Breast Cancer

Overview

The breast is made up of glands called lobules that can make milk and thin tubes called ducts that carry the milk from the lobules to the nipple. Breast tissue also contains fat and connective tissue, lymph nodes, and blood vessels.

The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Breast cancer can also begin in the cells of the lobules and in other tissues in the breast. Invasive breast cancer is breast cancer that has spread from where it began in the ducts or lobules to surrounding tissue.

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 very rare in men. Each year there are about 2,300 new cases of breast cancer in men and about 230,000 new cases in women.

Signs and symptoms of breast cancer may include:

  • A breast lump or thickening that feels different from the surrounding tissue
  • Bloody discharge from the nipple
  • Change in the size, shape or appearance of a breast
  • Changes to the skin over the breast, such as dimpling
  • A newly inverted nipple
  • Peeling, scaling or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin
  • Redness or pitting of the skin over your breast, like the skin of an orange

When to see a doctor

If you find a lump or other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor for prompt evaluation.

Causes

It’s not clear what causes breast cancer.

Doctors know that breast cancer occurs when some breast cells begin growing abnormally. These cells divide more rapidly than healthy cells do and continue to accumulate, forming a lump or mass. The cells may spread (metastasize) through your breast to your lymph nodes or to other parts of your body.

Breast cancer most often begins with cells in the milk-producing ducts (invasive ductal carcinoma). Breast cancer may also begin in the glandular tissue called lobules (invasive lobular carcinoma) or in other cells or tissue within the breast.

Researchers have identified hormonal, lifestyle and environmental factors that may increase your risk of breast cancer. But it’s not clear why some people who have no risk factors develop cancer, yet other people with risk factors never do. It’s likely that breast cancer is caused by a complex interaction of your genetic makeup and your environment.

Inherited breast cancer

Doctors estimate that only 5 to 10 percent of breast cancers are linked to gene mutations passed through generations of a family.

A number of inherited mutated genes that can increase the likelihood of breast cancer have been identified. The most common are breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which significantly increase the risk of both breast and ovarian cancer.

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 with you and guide you on appropriate genetic testing.

Risk factors

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:

  • 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 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 common 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.
  • 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 35 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.

Breast cancer, DCIS

Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means “in its original place.” DCIS is called “non-invasive” because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue. DCIS isn’t life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.

When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a recurrence are under 30%.

Women who have breast-conserving surgery (lumpectomy) for DCIS without radiation therapy have about a 25% to 30% chance of having a recurrence at some point in the future. Including radiation therapy in the treatment plan after surgery drops the risk of recurrence to about 15%. If breast cancer does come back after earlier DCIS treatment, the recurrence is non-invasive (DCIS again) about half the time and invasive about half the time. (DCIS itself is NOT invasive.)

According to the American Cancer Society, about 60,000 cases of DCIS are diagnosed in the United States each year, accounting for about 1 out of every 5 new breast cancer cases.

There are two main reasons this number is so large and has been increasing over time:

  • People are living much longer lives. As we grow older, our risk of breast cancer increases.
  • More people are getting mammograms, and the quality of the mammograms has improved. With better screening, more cancers are being spotted early.

What is breast cancer in men?

A breast cancer is a malignant tumor that starts from cells of the breast. A malignant tumor is a group of cancer cells that may grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. Breast cancer occurs mainly in women, but men can get it, too. Many people do not realize that men have breast tissue and that they can develop breast cancer.

Normal breast structure

To understand breast cancer, it helps to have some basic knowledge about the normal structure of the breasts.

The breast is made up mainly of lobules (glands that can produce milk if the right hormones are present), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels).

Until puberty (on average around age 9 or 10), young boys and girls have a small amount of breast tissue consisting of a few ducts located under the nipple and areola (area around the nipple). At puberty, a girl’s ovaries make female hormones, causing breast ducts to grow, lobules to form at the ends of ducts, and the amount of stroma to increase. Even after puberty, men and boys normally have low levels of female hormones, and breast tissue doesn’t grow much. Men’s breast tissue has ducts, but only a few if any lobules.

