most common types are ductal carcinoma in situ (DCIS), invasive ductal carcinoma, and invasive lobular carcinoma.

The type of breast cancer is determined by the specific cells in the breast that are affected. Most breast cancers are carcinomas. Carcinomas are tumors that start in the epithelial cells that line organs and tissues throughout the body. Sometimes, an even more specific term is used. For example, most breast cancers are a type of carcinoma called adenocarcinoma, which starts in cells that make up glands (glandular tissue). Breast adenocarcinomas start in the ducts (the milk ducts) or the lobules (milk-producing glands).

There are other, less common, types of breast cancers, too, such as sarcomas, phyllodes, Paget disease, and angiosarcomas which start in the cells of the muscle, fat, or connective tissue.

Sometimes a single breast tumor can be a combination of different types. And in some very rare types of breast cancer, the cancer cells may not form a lump or tumor at all.

  • Angiosarcoma
  • Ductal carcinoma in situ (DCIS)
  • Inflammatory breast cancer
  • Invasive lobular carcinoma
  • Male breast cancer
  • Paget’s disease of the breast
  • Recurrent breast cancer

When a biopsy is done to find out the specific type of breast cancer, the pathologist will also check if the cancer has spread into the surrounding tissues. The following terms are used to describe the extent of the cancer:

  • In situ breast cancers have not spread.
  • Invasive or infiltrating cancers have spread (invaded) into the surrounding breast tissue.

Common kinds of breast cancer

The most common kinds of breast cancer are carcinomas, and are named based on where they form and how far they have spread.

In situ cancers

Ductal Carcinoma In Situ (DCIS)

Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is a non-invasive or pre-invasive breast cancer 6).

About 1 in 5 new breast cancers will be DCIS or ductal carcinoma in situ. Nearly all women with this early stage of breast cancer can be cured.

Ductal carcinoma in situ(DCIS), is also called intraductal carcinoma and Stage 0 breast cancer. DCIS is a non-invasive or pre-invasive breast cancer. This means the cells that line the ducts have changed to cancer cells but they have not spread through the walls of the ducts into the nearby breast tissue.

Because DCIS hasn’t spread into the breast tissue around it, it can’t spread (metastasize) beyond the breast to other parts of the body.

DCIS is considered a pre-cancer because sometimes it can become an invasive cancer. This means that over time, DCIS may spread out of the duct into nearby tissue, and could metastasize (spread). Right now, though, there’s no good way to know for sure which will become invasive cancer and which ones won’t. So almost all women with DCIS will be treated.

Lobular carcinoma in situ (LCIS)

Lobular carcinoma in situ (LCIS) may also be called lobular neoplasia. This breast change is not a cancer, though the name can be confusing. In LCIS, cells that look like cancer cells are growing in the lobules of the milk-producing glands of the breast, but they don’t grow through the wall of the lobules.

Women with LCIS have about a 7 to 12 times higher risk of developing invasive cancer in either breast. For this reason, women with LCIS should make sure they have regular breast cancer screening tests and follow-up visits with a health care provider for the rest of their lives.

LCIS is not considered to be cancer, and it typically does not spread beyond the lobule (become invasive breast cancer) if it isn’t treated. But having LCIS does increase your risk of developing an invasive breast cancer in either breast later on, so close follow-up is important.

Treatment

In most cases, LCIS does not need to be treated. Sometimes if LCIS is found using a needle biopsy, the doctor might recommend that it be removed completely (with an excisional biopsy or some other type of breast-conserving surgery) to help make sure that LCIS was the only thing there. This is especially true if the LCIS is described as pleomorphic or if it has necrosis (areas of dead cells), in which case it might be more likely to grow quickly.

Invasive (infiltrating) breast cancer

Breast cancers that have spread into surrounding breast tissue are known as invasive breast cancer.

This is the most common type of breast cancer. About 8 of 10 invasive breast cancers are invasive (or infiltrating) ductal carcinomas (IDC).

IDC starts in the cells that line a milk duct in the breast, breaks through the wall of the duct, and grows into the nearby breast tissues. At this point, it may be able to spread (metastasize) to other parts of the body through the lymph system and bloodstream.

Invasive lobular carcinoma (ILC)

Invasive lobular carcinoma (ILC) starts in the milk-producing glands (lobules). Like IDC, it can spread (metastasize) to other parts of the body. About 1 invasive breast cancer in 10 is an ILC. Invasive lobular carcinoma may be harder to detect on physical exam as well as imaging, like mammograms, than invasive ductal carcinoma. And compared to other kinds of invasive carcinoma, about 1 in 5 women with ILC might have cancer in both breasts.

Special types of invasive breast cancer

There are some special types of breast cancer that are sub-types of invasive carcinoma. They are much less common than the breast cancers listed named above and each typically make up fewer than 5% of all breast cancers. These are often named after features seen when they are viewed under the microscope, like the ways the cells are arranged.

Some of these may have a better prognosis than standard invasive infiltrating ductal carcinoma. These include:

  • Adenoid cystic (or adenocystic) carcinoma
  • Low-grade adenosquamous carcinoma (this is a type of metaplastic carcinoma)
  • Medullary carcinoma
  • Mucinous (or colloid) carcinoma
  • Papillary carcinoma
  • Tubular carcinoma

Some sub-types have the same or maybe worse prognoses than standard invasive infiltrating ductal carcinoma. These include:

  • Metaplastic carcinoma (most types, including spindle cell and squamous, except low grade adenosquamous carcinoma)
  • Micropapillary carcinoma
  • Mixed carcinoma (has features of both invasive ductal and lobular)

In general, all of these sub-types are still treated like standard invasive infiltrating ductal carcinoma.

Less common types of breast cancer

Inflammatory breast cancer

Inflammatory breast cancer (IBC) is rare. It differs from other types of breast cancer in its symptoms, outlook, and treatment. Symptoms include breast swelling, purple or red color of the skin, and pitting or thickening of the skin of the breast so that it may look and feel like an orange peel. Often, a lump is not felt. If you have any of these symptoms, it does not mean that you have IBC, but you should see a doctor right away.

Inflammatory breast cancer (IBC) has some symptoms of inflammation like swelling and redness. But infection or injury do not cause IBC or the symptoms. IBC symptoms are caused by cancer cells blocking lymph vessels in the skin. It accounts for about 1% to 5% of all breast cancers.

Inflammatory breast cancer differs (IBC) from other types of breast cancer in several key ways:

  • IBC doesn’t look like a typical breast cancer. It often does not cause a breast lump, and it might not show up on a mammogram. This makes it harder to diagnose.
  • IBC tends to occur in younger women (at an average age of 52 versus 57 for more common forms of breast cancer).
  • African-American women appear to be at higher risk of IBC than white women.
  • IBC is more common among women who are overweight or obese.
  • IBC also tends to be more aggressive—it grows and spreads much more quickly—than more common types of breast cancer.
  • IBC is always at a locally advanced stage when it’s first diagnosed because the breast cancer cells have grown into the skin. (This means it at least stage IIIB.)
  • In about 1 of every 3 cases, IBC has already spread (metastasized) to distant parts of the body when it is diagnosed. This makes it harder to treat successfully.

Signs and symptoms of inflammatory breast cancer?

Inflammatory breast cancer (IBC) causes a number of signs and symptoms, most of which develop quickly (withing 3-6 months), including:

  • Thickening (edema/swelling) of the skin of the breast
  • Redness involving more than one-third of the breast
  • Pitting or thickening of the skin of the breast so that it may look and feel like an orange peel
  • A retracted or inverted nipple
  • One breast looking larger than the other because of swelling
  • One breast feeling warmer and heavier than the other
  • A breast that may also be tender, painful or itchy

Tenderness, redness, warmth, and itching are also common symptoms of a breast infection or inflammation, such as mastitis if you’re pregnant or breastfeeding. Because these problems are much more common than IBC, your doctor might at first suspect infection as a cause and treat you with antibiotics.

This may be a good first step, but if your symptoms don’t get better in 7 to 10 days, more tests need to be done to look for cancer. The possibility of IBC should be considered more strongly if you have these symptoms and are not pregnant or breastfeeding, or have been through menopause.

IBC grows and spreads quickly, so the cancer may have already spread to nearby lymph nodes by the time symptoms are noticed. This spread can cause swollen lymph nodes under your arm or above your collar bone. If the diagnosis is delayed, the cancer can spread to lymph nodes in your chest or to distant sites.

