Breast Cancer Overview

Breast
Breast cancer is the most commonly diagnosed cancer among women in the United States, with over a quarter of a million new diagnoses each year. It is the second leading cause of cancer-related deaths in women. 

If you have been diagnosed with breast cancer, you may feel concerned and overwhelmed by the disease, treatment options, and prognosis. Our comprehensive team at The Breast Center -- Smilow Cancer Hospital at Yale-New Haven can provide comfort and support by answering all your questions in detail. Through the combined experience of our nationally renowned surgeons and multidisciplinary clinical professionals at the Smilow Cancer Hospital at Yale-New Haven, our team will provide you with the highest-quality care, including the latest therapies and surgeries in breast cancer and clinical trials for which you may be eligible.

As faculty of the Yale School of Medicine Department of Surgery, our surgeons, who include Dr. Anees Chagpar, Dr. Don Lannin, Dr. Brigid Killelea, and Dr. Nina Horowitz, are leading innovators in breast cancer research and treatment; they continue to better understand the nature of breast cancer and are increasingly hopeful about creating a cancer-free future. Through a combination of skill and knowledge, we can begin to ease the fear that cancer often creates and inspire a better life instead.

The Breast
The breast of a woman is made up of the sacs that make the breast milk (the lobules), the tubes that carry the milk to the nipple (the ducts), and the surrounding fatty tissue. The areola is the darker-colored skin surrounding the nipple. Nearly all breast cancers begin in either the lobules or the ducts. 

Blood vessels and lymph (pronounced limf) channels are found in each breast in the fatty tissue. Lymph nodes are small lima bean-shaped organs that are part of our body's immune system. They are found from our head to our toes. Part of their job is to filter germs and abnormal cells that are released into the lymph channels. There are groups of lymph nodes in our axilla (armpit), above our collarbone and in our chest, which drain the fluid coming from the breast. 

In our conversation about your breast cancer, we will discuss the need to know whether or not cancer cells have spread to these lymph nodes. The axillary lymph nodes are one of our best predictors of the risk that the cancer cells have escaped to other places in your body. This will be important in making some of your treatment decisions.

What Is Breast Cancer?

The body is made up of hundreds of millions of living cells of many different types. Normal cells grow, divide and die in a very orderly process. This helps replace normal cells and helps to keep us all healthy. Sometimes cells begin to divide even when new cells are not needed, and these extra cells can form a mass of tissue called a tumor. Not all tumors are cancerous. Benign (be-nine) tumors can grow large and press on other organs but have no ability to invade other tissues or spread to other parts of the body. Benign breast tumors are never a threat to your life.

Malignant tumors are cancer and their cells are not normal. Instead of dying, cancer cells keep on growing and forming new cancer cells. Cancer cells can invade, or grow into, other nearby tissues. They can also break away from their original site and enter the bloodstream or lymphatic channel. This is how a metastasis (muh-tas-tuh-sis) begins. These breakaway cells can then form new tumors in other vital organs, and it is this process that can make cancer life threatening.

Breast cancer is a malignant tumor that starts from the cells lining the milk-making part of the breast. If the cancer has spread outside the breast, it is commonly seen in the lymph nodes under the armpit (axillary nodes). Cancer cells may also spread to other parts of the body, like the lungs, liver, bones, or brain. If a cancer spreads to other parts of the body, the new spots are still named after the primary tumor. For example, if a breast cancer spreads to the bones, a biopsy of this area would show breast cancer cells. We would call this metastatic breast cancer, not bone cancer.


Types of Breast Cancer

Breast cancers can range from very common to quite rare; having an experienced surgeon will help you understand and navigate through the physical and emotional challenges of any type of breast cancer. Our surgeons at The Breast Center specialize exclusively in breast surgery and have extensive experience in treating even the most complex breast cancers.

Cancers are generally considered to be invasive or in situ. Breast cancer that is determined to be invasive means that the breast cancer cells have the ability to spread, but may not. Breast cancer can also be in situ, which means the breast cancer cells are still in their pre-cancerous stage.

The two most common types of breast cancer are ductal and lobular. Ductal breast cancer is found within the ducts of the breast that transport milk. Lobular breast cancer is found within the lobules of the breast that make the milk.

Ductal Breast Cancers Include:

Ductal carcinoma in situ (DCIS):
This is the earliest type of breast cancer, when the cells lining the milk duct have become malignant, but have not had a chance to spread through the walls of the milk ducts into the surrounding tissue. DCIS has no ability to spread and is associated with a 99 percent cure rate. This is part of the spectrum referred to as ductal intraepithelial neoplasia (DIN).

Invasive (or infiltrating) ductal carcinoma:
This occurs when the malignant cells in the milk duct have had the opportunity to break through the wall of the duct into the surrounding breast tissue. This is the most common type of breast cancer, accounting for 80 percent of invasive cancers. The term invasive does not mean that cancer has spread, but all of these cancers have the ability to metastasize.

Paget’s Disease:
This type of ductal breast cancer presents with a visible rash or scaly change in the skin of the nipple. It can be either localized or invasive, but the nipple will need to be removed.

Lobular Breast Cancers Include:

Invasive (or infiltrating) lobular cancer:
These cancers begin in the sacs of the breast, which produce the milk. Only 20 percent of all breast cancers are lobular. They have the same prognosis as ductal cancers, but can be much harder to detect and are more often missed by breast imaging.

Inflammatory breast cancer:
This uncommon type of breast cancer presents with visible breast skin changes that look like an infection. This is a more aggressive form of breast cancer and is more likely to metastasize.  This type of breast cancer is often treated with chemotherapy prior to surgery.

