Breast Cancer Information

Breast Cancer Information

Posted on: December 12, 2018

đź“·What Is Breast Cancer?


Breast cancer starts when cells in the breast begin to grow out of control. These cells usually form a tumor that can often be seen on an x-ray or felt as a lump. The tumor is malignant (cancer) if the cells can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. Breast cancer occurs almost entirely in women, but men can get breast cancer, too.

Cells in nearly any part of the body can become cancer and can spread to other areas.

Where breast cancer starts

Breast cancers can start from different parts of the breast. Most breast cancers begin in the ducts that carry milk to the nipple (ductal cancers). Some start in the glands that make breast milk (lobular cancers). There are also other types of breast cancer that are less common.

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.


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How breast cancer spreads

Breast cancer can spread when the cancer cells get into the blood or lymph system 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.


Mammogram Basics


A mammogram is a low-dose x-ray that allows doctors called radiologists to look for changes in breast tissue.

Why do I need mammograms ?

A mammogram can often find or detect breast cancer early, when it’s small and even before a lump can be felt. This is when it’s easiest to treat.

What are the types of mammograms?

Screening mammograms

A screening mammogram is used to look for signs of breast cancer in women who don’t have any breast symptoms or problems. X-ray pictures of each breast are taken from 2 different angles.

Diagnostic mammograms

Mammograms can also be used to look at a woman’s breast if she has breast symptoms or if a change is seen on a screening mammogram. When used in this way, they are called diagnostic mammograms. They may include extra views (images) of the breast that aren’t part of screening mammograms. Sometimes diagnostic mammograms are used to screen women who were treated for breast cancer in the past.

What do mammograms show?

Mammograms can often show abnormal areas in the breast. They can’t prove that an abnormal area is cancer, but they can help health care providers decide whether more testing is needed. The 2 main types of breast changes found with a mammogram are calcifications and masses. Learn more about these and other breast changes in What Does the Doctor Look for on a Mammogram?

How do mammograms work?

A mammogram uses a machine designed to look only at breast tissue. The machine takes x-rays at lower doses than usual x-rays. Because these x-rays don’t go through tissue easily, the machine has 2 plates that compress or flatten the breast to spread the tissue apart. This gives a better picture and allows less radiation to be used.

To learn more about how they are done, see Mammograms: What to Know Before You Go.

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In the past, mammograms were typically printed on large sheets of film. Today, digital mammograms (also known as full-field digital mammography or FFDM) are much more common. Digital images are recorded and saved as files in a computer.

A newer type of mammogram is known as breast tomosynthesis or 3D mammography. For this, the breast is compressed once, and a machine takes many low-dose x-rays as it moves over the breast. A computer then puts the images together into a 3-dimensional picture. In some cases, this uses more radiation than standard 2-view mammograms, but it may allow doctors to see the breast tissues more clearly. Some studies have suggested it might lower the chance of being called back for follow-up testing. It may also be able to find more cancers. But not all health insurance providers may cover tomosynthesis.

Are mammograms safe?

Mammograms expose the breasts to small amounts of radiation. But the benefits of mammography outweigh any possible harm from the radiation exposure. Modern machines use low radiation doses to get breast x-rays that are high in image quality. On average the total dose for a typical mammogram with 2 views of each breast is about 0.4 millisieverts, or mSv. (A mSv is a measure of radiation dose.)

To put the dose into perspective, people in the US are normally exposed to an average of about 3 mSv of radiation each year just from their natural surroundings. (This is called background radiation.) The dose of radiation used for a screening mammogram of both breasts is about the same amount of radiation a woman would get from her natural surroundings over about 7 weeks.

If there’s any chance you might be pregnant, let your health care provider and x-ray technologist know. Although the risk to the fetus is likely very small, screening mammograms aren’t routinely done in pregnant women.


Breast Cancer Stages  📷


After someone is diagnosed with breast cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer’s stage when talking about survival statistics.

The earliest stage breast cancers are stage 0 (carcinoma in situ). It then ranges from stage I (1) through IV (4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more. And within a stage, an earlier letter means a lower stage.

How is the stage determined?

The staging system most often used for breast cancer is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 7 key pieces of information:

The extent (size) of the tumor (T): How large is the cancer?  Has it grown into nearby areas?The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes? If so, how many?The spread (metastasis) to distant sites (M): Has the cancer spread to distant organs such as the lungs or liver?Estrogen Receptor (ER) status: Does the cancer have the protein called an estrogen receptor?Progesterone Receptor (PR) status: Does the cancer have the protein called a progesterone receptor?Her2/neu (Her2) status: Does the cancer make too much of a protein called Her2?Grade of the cancer (G): How much do the cancer cells look like normal cells?

Oncotype Dx Recurrence Score results may also be considered in the stage in certain circumstances.

The most recent AJCC system, effective January 2018, has both clinical and pathologic staging systems for breast cancer. The pathologic stage (also called the surgical stage) is determined by examining tissue removed during an operation. Sometimes, if surgery is not possible right away or at all, the cancer will be given a clinical stage instead. This is based on the results of a physical exam, biopsy, and imaging tests. The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates, and may not predict the patient’s outlook as accurately as a pathologic stage.

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories, as well as ER, PR, Her2 status and grade of the cancer have been determined, this information is combined in a process called stage grouping to assign an overall stage. For more information see Cancer Staging. Detailed explanations of the TNM categories are seen below. The addition of information about ER, PR, and Her2 status along with grade has made stage grouping complex, so, it is best to ask your doctor about your specific stage and what it means.