If you have any of these symptoms, it does not mean that you have IBC, but you should see a doctor right away. If treatment with antibiotics is started, you’ll need to let your doctor know if it doesn’t help, especially if the symptoms get worse or the affected area gets larger. Ask to see a specialist (like a breast surgeon) or you might want to get a second opinion if you’re concerned.

Stages of inflammatory breast cancer

All Inflammatory breast cancers start as Stage IIIB since they involve the skin. If the cancer has spread to lymph nodes around the collarbone or inside the chest, it’s stage IIIC. Cancer that has spread outside the breast and nearby lymph nodes is stage IV.

Survival rates for inflammatory breast cancer

Inflammatory breast cancer (IBC) is considered an aggressive cancer because it grows quickly, is more likely to have spread at the time it’s found, and is more likely to come back after treatment than other types of breast cancer. The outlook is generally not as good as it is for other types of breast cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person’s case. Many other factors can affect a person’s outlook, such as age, general health, treatment received, and how well the cancer responds to treatment. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with your situation.

These survival rates are based on people diagnosed years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with inflammatory breast cancer.

These numbers are based on data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, for patients who were diagnosed with inflammatory breast cancer between 1990 and 2008.

Median survival is the length of time for half of the patients in a group to have died. By definition, half of the patients in that group are still alive. It is important to remember that the median is just a kind of average used by researchers. No one is “average” and many people have much better outcomes than the median. Also, people with inflammatory breast cancer can die of other things, and these numbers don’t take that into account.

  • The median survival rate for people with stage III inflammatory breast cancer is about 57 months.
  • The median survival rate for people with stage IV inflammatory breast cancer is about 21 months.

Paget disease of the nipple

Paget disease of the nipple starts in the breast ducts and spreads to the skin of the nipple and then to the areola(the dark circle around the nipple). It is rare, accounting for only about 1-3% of all cases of breast cancer.

Phyllodes tumor

Phyllodes tumors are rare breast tumors. They develop in the connective tissue (stroma) of the breast, in contrast to carcinomas, which develop in the ducts or lobules. Most are benign, but there are others that are malignant (cancer).

Angiosarcoma

Sarcomas of the breast are rare making up less than 1% of all breast cancers. Angiosarcoma starts in cells that line blood vessels or lymph vessels. It can involve the breast tissue or the skin of the breast. Some may be related to prior radiation therapy in that area.

Breast cancer in Men

Male breast cancer is a rare cancer that forms in the breast tissue of men. Though breast cancer is most commonly thought of as a woman’s disease, male breast cancer does occur.

Male breast cancer is most common in older men, though it can occur at any age.

Men diagnosed with male breast cancer at an early stage have a good chance for a cure. Still, many men delay seeing their doctors if they notice one of the usual signs or symptoms, such as a breast lump. For this reason, many male breast cancers are diagnosed when the disease is more advanced.

Symptoms

Signs and symptoms of male breast cancer can include:

  • A painless lump or thickening in your breast tissue
  • Changes to the skin covering your breast, such as dimpling, puckering, redness or scaling
  • Changes to your nipple, such as redness or scaling, or a nipple that begins to turn inward
  • Discharge from your nipple

Causes of breast cancer in men

It’s not clear what causes male breast cancer.

Doctors know that male breast cancer occurs when some breast cells divide more rapidly than healthy cells do. The accumulating cells form a tumor that may spread (metastasize) to nearby tissue, to the lymph nodes or to other parts of the body.

Where breast cancer begins in men

Everyone is born with a small amount of breast tissue. Breast tissue consists of milk-producing glands (lobules), ducts that carry milk to the nipples, and fat.

During puberty, women begin developing more breast tissue, and men do not. But because men are born with a small amount of breast tissue, they can develop breast cancer.

Types of breast cancer diagnosed in men include:

  • Cancer that begins in the milk ducts (ductal carcinoma). Nearly all male breast cancer is ductal carcinoma.
  • Cancer that begins in the milk-producing glands (lobular carcinoma). This type is rare in men because they have few lobules in their breast tissue.
  • Cancer that spreads to the nipple (Paget’s disease of the nipple). Rarely, male breast cancer forms in the milk ducts and spreads to the nipple, causing crusty, scaly skin around the nipple.

Inherited genes that increase breast cancer risk

Some men inherit abnormal (mutated) genes from their parents that increase the risk of breast cancer. Mutations in one of several genes, especially a gene called BRCA2, put you at greater risk of developing breast and prostate cancers.

These genes normally make proteins that keep cells from growing abnormally — which helps prevent cancer. But mutated genes aren’t as effective at protecting you from cancer.

Meeting with a genetic counselor and undergoing genetic testing can determine whether you carry gene mutations that increase your risk of breast cancer — and if you can pass this gene along to your children, both boys and girls. Discuss the benefits and risks of genetic testing with your doctor.

Risk factors breast cancer in men

Factors that increase the risk of male breast cancer include:

  • Older age. Your risk of male breast cancer increases as you age. The peak incidence of male breast cancer occurs between the ages of 68 and 71.
  • Exposure to estrogen. If you take estrogen-related drugs, such as those used as part of a sex-change procedure or for hormone therapy for prostate cancer, your risk of breast cancer is increased.
  • Family history of breast cancer. If you have a close family member with breast cancer, you have a greater chance of developing the disease.
  • Klinefelter’s syndrome. This genetic syndrome occurs when a boy is born with more than one copy of the X chromosome. Klinefelter’s syndrome causes abnormal development of the testicles. As a result, men with this syndrome produce lower levels of certain male hormones (androgens) and more female hormones (estrogens).
  • Liver disease. Certain conditions, such as cirrhosis of the liver, can reduce male hormones and increase female hormones, increasing your risk of breast cancer.
  • Obesity. Fat cells convert androgens into estrogen. A higher number of fat cells in your body may result in increased estrogen and higher risk of breast cancer.
  • Radiation exposure. If you’ve received radiation treatments to your chest, such as those used to treat cancers in the chest, you’re more likely to develop breast cancer later in life.
  • Testicle disease or surgery. Having inflamed testicles (orchitis) or surgery to remove a testicle (orchiectomy) can increase your risk of male breast cancer.

Diagnosing male breast cancer

Your doctor may conduct a number of diagnostic tests and procedures, such as:

  • Clinical breast exam. The doctor uses his or her fingertips to examine your breasts and surrounding areas for lumps or other changes. Your doctor assesses how large the lumps are, how they feel, and how close they are to your skin and muscles.
  • Imaging tests. Mammogram and ultrasound can detect suspicious masses in your breast tissue.
  • Biopsy. A fine needle is inserted into the breast to remove tissue for analysis in the laboratory. Test results can reveal whether you have breast cancer and if so, the type of breast cancer you have.

Determining the extent of the cancer

Determining the extent (stage) of your cancer helps your doctor evaluate treatment options. Biopsy, blood tests and imaging tests can be used to stage male breast cancer.

The stages of male breast cancer are:

  • Stage I. The tumor is no more than 2 centimeters (cm) in diameter (about 3/4 inch) and hasn’t spread to the lymph nodes.
  • Stage II. The tumor may be up to 5 cm (about 2 inches) in diameter and may have spread to nearby lymph nodes. Or the tumor may be larger than 5 cm but no cancer cells are found in the lymph nodes.
  • Stage III. The tumor may be larger than 5 cm (about 2 inches) in diameter and may involve several nearby lymph nodes. Lymph nodes above the collarbone may also contain cancer cells.
  • Stage IV. Cancer at this stage has spread beyond the breast to distant areas, such as the bone, brain, liver or lungs.

Signs and symptoms of breast cancer

Breast cancer typically produces no symptoms when the tumor is small and most easily treated, which is why screening is important for early detection 7). The most common physical sign is a painless lump. Sometimes breast cancer spreads to underarm lymph nodes and causes a lump or swelling, even before the original breast tumor is large enough to be felt. Less common signs and symptoms include breast pain or heaviness; persistent changes, such as swelling, thickening, or redness of the skin; and nipple abnormalities such as spontaneous discharge (especially if bloody), erosion, or retraction. Any persistent change in the breast should be evaluated by a doctor as soon as possible.

Knowing how your breasts normally look and feel is an important part of breast health. Finding breast cancer as early as possible gives you a better chance of successful treatment. But knowing what to look for does not take the place of having regular mammograms and other screening tests. Screening tests can help find breast cancer in its early stages, before any symptoms appear.