Like all cells of the body, a man’s breast duct cells can undergo cancerous changes. But breast cancer is less common in men because their breast duct cells are less developed than those of women and because they normally have lower levels of female hormones that affect the growth of breast cells.

The lymph (lymphatic) system of the breast

The lymph system is important to understand because it is one of the ways that breast cancers can spread. This system has several parts.

Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.

Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes under the breast bone (internal mammary nodes) and either above or below the collarbone (supraclavicular or infraclavicular nodes).

If the cancer cells have spread to these lymph nodes, there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. The more lymph nodes with breast cancer cells, the more likely it is that the cancer may be found in other organs as well. Because of this, finding cancer in one or more lymph nodes often affects the treatment plan. Still, not all men with cancer cells in their lymph nodes develop metastases to other areas, and some men can have no cancer cells in their lymph nodes and later develop metastases.

Benign breast conditions

Men can also have some benign (not cancerous) breast disorders.

Gynecomastia

Gynecomastia is the most common male breast disorder. It is not a tumor but rather an increase in the amount of a man’s breast tissue. Usually, men have too little breast tissue to be felt or noticed. Gynecomastia can appear as a button-like or disk-like growth under the nipple and areola (the dark circle around the nipple), which can be felt and sometimes seen. Some men have more severe gynecomastia and they may appear to have small breasts. Although gynecomastia is much more common than breast cancer in men, both can be felt as a growth under the nipple, which is why it’s important to have any such lumps checked by your doctor.

Gynecomastia is common among teenage boys because the balance of hormones in the body changes during adolescence. It is also common in older men due to changes in their hormone balance.

In rare cases, gynecomastia occurs because tumors or diseases of certain endocrine (hormone-producing) glands cause a man’s body to make more estrogen (the main female hormone). Men’s glands normally make some estrogen, but not enough to cause breast growth. Diseases of the liver, which is an important organ in male and female hormone metabolism, can change a man’s hormone balance and lead to gynecomastia. Obesity (being extremely overweight) can also cause higher levels of estrogens in men.

Some medicines can cause gynecomastia. These include some drugs used to treat ulcers and heartburn, high blood pressure, heart failure, and psychiatric conditions. Men with gynecomastia should ask their doctors if any medicines they are taking might be causing this condition.

Klinefelter syndrome, a rare genetic condition, can lead to gynecomastia as well as increase a man’s risk of developing breast cancer.

Benign breast tumors

There are many types of benign breast tumors (abnormal lumps or masses of tissue), such as papillomas and fibroadenomas. Benign tumors do not spread outside the breast and are not life threatening. Benign breast tumors are common in women but are very rare in men.

General breast cancer terms

Here are some of the key words used to describe breast cancer.

Carcinoma

This term describes a cancer that begins in the lining layer (epithelial cells) of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).

Adenocarcinoma

An adenocarcinoma is a type of carcinoma that starts in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk in women), so cancers starting in these areas are sometimes called adenocarcinomas.

Carcinoma in situ

This is an early stage of cancer, when it is confined to the layer of cells where it began. In breast cancer, in situ means that the abnormal cells remain confined to ducts (ductal carcinoma in situ, or DCIS). These cells have not grown into (invaded) deeper tissues in the breast or spread to other organs in the body. Ductal carcinoma in situ of the breast is sometimes referred to as non-invasive or pre-invasive breast cancer because it might develop into an invasive breast cancer if left untreated.

When cancer cells are confined to the lobules it is called lobular carcinoma in situ (LCIS). This is not actually a true pre-invasive cancer because it does not turn into an invasive cancer if left untreated. It is linked to an increased risk of invasive cancer in both breasts. LCIS is rarely, if ever seen in men.