Details of the TNM staging system

T categories for breast cancer

T followed by a number from 0 to 4 describes the main (primary) tumor’s size and if it has spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.

TX: Primary tumor cannot be assessed.

T0: No evidence of primary tumor.

Tis: Carcinoma in situ (DCIS, or Paget disease of the nipple with no associated tumor mass)

T1 (includes T1a, T1b, and T1c): Tumor is 2 cm (3/4 of an inch) or less across.

T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.

T3: Tumor is more than 5 cm across.

T4 (includes T4a, T4b, T4c, and T4d): Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

N categories for breast cancer

N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are involved.

Lymph node staging for breast cancer is based on how the nodes look under the microscope, and has changed as technology has improved. Newer methods have made it possible to find smaller and smaller collections of cancer cells, but experts haven’t been sure how much these tiny deposits of cancer cells affect outlook.

It’s not yet clear how much cancer in the lymph node is needed to see a change in outlook or treatment. This is still being studied, but for now, a deposit of cancer cells must contain at least 200 cells or be at least 0.2 mm across (less than 1/100 of an inch) for it to change the N stage. An area of cancer spread that is smaller than 0.2 mm (or fewer than 200 cells) doesn’t change the stage, but is recorded with abbreviations (i+ or mol+) that indicate the type of special test used to find the spread.

If the area of cancer spread is at least 0.2 mm (or 200 cells), but still not larger than 2 mm, it is called a micrometastasis (one mm is about the size of the width of a grain of rice). Micrometastases are counted only if there aren’t any larger areas of cancer spread. Areas of cancer spread larger than 2 mm are known to affect outlook and do change the N stage. These larger areas are sometimes called macrometastases, but are more often just called metastases.

NX: Nearby lymph nodes cannot be assessed (for example, if they were removed previously).

N0: Cancer has not spread to nearby lymph nodes.

N0(i+): The area of cancer spread contains less than 200 cells and is smaller than 0.2 mm. The abbreviation “i+” means that a small number of cancer cells (called isolated tumor cells) were seen in routine stains or when a special type of staining technique, called immunohistochemistry, was used.

N0(mol+): Cancer cells cannot be seen in underarm lymph nodes (even using special stains), but traces of cancer cells were detected using a technique called RT-PCR. RT-PCR is a molecular test that can find very small numbers of cancer cells. (This test is not often used to find breast cancer cells in lymph nodes because the results do not influence treatment decisions.)

N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy.

N1mi: Micrometastases (tiny areas of cancer spread) in the lymph nodes under the arm. The areas of cancer spread in the lymph nodes are at least 0.2mm across, but not larger than 2mm.

N1a: Cancer has spread to 1 to 3 lymph nodes under the arm with at least one area of cancer spread greater than 2 mm across.

N1b: Cancer has spread to internal mammary lymph nodes on the same side as the cancer, but this spread could only be found on sentinel lymph node biopsy (it did not cause the lymph nodes to become enlarged).

N1c: Both N1a and N1b apply.

N2: Cancer has spread to 4 to 9 lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes

N2a: Cancer has spread to 4 to 9 lymph nodes under the arm, with at least one area of cancer spread larger than 2 mm.

N2b: Cancer has spread to one or more internal mammary lymph nodes, causing them to become enlarged.

N3: Any of the following:

N3a: either:

Cancer has spread to 10 or more axillary lymph nodes, with at least one area of cancer spread greater than 2 mm,

OR

Cancer has spread to the lymph nodes under the collarbone (infraclavicular nodes), with at least one area of cancer spread greater than 2 mm.

N3b: either:

Cancer is found in at least one axillary lymph node (with at least one area of cancer spread greater than 2 mm) and has enlarged the internal mammary lymph nodes,

OR

Cancer has spread to 4 or more axillary lymph nodes (with at least one area of cancer spread greater than 2 mm), and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

N3c: Cancer has spread to the lymph nodes above the collarbone (supraclavicular nodes) with at least one area of cancer spread greater than 2 mm.

M categories for breast cancer

M followed by a 0 or 1 indicates whether the cancer has spread to distant organs — for example, the lungs, liver, or bones.

MX: Distant spread (metastasis) cannot be assessed.

M0: No distant spread is found on x-rays (or other imaging tests) or by physical exam.

cM0(i+): Small numbers of cancer cells are found in blood or bone marrow (found only by special tests), or tiny areas of cancer spread (no larger than 0.2 mm) are found in lymph nodes away from the underarm, collarbone, or internal mammary areas.

M1: Cancer has spread to distant organs (most often to the bones, lungs, brain, or liver).

Examples using the new staging system

Example #1

If the cancer size is between 2 and 5 cm (T2) but it has not spread to the nearby lymph nodes (N0) or to distant organs (M0) AND is:

Grade 3Her2 negativeER positivePR positive

The cancer stage is IB.

Example #2

If the cancer is larger than 5 cm (T3) and has spread to 4 to 9 lymph nodes under the arm or to any internal mammary lymph nodes (N2) but not to distant organs (M0) AND is:

Grade 2Her2 positiveER positivePR positive

The cancer stage is IB.

Example #3

If the cancer is larger than 5 cm (T3) and has spread to 4 to 9 lymph nodes under the arm or to any internal mammary lymph nodes (N2) but not to distant organs (M0) AND is:

Grade 2Her2 negativeER negativePR negative

The cancer stage is IIIB.

Please visit www.cancer.org for more information OR call the Cancer Helpline in the United States at 800.227.2345. 

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