The most common symptom of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancer, but breast cancers can be tender, soft, or rounded. They can even be painful. For this reason, it is important to have any new breast mass, lump, or breast change checked by a health care professional experienced in diagnosing breast diseases.

Other possible symptoms of breast cancer include:

  • Swelling of all or part of a breast (even if no distinct lump is felt)
  • Skin irritation, redness, dimpling or pitting of the skin over your breast, like the skin of an orange
  • Breast or nipple pain
  • Nipple retraction (turning inward) or newly inverted nipple
  • Redness, scaliness, or thickening of the nipple or breast skin
  • Nipple discharge (other than breast milk)
  • Peeling, scaling, crusting or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin

Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast is large enough to be felt. Swollen lymph nodes should also be checked by a health care provider.

Although any of these symptoms can be caused by things other than breast cancer, if you have them, they should be reported to a health care professional so that the cause can be found.

Because mammograms do not find every breast cancer, it is important for you to be aware of changes in your breasts and to know the signs and symptoms of breast cancer.

Breast cancer screening for the Early Detection of Breast Cancer

Finding breast cancer early and getting state-of-the-art cancer treatment are the most important strategies to prevent deaths from breast cancer. Breast cancer that’s found early, when it’s small and has not spread, is easier to treat successfully. Getting regular screening tests is the most reliable way to find breast cancer early. The American Cancer Society has screening guidelines for women at average risk of breast cancer, and for those at high risk for breast cancer.

The goal of screening tests for breast cancer is to find it before it causes symptoms (like a lump that can be felt). Screening refers to tests and exams used to find a disease in people who don’t have any symptoms. Early detection means finding and diagnosing a disease earlier than if you’d waited for symptoms to start.

Breast cancers found during screening exams are more likely to be smaller and still confined to the breast. The size of a breast cancer and how far it has spread are some of the most important factors in predicting the prognosis (outlook) of a woman with this disease.

American Cancer Society screenings recommendations for women at average breast cancer risk

These guidelines are for women at average risk for breast cancer. For screening purposes, a woman is considered to be at average risk if she doesn’t have a personal history of breast cancer, a strong family history of breast cancer, or a genetic mutation known to increase risk of breast cancer (such as in a BRCA gene), and has not had chest radiation therapy before the age of 30. (See below for guidelines for women at high risk.)

  • Women between 40 and 44 have the option to start screening with a mammogram every year.
  • Women 45 to 54 should get mammograms every year.
  • Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
  • All women should understand what to expect when getting a mammogram for breast cancer screening – what the test can and cannot do.

Mammograms

Regular mammograms can help find breast cancer at an early stage, when treatment is most successful. A mammogram can find breast changes that could be cancer years before physical symptoms develop. Results from many decades of research clearly show that women who have regular mammograms are more likely to have breast cancer found early, are less likely to need aggressive treatment like surgery to remove the breast (mastectomy) and chemotherapy, and are more likely to be cured.

Mammograms are not perfect. They miss some cancers. And sometimes a woman will need more tests to find out if something found on a mammogram is or is not cancer. There’s also a small possibility of being diagnosed with a cancer that never would have caused any problems had it not been found during screening. It’s important that women getting mammograms know what to expect and understand the benefits and limitations of screening.

Clinical breast exam and breast self-exam

Research has not shown a clear benefit of regular physical breast exams done by either a health professional (clinical breast exams) or by yourself (breast self-exams). There is very little evidence that these tests help find breast cancer early when women also get screening mammograms. Most often when breast cancer is detected because of symptoms (such as a lump), a woman discovers the symptom during usual activities such as bathing or dressing. Women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.

American Cancer Society screening recommendations for women at high risk

Women who are at high risk for breast cancer based on certain factors should get an MRI and a mammogram every year, typically starting at age 30. This includes women who:

  • Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tools that are based mainly on family history (see below)
  • Have a known BRCA1 or BRCA2 gene mutation (based on having had genetic testing)
  • Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves
  • Had radiation therapy to the chest when they were between the ages of 10 and 30 years
  • Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%.

There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a higher lifetime risk based on certain factors , such as:

  • Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
  • Having “extremely” or “heterogeneously” dense breasts as seen on a mammogram

If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is more likely to detect cancer than a mammogram, it may still miss some cancers that a mammogram would detect.

Most women at high risk should begin screening with MRI and mammograms when they are 30 and continue for as long as they are in good health. But a woman at high risk should make the decision to start with her health care providers, taking into account her personal circumstances and preferences.

Tools used to assess breast cancer risk

Several risk assessment tools are available to help health professionals estimate a woman’s breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets.

Because the different tools use different factors to estimate risk, they may give different risk estimates for the same woman. Two models could easily give different estimates for the same person.

Risk assessment tools that include family history in first-degree relatives (parents, siblings, and children) and second-degree relatives (such as aunts and cousins) on both sides of the family should be used with the American Cancer Society guidelines to decide if a woman should have MRI screening. The use of any of the risk assessment tools and its results should be discussed by a woman with her health care provider.

Diagnosing breast cancer

Tests and procedures used to diagnose breast cancer include:

  • Breast exam. Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.
  • Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality.
  • Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst.
  • Removing a sample of breast cells for testing (biopsy). A biopsy is the only definitive way to make a diagnosis of breast cancer. During a biopsy, your doctor uses a specialized needle device guided by X-ray or another imaging test to extract a core of tissue from the suspicious area. Often, a small metal marker is left at the site within your breast so the area can be easily identified on future imaging tests.

Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options.

  • Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. Unlike other types of imaging tests, an MRI doesn’t use radiation to create the images.

Other tests and procedures may be used depending on your situation.

Finding Breast Cancer During Pregnancy

Breast cancer during pregnancy is rare. But if you find a lump or notice any changes in your breasts that concern you, tell your doctor or nurse right away. There are a variety of tests a pregnant woman can have if breast cancer is suspected. And there are options for treating breast cancer if you are pregnant.

If you are pregnant and breast cancer is found, it may be called gestational breast cancer or pregnancy-associated breast cancer (PABC).

How common is breast cancer during pregnancy?

  • Breast cancer is found in about 1 in every 3,000 pregnant women. But it is the most common type of cancer found during pregnancy.

Breast cancers can be harder to find when you’re pregnant

Hormone changes during pregnancy cause the breasts to change. They may become larger, lumpy, and/or tender. This can make it harder for you or your doctor to notice a lump caused by cancer until it gets quite large.

Another reason it may be hard to find breast cancers early during pregnancy is that many women put off breast cancer screening with mammograms until after the pregnancy. And because pregnancy and breastfeeding can make breast tissue denser, it can be harder to see an early cancer on a mammogram.

Because of these challenges, when a pregnant woman develops breast cancer, it’s often diagnosed at a later stage than it would be if she were not pregnant. It’s also more likely to have spread to lymph nodes.

What to look for

If you find a lump or notice any changes in your breasts that concern you, don’t ignore them. Tell your doctor or nurse right away. If your doctor doesn’t want to check it out with a mammogram, ask about other kinds of imaging tests such as ultrasound or magnetic resonance imaging (MRI). You may need to get a second opinion. Any suspicious breast changes should be checked out or even biopsied (see below) before assuming they are a normal response to pregnancy.

Are mammograms and other imaging tests safe during pregnancy?

A main concern with any imaging test during pregnancy is whether it exposes the developing fetus to radiation, which could be harmful.

Mammograms can find most breast cancers that start when a woman is pregnant, and it’s thought to be safe to have a mammogram during pregnancy. The amount of radiation needed for a mammogram is small. And the radiation is focused on the breasts, so that most of it doesn’t reach other parts of the body. For extra protection, a lead shield is placed over the lower part of the belly to help keep radiation from reaching the womb. Still, scientists can’t be certain about the

effects of even a very small dose of radiation on an unborn baby.

Ultrasound exams of the breast do not use radiation and are thought to be safe during pregnancy. This is typically an easy test to have, so it’s often the first test done to evaluate a change in the breast (such as a lump).

MRI scans do not use radiation and are thought to be safe during pregnancy. But the contrast material (dye) used in MRI can cross the placenta, the organ that connects the mother to the fetus. This dye has been linked with fetal abnormalities in lab animals. For this reason, many doctors do not recommend MRI with contrast dye during pregnancy. An MRI without contrast can be used if needed.