Invasive (or infiltrating) carcinoma

An invasive cancer is one that has already grown beyond the layer of cells where it started (as opposed to carcinoma in situ). Most breast cancers are invasive carcinomas, either invasive ductal carcinoma or invasive lobular carcinoma.

Sarcoma

Sarcomas are cancers that start in connective tissues such as muscle tissue, fat tissue, or blood vessels. Sarcomas of the breast are rare.

Types of breast cancer in men

Breast cancer can be separated into several types based on the way the cancer cells look under the microscope. In some cases a single breast tumor can be a combination of these types or be a mixture of invasive and in situ cancer. And in some rarer types of breast cancer, the cancer cells may not form a tumor at all.

Breast cancer can also be classified based on proteins on or in the cancer cells, into groups like hormone receptor-positive and triple-negative.

Ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is considered non-invasive or pre-invasive breast cancer. In DCIS (also known as intraductal carcinoma), cells that lined the ducts have changed to look like cancer cells. The difference between DCIS and invasive cancer is that the cells have not spread (invaded) through the walls of the ducts into the surrounding tissue of the breast (or spread outside the breast). DCIS is considered a pre-cancer because some cases can go on to become invasive cancers. Right now, though, there is no good way to know for certain which cases will go on to become invasive cancers and which ones won’t. DCIS accounts for about 1 in 10 cases of breast cancer in men. It is almost always curable with surgery.

Infiltrating (or invasive) ductal carcinoma (IDC)

Invasive (or infiltrating) ductal carcinoma (IDC) starts in a milk duct of the breast, breaks through the wall of the duct, and grows into the fatty tissue of the breast. At this point, it may be able to spread (metastasize) to other parts of the body through the lymphatic system and bloodstream. At least 8 out of 10 male breast cancers are IDCs (alone or mixed with other types of invasive or in situ breast cancer). Because the male breast is much smaller than the female breast, all male breast cancers start relatively close to the nipple, so they are more likely to spread to the nipple. This is different from Paget disease as described below.

Infiltrating (or invasive) lobular carcinoma (ILC)

This type of breast cancer starts in the breast lobules (collections of cells that, in women, produce breast milk) and grows into the fatty tissue of the breast. ILC is very rare in men, accounting for only about 2% of male breast cancers. This is because men do not usually have much lobular tissue.

Paget disease of the nipple

This type of breast cancer starts in the breast ducts and spreads to the nipple. It may also spread to the areola (the dark circle around the nipple). The skin of the nipple usually appears crusted, scaly, and red, with areas of itching, oozing, burning, or bleeding. There may also be an underlying lump in the breast.

Paget disease may be associated with DCIS or with infiltrating ductal carcinoma. It accounts for about 1% of female breast cancers and a higher percentage of male breast cancers.

Inflammatory breast cancer

Inflammatory breast cancer is an aggressive, but rare type of breast cancer. It makes the breast swollen, red, warm and tender rather than forming a lump. It can be mistaken for an infection of the breast. This is very rare in men.

  • Breast cancer, secondary
  • Secondary breast cancer occurs when breast cancer cells spread from the first (primary) tumor in the breast through the lymphatic or blood system to other parts of the body.
  • This is also referred to as metastases, advanced breast cancer, secondary tumors, secondaries or stage 4 breast cancer.
  • When breast cancer spreads, for example to the bones, it is called secondary breast cancer in the bone. The cells in the bone are breast cancer cells.
  • Usually secondary breast cancer is diagnosed some time after the primary breast cancer, but sometimes it is diagnosed at the same time as the primary breast cancer or on rare occasions before the primary breast cancer has been diagnosed.
  • A diagnosis of secondary breast cancer means that the cancer can be treated but it can’t be cured. The aim is to control and slow down the spread of the disease, to relieve symptoms, and to give you the best possible quality of life, for as long as possible. There are many treatments that can keep the cancer under control, often for many years.

Your specialist will be able to tell you about the likely progress of your cancer, and what you might expect.

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