Other tests, such as PET scans, bone scans, and computed tomography (CT) scans are more likely to expose the fetus to radiation.

Breast biopsy during pregnancy

A new lump or abnormal imaging test result may cause concern, but a biopsy is the only way to find out if a breast change is cancer. During a biopsy a small piece of tissue is taken from the area of concern. Breast biopsies are most often done using a needle. They’re usually done as an outpatient procedure, even if you’re pregnant. The doctor uses medicine to numb just the area of the breast involved in the biopsy. This causes little risk to the fetus.

If a needle biopsy doesn’t give an answer, a surgical biopsy is typically the next step. This means taking out a piece of tissue through a small cut (incision) in the breast. Surgical biopsies are often done under general anesthesia (where drugs are used to put the patient into a deep sleep), which carries a small risk to the fetus.

Tests to stage the breast cancer

If breast cancer is found, you might need other tests to find out if cancer cells have spread within the breast or to other parts of the body. This process is called staging. Different staging tests may be needed, depending on your case.

As noted above, tests like ultrasound and MRI scans do not use radiation and are thought to be safe during pregnancy. But the contrast material (dye) sometimes used in MRI is typically not recommended during pregnancy. An MRI without contrast can be used if needed.

Chest x-rays are sometimes needed to help make treatment decisions. They use a small amount of radiation. They’re thought to be safe to have when you’re pregnant, as long as your belly is shielded.

Other tests, such as PET scans, bone scans, and computed tomography (CT) scans are more likely to expose the fetus to radiation. These tests are not often needed, especially if the cancer is thought to be just in the breast. If one of these tests is needed, doctors might be able to make adjustments to limit the amount of radiation exposure to the fetus.

Treatments are available if a pregnant woman has breast cancer. Learn about treating breast cancer during pregnancy.

Can breast cancer spread to the baby?

There are no reported cases of breast cancer spreading from the mother to the fetus. But in a very few cases, the cancer has reached the placenta (the organ that connects the mother to the fetus). This could affect the amount of nutrition the fetus gets from the mother.

Staging breast cancer

Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Your cancer’s stage helps determine your prognosis and the best treatment options.

Complete information about your cancer’s stage may not be available until after you undergo breast cancer surgery.

Tests and procedures used to stage breast cancer may include:

  • Blood tests, such as a complete blood count
  • Mammogram of the other breast to look for signs of cancer
  • Breast MRI
  • Bone scan
  • Computerized tomography (CT) scan
  • Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances and taking into account new symptoms you may be experiencing.

Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Breast cancer staging also takes into account your cancer’s grade; the presence of tumor markers, such as receptors for estrogen, progesterone and HER2; and proliferation factors.

Breast cancer stages

Staging is a way of describing where the cancer is located, how much the cancer has grown, and if or where it has spread. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

The most commonly used tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?
  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?
  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person.

There are 5 stages: stage 0 (zero), which is noninvasive ductal carcinoma in situ (DCIS), and stages I through IV (1 through 4), which are used for invasive breast cancer. The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

There are 2 types of TNM staging for breast cancer.

  1. First, the clinical stage is based on the results of tests done before surgery, which may include physical examination, mammogram, ultrasound, and MRI scans.
  2. Then, the pathologic stage is assigned based on the pathology results from the breast tissue and any lymph nodes removed during surgery. It is usually determined several days after surgery. In general, more importance is placed on the pathologic stage than the clinical stage.

Here are more details on each part of the TNM system for breast cancer:

Tumor (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of cancer in the breast.

Tis: Refers to carcinoma in situ. The cancer is confined within the ducts or lobules of the breast tissue and has not spread into the surrounding tissue of the breast. There are types of breast carcinoma in situ:

Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it can develop into an invasive breast cancer later. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.

Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.

Tis(Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is associated with another, invasive breast cancer. If there is also an invasive breast cancer present, it is classified according to the stage of the invasive tumor.

T1: The invasive part of the tumor in the breast is 20 millimeters (mm) or smaller in size at its widest area. This is a little less than an inch. This stage is then broken into 3 substages depending on the size of the tumor:

T1a is a tumor that is larger than 1 mm, but 5 mm or smaller.

T1b is a tumor that is larger than 5 mm, but 10 mm or smaller.

T1c is a tumor that is larger than 10 mm, but 20 mm or smaller.

T2: The invasive part of the tumor is larger than 20 mm but not larger than 50 mm.

T3: The invasive part of the tumor is larger than 50 mm.

T4: The tumor falls into 1 of the following groups:

T4a means the tumor has grown into the chest wall.

T4b is when the tumor has grown into the skin.

T4c is cancer that has grown into the chest wall and the skin.

T4d is inflammatory breast cancer.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. As explained above, if the doctor evaluates the lymph nodes before surgery, based on other tests and/or a physical examination, a letter “c” for “clinical” staging is placed in front of the “N.” If the doctor evaluates the lymph nodes after surgery, which is a more accurate assessment, a letter “p” for “pathologic” staging is placed in front of the “N.” The information below describes the pathologic staging.

NX: The lymph nodes cannot be evaluated.

N0: No cancer was found in the lymph nodes.

N0(i+): When very small areas of “isolated” tumor cells are found in a lymph node under the arm, called the axillary lymph nodes. This is usually less than 0.2 mm or less than 200 cells. In this stage, the nodes are still called N0, but an “i+” is also listed.

N1mic: Cancer in the axillary lymph nodes is larger than 0.2 mm but less than 2 mm in size and can only be seen through a microscope. This is often called a micrometastasis.

N1: The cancer has spread to 1 to 3 axillary lymph nodes under the arm, and is at least 2 mm in size. This is called a macrometastasis. This category can include positive internal mammary lymph nodes if they are found during a sentinel lymph node procedure and not through other tests. The internal mammary lymph nodes are located under the sternum or breastbone.

N2: The cancer within the lymph nodes falls into 1 of the following groups:

N2a is when the cancer has spread to 4 to 9 axillary, or underarm, lymph nodes.

N2b is when the cancer has spread to or to internal mammary lymph nodes without spread to the axillary nodes.

N3: The cancer falls within 1 of the following groups:

N3a is when the cancer has spread to 10 or more lymph nodes under the arm or to those located under the clavicle, or collarbone.

N3b is when the cancer has spread to the internal mammary nodes and the axillary nodes. N3c is when the cancer has spread to the lymph nodes located above the clavicle, called the supraclavicular lymph nodes.

If there is cancer in the lymph nodes, knowing how many lymph nodes are involved and where they are helps doctors to plan treatment. The pathologist can find out the number of axillary lymph nodes that contain cancer after they are removed during surgery. It is not common to remove the supraclavicular or internal mammary lymph nodes during surgery. If there is cancer in these lymph nodes, treatment other than surgery, such as radiation therapy, chemotherapy, and hormonal therapy is used.

Metastasis (M)

The “M” in the TNM system indicates whether the cancer has spread to other parts of the body. Evidence of metastatic cancer means this is no longer considered early-stage or locally advanced cancer.

MX: Distant spread cannot be evaluated.

M0: The disease has not metastasized.

M0 (i+): There is no clinical or radiographic evidence of distant metastases. Microscopic evidence of tumor cells is found in the blood, bone marrow, or other lymph nodes that are no larger than 0.2 mm.

M1: There is evidence of metastasis to another part of the body, meaning there are breast cancer cells growing in other organs.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications. Most patients are anxious to learn the exact stage of the cancer. However, it is important to keep in mind that tumor biology, including the diagnostic markers outlined above, has a significant impact on the recommended treatment plan, as well as on the prognosis. Your doctor will generally confirm the stage of the cancer when the testing after surgery is finalized, usually about 5 to 7 days after surgery. When systemic or whole body treatment is given before surgery, called neoadjuvant therapy, the stage of the cancer is primarily determined clinically. Doctors may refer to stage I to stage IIA cancer as early stage, and stage IIB to stage III as locally advanced.

Stage O (Stage Zero)

Stage 0: Stage zero (0) describes disease that is only in the ducts and lobules of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called noninvasive cancer (Tis, N0, M0).

Figure 3. Breast cancer stage O

breast cancer_stage 0

Stage 1A

Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).

breast cancer_stage 1AStage 1B

Stage IB: Cancer has spread only to the lymph nodes, and is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller (T0 or T1, N1mic, M0).

breast cancer_stage 1Bbreast cancer_stage 1B group 2Stage IIA

Stage IIA: Any 1 of these conditions:

  • There is no evidence of a tumor in the breast, but the cancer has spread to the axillary lymph nodes but not to distant parts of the body. (T0, N1, M0).
  • The tumor is 20 mm or smaller and has spread to the axillary lymph nodes (T1, N1, M0).
  • The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the axillary lymph nodes (T2, N0, M0).
breast cancer_stage 2Abreast cancer_stage 2A group 2
breast cancer_stage 2A group 3

Stage IIB

Stage IIB: Either of these conditions:

  • The tumor is larger than 20 mm but not larger than 50 mm and has spread to 1 to 3 axillary lymph nodes (T2, N1, M0).
  • The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0, M0).
breast cancer_stage 2 Bbreast cancer_stage 2 B group 2

Stage IIIA

Stage IIIA: The cancer of any size has spread to 4 to 9 axillary lymph nodes, but not to other parts of the body (T0, T1, T2 or T3, N2, M0). Stage IIIA may also be a tumor larger than 50 mm that has spread to 1 to 3 lymph nodes (T3, N1, M0).

breast cancer_stage 3Abreast cancer_stage 3A group 2breast cancer_stage 3A group 3breast cancer_stage 3A group 4breast cancer_stage 3A group 5

Stage 3B

Stage IIIB: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but it has not spread to other parts of the body (T4; N0, N1 or N2; M0).

breast cancer_stage 3Bbreast cancer_stage 3B group 2breast cancer_stage 3B group 3Stage 3C

Stage IIIC: A tumor of any size that has not spread to distant parts of the body but has spread to 10 or more axillary lymph nodes or the lymph nodes in the N3 group (any T, N3, M0).

breast cancer_stage 3CStage 4 Metastatic breast cancer

Stage IV (metastatic): The tumor can be any size and has spread to other organs, such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1). Metastatic cancer spread found when the cancer is first diagnosed occurs about 5% to 6% of the time. This may be called de novo metastatic breast cancer. Most commonly, metastatic breast cancer is found after a previous diagnosis of early breast cancer.

breast cancer_stage 4

Recurrent breast cancer

Recurrent: Recurrent cancer is cancer that has come back after treatment, and can be described as local, regional, and/or distant. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Breast cancer treatment

Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones. Your doctor also considers your overall health and your own preferences.

Most women undergo surgery for breast cancer and also receive additional treatment before or after surgery, such as chemotherapy, hormone therapy or radiation.

There are many options for breast cancer treatment, and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision.

Breast cancer surgery

Operations used to treat breast cancer include:

Removing the breast cancer (lumpectomy). During a lumpectomy, which may be referred to as breast-conserving surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue.

A lumpectomy may be recommended for removing smaller tumors. Some people with larger tumors may undergo chemotherapy before surgery to shrink a tumor and make it possible to remove completely with a lumpectomy procedure.

Removing the entire breast (mastectomy). A mastectomy is an operation to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (total or simple mastectomy).

Newer surgical techniques may be an option in selected cases in order to improve the appearance of the breast. Skin-sparing mastectomy and nipple-sparing mastectomy are increasingly common operations for breast cancer.

Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that are the first to receive the lymph drainage from your tumor.

If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.

Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel lymph nodes, your surgeon will discuss with you the role of removing additional lymph nodes in your armpit.

Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast because of a genetic predisposition or strong family history.

Most women with breast cancer in one breast will never develop cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure.

Complications of breast cancer surgery depend on the procedures you choose. Breast cancer surgery carries a risk of pain, bleeding, infection and arm swelling (lymphedema).

You may choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon.

Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a breast implant (silicone or water) or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

Radiation therapy

Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).

External beam radiation of the whole breast is commonly used after a lumpectomy. Breast brachytherapy may be an option after a lumpectomy if you have a low risk of cancer recurrence.

Doctors may also recommend radiation therapy to the chest wall after a mastectomy for larger breast cancers or cancers that have spread to the lymph nodes.

Breast cancer radiation can last from three days to six weeks, depending on the treatment. A doctor who uses radiation to treat cancer (radiation oncologist) determines which treatment is best for you based on your situation, your cancer type and the location of your tumor.

Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as damage to the heart or lungs or, very rarely, second cancers in the treated area.

Chemotherapy

Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells. If your cancer has a high risk of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur.

Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery.

Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing an infection. Rare side effects can include premature menopause, infertility (if premenopausal), damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.

Hormone therapy

Hormone therapy — perhaps more properly termed hormone-blocking therapy — is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.

Hormone therapy can be used before or after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Treatments that can be used in hormone therapy include:

  • Medications that block hormones from attaching to cancer cells (selective estrogen receptor modulators)
  • Medications that stop the body from making estrogen after menopause (aromatase inhibitors)
  • Surgery or medications to stop hormone production in the ovaries

Hormone therapy side effects depend on your specific treatment, but may include hot flashes, night sweats and vaginal dryness. More serious side effects include a risk of bone thinning and blood clots.

Targeted therapy drugs

Targeted drug treatments attack specific abnormalities within cancer cells. As an example, several targeted therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal growth factor receptor 2 (HER2). The protein helps breast cancer cells grow and survive. By targeting cells that make too much HER2, the drugs can damage cancer cells while sparing healthy cells.

Targeted therapy drugs that focus on other abnormalities within cancer cells are available. And targeted therapy is an active area of cancer research.

Your cancer cells may be tested to see whether you might benefit from targeted therapy drugs. Some medications are used after surgery to reduce the risk that the cancer will return. Others are used in cases of advanced breast cancer to slow the growth of the tumor.

Treatment of Ductal Carcinoma in Situ (DCIS)

Ductal carcinoma in situ (DCIS) means the cells that line the milk ducts of the breast have become cancer , but they have not spread into surrounding breast tissue.

DCIS is considered non-invasive or pre-invasive breast cancer. DCIS can’t spread outside the breast, but it still needs to be treated because it can sometimes go on to become invasive breast cancer (which can spread).

In most cases, a woman with DCIS can choose between breast-conserving surgery (BCS) and simple mastectomy. But sometimes a mastectomy might be a better option.

Breast-conserving surgery (BCS)

In breast-conserving surgery (BCS), the surgeon removes the tumor and a small amount of normal breast tissue around it. Lymph node removal is not always needed with breast-conserving surgery (BCS), but it may be done if the doctor thinks the area of DCIS might also contain invasive cancer. The chances an area of DCIS contains invasive cancer goes up with tumor size and how fast the cancer is growing. . If lymph nodes are removed, this is usually done as a sentinel lymph node biopsy.

If breast-conserving surgery (BCS) is done, it is usually followed by radiation therapy. This lowers the chance of the cancer coming back in the same breast (either as more DCIS or as an invasive cancer). BCS without radiation therapy is not a standard treatment, but it might be an option for certain women who had small areas of low-grade DCIS that were removed with large enough cancer-free surgical margins.
Mastectomy

Simple mastectomy (removal of the entire breast) may be needed if the area of DCIS is very large, if the breast has several areas of DCIS, or if breast-conserving surgery (BCS) cannot remove the DCIS completely (that is, the BCS specimen and re-excision specimens still have cancer cells in or near the surgical margins). Many doctors will do a sentinel lymph node biopsy along with the mastectomy. This is because if an area of invasive cancer is found in the tissue removed during a mastectomy, the doctor won’t be able to go back and do the sentinel lymph node biopsy later, and so may have to do a full axillary lymph node dissection.

Women having a mastectomy for DCIS may choose to have breast reconstruction immediately or later.

Hormone therapy after surgery

If the DCIS is hormone receptor-positive (ER-positive or PR-positive), adjuvant treatment with tamoxifen (for any woman) or an aromatase inhibitor (for women past menopause) for 5 years after surgery can lower the risk of another DCIS or invasive cancer developing in either breast. If you have hormone receptor-positive DCIS, discuss the pros and cons of hormone therapy with your doctors.

Treatment of Lobular Carcinoma in Situ (LCIS)

Lobular carcinoma in situ (LCIS) means abnormal cells are in the lobules of the breast. LCIS is sometimes grouped with ductal carcinoma in situ (DCIS) as a type of non-invasive breast cancer, but LCIS is different from DCIS and is not cancer. It is a benign (noncancerous) condition that puts you at risk to develop invasive cancer.

Does LCIS need to be treated?

Having LCIS does increase your risk of developing invasive breast cancer later on. But since LCIS is not a true cancer or pre-cancer, often no treatment is recommended. Sometimes if a needle biopsy result shows LCIS , the doctor might recommend that it be removed completely (with an excisional biopsy or some other type of breast-conserving surgery) to help make sure that LCIS was the only thing there. This is especially true if the LCIS is described as pleomorphic or if it has necrosis (areas of dead cells), in which case it might be more likely to grow quickly.

With LCIS, close follow-up is very important. This usually includes a yearly mammogram and a breast exam. Close follow-up of both breasts is important because women with LCIS in one breast have the same increased risk of developing cancer in both breasts. There isn’t enough evidence to recommend getting routine magnetic resonance imaging (MRI) in addition to mammograms for all women with LCIS, but it’s reasonable for women with LCIS to talk with their doctors about their other risk factors and the benefits and limits of being screened yearly with MRI.

Most of the time, LCIS is only a risk factor for developing breast cancer, except in a certain kind of LCIS, called pleomorphic LCIS. This type may be more likely to turn into invasive cancer than most types of LCIS. Some doctors feel that this kind of LCIS needs to be removed completely with surgery.

Newer evidence is suggesting LCIS may be more of a pre-cancer than we thought. More research is being done.

Can you lower your risk of invasive breast cancer?

If you have LCIS, you may want to consider taking a hormone medicine such as tamoxifen, raloxifene, or aromatase inhibitors to help reduce your risk of breast cancer. You might also want to consider taking part in a clinical trial for breast cancer prevention, or discussing other possible prevention strategies (such as getting to a healthy weight or starting an exercise program) with your doctor.

Because LCIS is linked to an increased risk of cancer in both breasts, some women with LCIS choose to have a bilateral simple mastectomy (removal of both breasts but not nearby lymph nodes) to lower this risk. This is more likely to be a reasonable option in women who also have other risk factors for breast cancer, such as a BRCA gene mutation or a strong family history. This may be followed by delayed breast reconstruction.

Treatment of Breast Cancer Stages I-III

The stage (extent) of your breast cancer is an important factor in making decisions about your treatment.

Most women with breast cancer in stages I, II, or III are treated with surgery, often followed by radiation therapy. Many women also get some kind of drug therapy. In general, the more the breast cancer has spread, the more treatment you will likely need. But your treatment options are affected by your personal preferences and other information about your breast cancer, such as:

  • If the cancer cells contain hormone receptors (that is, if the cancer is ER-positive or PR-positive)
  • If the cancer cells have large amounts of the HER2 protein (that is, if the cancer is HER2-positive)
  • How fast the cancer is growing (measure by grade or Ki-67)
  • Your overall health
  • If you have gone through menopause or not

Talk with your doctor about how these factors can affect your treatment options.

What type of drug treatment(s) might I get?

Most women with breast cancer in stages I to III will get some kind of drug therapy as part of their treatment. This may include:

  • Chemotherapy
  • Hormone therapy (tamoxifen, an aromatase inhibitor, or one followed by the other)
  • HER2 targeted drugs, such as trastuzumab (Herceptin) and pertuzumab (Perjeta)
  • Some combination of these

The types of drugs that might work best depend on the tumor’s hormone receptor status, HER2 status, and other factors.

Treating stage I breast cancer

These breast cancers are still relatively small and either have not spread to the lymph nodes or have spread to only a tiny area in the sentinel lymph node (the first lymph node to which cancer is likely to spread).

Surgery

Surgery is the main treatment for stage I breast cancer. These cancers can be treated with either breast-conserving surgery (BCS; sometimes called lumpectomy or partial mastectomy) or mastectomy. The nearby lymph nodes will also need to be checked, either with a sentinel lymph node biopsy (SLNB) or an axillary lymph node dissection (ALND).

In some cases, breast reconstruction can be done at the same time as the surgery to remove the cancer. But if you will need radiation therapy after surgery, it is better to wait to get reconstruction until after the radiation is complete.

Radiation therapy

If BCS is done, radiation therapy is usually given after surgery to lower the chance of the cancer coming back in the breast. Women who are at least 70 years old may consider BCS without radiation therapy if ALL of the following are true:

  • The tumor was 2 cm (a little less than 1 inch) or less across and it has been removed completely.
  • None of the lymph nodes removed contained cancer.
  • The cancer is ER-positive or PR-positive, and hormone therapy is given.

Radiation after BCS still lowers the chance of the cancer coming back in women who meet these criteria, but it has not been shown to help them live longer.

Some women who do not meet these criteria may be tempted to avoid radiation, but studies have shown that not getting radiation increases the chances of the cancer coming back and can shorten their lives.

If mastectomy is done, radiation therapy is less likely to be needed, but it might be given depending on the details of your specific cancer. You should discuss if you need radiation treatment with your doctor. They may send you to a doctor who specializes in radiation, called a radiation oncologist, for evaluation.

Adjuvant systemic therapy (chemo and other drugs)

For women who have a hormone receptor-positive (ER-positive or PR-positive) breast cancer, most doctors will recommend hormone therapy (tamoxifen or an aromatase inhibitor, or one followed by the other) as an adjuvant (additional) treatment, no matter how small the tumor is. Women with tumors larger than 0.5 cm (about ¼ inch) across may be more likely to benefit from it. Hormone therapy is typically given for at least 5 years.

If the tumor is larger than 1 cm (about ½ inch) across, adjuvant chemotherapy (chemo) is sometimes recommended. Some doctors may suggest chemo for smaller tumors as well, especially if they have any unfavorable features (a cancer that is growing fast; hormone receptor-negative, HER2-positive; or having a high score on a gene panel such as Oncotype Dx).

For HER2-positive cancers, a year of adjuvant trastuzumab (Herceptin) is usually recommended as well.

Treating stage II breast cancer

These breast cancers are larger than stage I cancers and/or have spread to a few nearby lymph nodes.

Local therapy (surgery and radiation therapy)

Stage II cancers are treated with either breast-conserving surgery (BCS; sometimes called lumpectomy or partial mastectomy) or mastectomy. The nearby lymph nodes will also need to be checked, either with a sentinel lymph node biopsy (SLNB) or an axillary lymph node dissection (ALND).

Women who have BCS are treated with radiation therapy after surgery. Women who have a mastectomy are typically treated with radiation if the cancer is found in the lymph nodes. Some patients who have a SLNB that shows cancer in a few lymph nodes may not have the rest of their lymph nodes removed (ALND) to check for more cancer. In these patients, radiation may be discussed as a treatment option after mastectomy.

If you were initially diagnosed with stage II breast cancer and were given treatment such as chemotherapy or hormone therapy before surgery, radiation therapy might be recommended if cancer is found in the lymph nodes at the time of the mastectomy. A doctor who specializes in radiation, called a radiation oncologist, may review your case to discuss whether radiation would be helpful to you.

If chemotherapy is also needed after surgery, the radiation is delayed until the chemo is done.

In some cases, breast reconstruction can be done during the surgery to remove the cancer. But if you will need radiation after surgery, it is better to wait to get reconstruction until after the radiation is complete.

Neoadjuvant and adjuvant systemic therapy (chemo and other drugs)

Systemic therapy is recommended for women with stage II breast cancer. Some systemic therapies are given before surgery (neoadjuvant therapy), and others are given after surgery (adjuvant therapy). Neoadjuvant treatments are often a good option for women with large tumors, because they can shrink the tumor before surgery, possibly enough to make BCS an option. But this doesn’t improve survival more than getting these treatments after surgery. In some cases, systemic therapy will be started before surgery and then continued after surgery.

The drugs used will depend on the woman’s age and the tumor’s hormone-receptor status and HER2 status. They may include:

  • Chemotherapy: Chemo can be given before or after surgery.
  • HER2 targeted drugs: If the cancer is HER2-positive, HER2 targeted drugs are started along with chemo. Both trastuzumab (Herceptin) and pertuzumab (Perjeta) may be used as a part of neoadjuvant treatment. Then trastuzumab is continued after surgery for a total of one year of treatment.
  • Hormone therapy: If the cancer is hormone receptor-positive, hormone therapy (tamoxifen, an aromatase inhibitor, or one followed by the other) is typically used. It can be started before surgery, but because it continues for at least 5 years, it needs to be given after surgery as well.

Treating stage III breast cancer

In stage III breast cancer, the tumor is large (more than 5 cm or about 2 inches across) or growing into nearby tissues (the skin over the breast or the muscle underneath), or the cancer has spread to many nearby lymph nodes.

If you have inflammatory breast cancer: Stage III cancers also include some inflammatory breast cancers that have not spread beyond nearby lymph nodes. Treatment of these cancers can be slightly different from the treatment of other stage III breast cancers. You can find more details in our section about treatment for inflammatory breast cancer.

There are two main approaches to treating stage III breast cancer:

Starting with neoadjuvant therapy

Most often, these cancers are treated with neoadjuvant chemotherapy (before surgery). For HER2-positive tumors, the targeted drug trastuzumab (Herceptin) is given as well, sometimes along with pertuzumab (Perjeta). This may shrink the tumor enough to allow a woman to have breast-conserving surgery (BCS). If the tumor doesn’t shrink enough, a mastectomy is done. Nearby lymph nodes will also need to be checked. A sentinel lymph node biopsy (SLNB) is often not an option for stage III cancers, so an axillary lymph node dissection (ALND) is usually done.

Often, radiation therapy is needed after surgery. If breast reconstruction is done, it is usually delayed until after radiation is complete. In some cases, additional (adjuvant) chemo is given after surgery as well. Women with HER2-positive cancers receive trastuzumab after surgery to complete a year of treatment with this drug. Women with hormone receptor-positive (ER-positive or PR-positive) breast cancers will also get adjuvant hormone therapy which can typically be taken at the same time as trastuzumab..

Starting with surgery

Another option for stage III cancers is treatment with surgery first. Because these tumors are fairly large and/or have grown into nearby tissues, this usually means getting a mastectomy. For women with fairly large breasts, BCS may be an option if the cancer hasn’t grown into nearby tissues. SLNB may be an option for some patients, but most will need an ALND. Surgery is usually followed by adjuvant chemotherapy, and/or hormone therapy, and/or trastuzumab. Radiation is recommended after surgery.

Online tools to help make decisions

To help decide if adjuvant therapy is right for you, you might want to visit the Mayo Clinic website at www.mayoclinic.com and type “adjuvant therapy for breast cancer” into the search box. You will find a page that will help you to understand the possible benefits and limits of adjuvant therapy.

Other online guides, such as www.adjuvantonline.com, are designed to be used by health care professionals. This website provides information about your risk of the cancer returning within the next 10 years and what benefits you might expect from hormone therapy and/or chemotherapy.

Treatment of Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is an uncommon type of invasive breast cancer that typically makes the skin on the breast look red and feel warm. It also may give the breast skin a thick, pitted appearance that looks a lot like an orange peel. These changes are caused by cancer cells blocking lymph vessels in the skin.

Because inflammatory breast cancer has reached these vessels and has caused changes in the skin, it is considered to be at least a stage III breast cancer. IBC that has spread to other parts of the body is considered stage IV. These cancers typically grow quickly and can be challenging to treat.

Treating stage III inflammatory breast cancer

IBC that has not spread outside the breast or nearby lymph nodes is stage IIIB or IIIC. Treatment usually starts with chemotherapy (chemo) to try to shrink the tumor. If the cancer is HER2-positive, targeted therapy is given along with the chemo. This is typically followed by surgery (mastectomy) to remove the cancer. Radiation therapy often follows surgery. In some cases, more chemo may be given after surgery but before radiation. If the cancer is hormone receptor-positive (ER- or PR-positive), hormone therapy is given as well. Combining these treatments has improved survival significantly over the years.

Chemotherapy (possibly along with targeted therapy)

Chemo drugs enter the bloodstream and circulate throughout the body to reach and destroy cancer cells wherever they are, so chemo is considered a type of systemic therapy. It treats both the main tumor as well as any cancer cells that have broken off and spread to lymph nodes or other parts of the body.

Using chemo before surgery is called neoadjuvant or preoperative treatment. Most women with IBC will receive two types of chemo drugs (although not necessarily at the same time):

  • An anthracycline, such as doxorubicin (Adriamycin) or epirubicin (Ellence)
  • A taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere)

Other chemo drugs may be used as well.

If the cancer is HER2-positive (the cancer cells make too much of a protein called HER2), the targeted therapy drug trastuzumab (Herceptin) is usually given, sometimes along with another targeted drug, pertuzumab (Perjeta). These drugs can lead to heart problems when given with an anthracycline, so one option is to give the anthracycline first (without trastuzumab or pertuzumab), followed by treatment with a taxane and trastuzumab (with or without pertuzumab).

Surgery and further treatments

If the cancer improves with chemo, surgery is typically the next step. The standard operation is a modified radical mastectomy, where the entire breast and the lymph nodes under the arm are removed. Because IBC affects so much of the breast and skin, breast-conserving surgery (partial mastectomy or lumpectomy) and skin-sparing mastectomy are not options. It isn’t clear that sentinel lymph node biopsy (where only one or a few nodes are removed) is reliable in IBC, so it is also not an option.

If the cancer does not respond to chemo (and the breast is still very swollen and red), surgery cannot be done. Either other chemo drugs will be tried, or the breast may be treated with radiation. Then if the cancer responds (the breast shrinks and is no longer red), surgery may be an option.

If breast radiation isn’t given before surgery, it is given after surgery, even if no cancer is thought to remain. This is called adjuvant radiation. It lowers the chance that the cancer will come back. Radiation is usually given 5 days a week for 6 weeks, but in some cases a more intense treatment (twice a day) can be used instead. Depending on how much tumor was found in the breast after surgery, radiation might be delayed until further chemo is given. If breast reconstruction is to be done, it is usually delayed until after the radiation therapy that most often follows surgery.

Treatment after surgery and radiation often includes additional systemic treatment. This is known as adjuvant therapy and can include chemo, hormone therapy (tamoxifen or an aromatase inhibitor) if the cancer cells contain hormone receptors, and/or trastuzumab if the cancer is HER2-positive.

Treating stage IV inflammatory breast cancer

Patients with metastatic (stage IV) IBC are treated with systemic therapy. This may include:

  • Chemotherapy
  • Hormonal therapy (if the cancer is hormone receptor-positive)
  • Targeted therapy with a drug that targets HER2 (if the cancer is HER2-positive)

One or more of these treatments might be used. Surgery and radiation may also be options in certain situations. For more on the treatment of stage IV cancers, see our page about treating stage IV breast cancer.

Regardless of the stage of the cancer, participation in a clinical trial of new treatments for IBC is also a good option because IBC is rare, and these studies often allow access to drugs not available for standard treatment. More information about clinical trials can be found in our clinical trials section.

Treatment of Stage IV (Metastatic) Breast Cancer

Most women with stage IV breast cancer are treated with systemic therapy. This may include hormone therapy, chemotherapy, targeted therapy, or some combination of these. Local treatments such as surgery or radiation might also be used to help prevent or treat symptoms.

Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. When breast cancer spreads, it most commonly goes to the bones, liver, and lungs. It may also spread to the brain or other organs.

Treatment options for stage IV breast cancer

For women with stage IV breast cancer, systemic (drug) therapies are the main treatments. These may include:

  • Hormone therapy
  • Chemotherapy (chemo)
  • Targeted drugs, such as trastuzumab (Herceptin) and pertuzumab (Perjeta)
  • Some combination of these

Surgery and/or radiation therapy may be useful in certain situations (see below).

Treatment can often shrink tumors (or slow their growth), improve symptoms, and help women live longer. These cancers are considered incurable.

Systemic (drug) treatments for stage IV breast cancer

The types of drugs used for stage IV breast cancer depend on the hormone receptor status and the HER2 status of the cancer:

  • Hormone receptor-positive cancers: Women with hormone receptor-positive (ER-positive or PR-positive) cancers are often treated first with hormone therapy (tamoxifen or an aromatase inhibitor). This may be combined with a targeted drug such as palbociclib (Ibrance), ribociclib (Kisqali), or everolimus (Afinitor). Women who haven’t yet gone through menopause are often treated first with tamoxifen. Because hormone therapy can take months to work, chemo is often the first treatment for patients with serious problems from their cancer spread, such as breathing problems.
  • Hormone receptor-negative cancers: Chemo is the main treatment for women with hormone receptor-negative (ER-negative and PR-negative) cancers, because hormone therapy isn’t helpful for these cancers.
  • HER2-positive cancers: Trastuzumab (Herceptin) may help women with HER2-positive cancers live longer if it’s given along with chemo or with other medications such as hormonal therapy or other anti-HER2 drugs. Pertuzumab (Perjeta), another targeted drug, might be added as well. Another option is the targeted drug ado-trastuzumab emtansine (Kadcyla), which is given alone or with lapatinib.

Treatment often continues until the cancer starts growing again or until side effects become unacceptable. If this happens, other drugs might be tried.

Local or regional treatments for stage IV breast cancer

Although systemic drugs are the main treatment for stage IV breast cancer, local and regional treatments such as surgery, radiation therapy, or regional chemotherapy are sometimes used as well. These can help treat breast cancer in a specific part of the body, but they are very unlikely to get rid of all of the cancer. These treatments are more likely to be used to help prevent or treat symptoms or complications from the cancer.

Radiation therapy and/or surgery may also be used in certain situations, such as:

  • When the breast tumor is causing an open wound in the breast (or chest)
  • To treat a small number of metastases in a certain area, such as the brain
  • To help prevent bone fractures
  • When an area of cancer spread is pressing on the spinal cord
  • To treat a blood vessel blockage in the liver
  • To provide relief of pain or other symptoms

In some cases, regional chemo (where drugs are delivered directly into a certain area, such as into the fluid around the brain and spinal cord) may be useful as well.

If your doctor recommends such local or regional treatments, it is important that you understand their goal—whether it is to try to cure the cancer or to prevent or treat symptoms.

Relieving symptoms of advanced breast cancer

Treatment to relieve symptoms depends on where the cancer has spread. For example, pain from bone metastases may be treated with radiation therapy, drugs called bisphosphonates such as pamidronate (Aredia) or zoledronic acid (Zometa), or the drug denosumab (Xgeva). For more, see our information about the treatment of bone metastases.

Advanced cancer that progresses during treatment

Treatment for advanced breast cancer can often shrink the cancer or slow its growth (sometimes for many years), but after a time, it tends to stop working. Further treatment options at this point depend on several factors, including previous treatments, where the cancer is located, and a woman’s age, general health, and desire to continue getting treatment.

Progression while on hormone therapy

For hormone receptor-positive (ER-positive or PR-positive) cancers that were being treated with hormone therapy, switching to another type of hormone therapy sometimes helps. For example, if either letrozole (Femara) or anastrozole (Arimidex) were given, using exemestane, possibly with everolimus (Afinitor), may be an option. Another option might be using fulvestrant (Faslodex), along with a CDK inhibitor such as palbociclib (Ibrance) or abemaciclib (Verzenio). If the cancer is no longer responding to any hormone drugs, chemotherapy is usually the next step.

Progression while on chemotherapy

If the cancer is no longer responding to one chemo regimen, trying another may be helpful. Many different drugs and combinations can be used to treat breast cancer. However, each time a cancer progresses during treatment, it becomes less likely that further treatment will have an effect.

Progression while getting HER2 drugs

HER2-positive cancers that no longer respond to trastuzumab (Herceptin) might respond to lapatinib (Tykerb), another drug that attacks the HER2 protein. This drug is often given along with the chemo drug capecitabine (Xeloda), but it can be used with other chemo drugs, with trastuzumab, or even alone (without chemo). Other options for women with HER2-positive cancers include pertuzumab (Perjeta) with chemo and trastuzumab, or ado-trastuzumab emtansine (Kadcyla).

Because current treatments are very unlikely to cure metastatic breast cancer, if you are in otherwise good health, you may want to think about taking part in a clinical trial testing a newer treatment.

Treatment of Recurrent Breast Cancer

For some women, breast cancer may come back after treatment – sometimes years later. This is called a recurrence. Recurrence can be local (in the same breast or in the surgery scar), regional (in nearby lymph nodes), or in a distant area. Cancer that is found in the opposite breast without any cancer elsewhere in the body is not a recurrence—it is a new cancer that requires its own treatment.

Treating local recurrence

For women whose breast cancer has recurred locally, treatment depends on their initial treatment.

If you had breast-conserving surgery (lumpectomy), a local recurrence in the breast is usually treated with mastectomy.
If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible. This is often followed by radiation therapy.

In either case, hormone therapy, targeted therapy (like trastuzumab), chemotherapy, or some combination of these may be used after surgery and/or radiation therapy.

Treating regional recurrence

When breast cancer comes back in nearby lymph nodes (such as those under the arm or around the collar bone), it is treated by removing those lymph nodes, if possible. This may be followed by radiation aimed at the area. Systemic treatment (such as chemo, targeted therapy, or hormone therapy) may be considered after surgery as well.

Treating distant recurrence

In general, women whose breast cancer comes back in other parts of the body, such as the bones, lungs, or brain, are treated the same way as those found to have stage IV breast cancer in these organs when they were first diagnosed (see Treating Stage IV (Metastatic) Breast Cancer). The only difference is that treatment may be affected by previous treatments a woman has had.

Recurrent breast cancer can sometimes be hard to treat. If you are in otherwise good health, you may want to think about taking part in a clinical trial testing a newer treatment.

Treatment of breast cancer in men

To determine your male breast cancer treatment options, your doctor considers your cancer’s stage, your overall health and your preferences. Male breast cancer treatment often involves surgery and may also include other treatments.

Surgery

The goal of surgery is to remove the tumor and surrounding breast tissue. The procedures include:

  • Removal of breast tissue and surrounding lymph nodes (modified radical mastectomy). The surgeon removes all of your breast tissue, including the nipple and areola, and some underarm lymph nodes.
  • Removal of one lymph node for testing (sentinel lymph node biopsy). The doctor identifies the lymph node most likely to be the first place your cancer cells would spread. That lymph node is removed and analyzed. If no cancer cells are found, there is a good chance that your breast cancer hasn’t spread beyond your breast tissue.

Radiation therapy

Radiation therapy uses high-energy beams to kill cancer cells. In male breast cancer, radiation therapy may be used after surgery to eliminate any remaining cancer cells in the breast, chest muscles or armpit.

During radiation therapy, radiation comes from a large machine that moves around your body, directing the energy beams to precise points on your chest.

Chemotherapy

Chemotherapy uses medications to kill cancer cells. These medications may be administered through a vein in your arm (intravenously), in pill form or by both methods.

Your doctor might recommend chemotherapy after surgery to kill any cancer cells that might have spread outside your breast. Chemotherapy may also be an option for men with advanced breast cancer.

Hormone therapy

Most men with male breast cancer have tumors that rely on hormones to grow (hormone-sensitive). If your cancer is hormone-sensitive, your doctor may recommend hormone therapy.

Hormone therapy for male breast cancer often involves the medication tamoxifen, which is also used for women. Other hormone therapy medications used in women with breast cancer haven’t been shown to be effective for men.

Coping and support

A breast cancer diagnosis can be overwhelming. And just when you’re trying to cope with the shock and the fears about your future, you’re asked to make important decisions about your treatment.

Every person finds his or her own way of coping with a cancer diagnosis. Until you find what works for you, it might help to:

Learn enough about your breast cancer to make decisions about your care. If you’d like to know more about your breast cancer, ask your doctor for the details of your cancer — the type, stage and hormone receptor status. Ask for good sources of up-to-date information on your treatment options.

Knowing more about your cancer and your options may help you feel more confident when making treatment decisions. Still, some women may not want to know the details of their cancer. If this is how you feel, let your doctor know that, too.
Talk with other breast cancer survivors. You may find it helpful and encouraging to talk to others in your same situation. Contact the American Cancer Society to find out about support groups in your area and online.
Find someone to talk about your feelings with. Find a friend or family member who is a good listener, or talk with a clergy member or counselor. Ask your doctor for a referral to a counselor or other professional who works with cancer survivors.

Keep your friends and family close. Your friends and family can provide a crucial support network for you during your cancer treatment.

As you begin telling people about your breast cancer diagnosis, you’ll likely get many offers for help. Think ahead about things you may want assistance with, whether it’s having someone to talk to if you’re feeling low or getting help preparing meals.
Maintain intimacy with your partner. In Western cultures, women’s breasts are associated with attractiveness, femininity and sexuality. Because of these attitudes, breast cancer may affect your self-image and erode your confidence in intimate relationships. Talk to your partner about your insecurities and your feelings.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

References   [ + ]