Our surgeons from the Yale School of Medicine Department of Surgery are committed to helping you understand, in depth, the most effective course of action to becoming cancer free. Together with professionals at Smilow Cancer Hospital at Yale-New Haven, we offer a multidisciplinary team of dedicated breast surgeons, plastic surgeons, medical oncologists, radiation oncologists, pathologists, psychologists, geneticists, nurses, social workers, physical therapists, and other medical experts who are focused on providing you with the very best care and ensuring optimal quality and quantity of life.

Causes Of Breast Cancer

DNA is the chemical in each of our cells that help make up our genes, and genes are the blueprint for how our cells are supposed to work. Sometimes a change occurs in the DNA that can make a normal breast cell become cancer. Most of these occur spontaneously, and the causes of these changes are not known. There are DNA changes, called mutations, which will run through families, and some of these mutations will increase the risk for developing breast cancer.

The most well known are called BRCA 1 and 2, which are tumor suppressor genes. In their normal state, they keep cancers from developing. When a mutation occurs, cells no longer die at the right time, and a cancer is much more likely to develop. Women with this mutation have a 60 to 80 percent lifetime risk for developing breast cancer, as well as an increased risk for ovarian cancer.

All women are at risk for breast cancer. Men can also get breast cancer, but this is rare (1:100). With the exception of skin cancer, breast cancer is the most common cancer diagnosed in women in the United States in all racial and ethnic groups. The two most important risk factors for developing breast cancer are being a female and getting older.

Here is a chart that shows the chances of developing breast cancer by age:
By age 25: 1 in 19,608
By age 35: 1 in 622
By age 45: 1 in 93
By age 55: 1 in 33
By age 65: 1 in 17
By age 75: 1 in 11
By age 85: 1 in 9
By age 95: 1 in 8

Risk Factors for Developing Breast Cancer

If you have breast cancer, it is normal to wonder why and how you got this disease, especially if it has not occurred in your family history.

No one knows exactly what causes breast cancer, but research has shown that certain risk factors have a higher association to breast cancer. It is important to understand that just because you may have an associated risk factor, it does not mean that you will get breast cancer or that the risk factor is what caused your breast cancer.

Some risk factors are found to be generalizations to the population and specific groups, and they cannot be changed or controlled.

Other risk factors are related to lifestyle choices, and we can minimize our risk of getting breast cancer by altering these activities. At The Breast Center -- Smilow Cancer Hospital at Yale-New Haven, we can help you reduce or eliminate these risk factors. Together, we will review your possible risk factors to best prepare for the future and to prevent possible recurrence.

Through clinical and translational research, our surgeons from the Yale School of Medicine Department of Surgery are dedicated to finding the causes of breast cancer so that women can have a better chance of preventing the disease. 

Risk Factors You Cannot Change

Gender:
Breast cancer is 100 times more common in women than men.

Age: 
About two out of three women with invasive breast cancer are 55 years old or older.

Family history:
Breast cancer risk is higher in women who have close blood relatives on either their mother’s or father’s side of the family. This risk increases with the number of individuals affected.

Genetic risk factors:
Approximately 5 to 10percent of breast cancers are thought to be linked to these inherited mutations, most commonly BRCA 1 or 2.
For more information, please visit: http://www.yalecancercenter.org/genetics
Or to make an appointment, please call us at (203) 764-8400.

Personal history of breast cancer:
A woman with breast cancer in one breast has a greater chance of getting a new breast cancer in either breast.

Race:
White women are more likely to develop breast cancer than African-American women, but African-American women are more likely to die of their cancers. Asian, Hispanic, and Native American women have a lower risk of developing or dying from breast cancer.

Early breast radiation:
Women who have had radiation treatments to the chest area during puberty or young adulthood have a greatly increased risk of developing breast cancer.

Atypical breast lesions:
Women who have had previous biopsies showing atypical proliferative lesions have an increased risk for developing breast cancer. There is a long list of these lesions including LCIS, atypical ductal hyperplasia, and papillomatosis.

Menstrual history:
Women who begin to have their periods at a younger age or who have menopause at an older age are at a slightly increased risk for developing breast cancer.

Risk Factors Related To Lifestyle Decisions

Pregnancy history:
Women who have not had children or who have their children after the age of 30 have an increased risk of breast cancer.

Hormone replacement therapy:
Postmenopausal combination hormone replacement with both estrogen and progesterone increases the risk of developing breast cancer. Estrogen alone does not appear to increase the risk.

Alcohol:
Women who have one drink a day have a small increased risk of developing breast cancer. Heavy alcohol users have much more risk.

Obesity:
Women who are overweight or obese, especially after menopause, have a higher risk of breast cancer.

Sedentary lifestyle:
Recent studies clearly show that exercise decreases the risk of breast cancer.

Symptoms of Breast Cancer

There are several symptoms people should be aware of that may indicate breast cancer. The earlier breast cancer is diagnosed, the sooner the team at The Breast Center -- Smilow Cancer Hospital at Yale-New Haven can begin taking the necessary steps to helping you become cancer free. We offer state-of-art technology that can ensure you experience total breast health.

Women should talk to their doctor if they are experiencing any of the following symptoms:
  • Any abnormal discharge from the nipple
  • Change in the size, shape or texture of the breast
  • Inverted nipple
  • Peeling or flaking of the nipple
  • Redness or pitting of the skin, like an orange
  • Pain in the breast
  • A lump in the underarm or breast
  • An abnormal mammogram

Ideally, women present without symptoms at all. Women should be proactive about screening for breast cancer and get a mammogram every year beginning at the age of 40. The Breast Center offers state-of-the-art technology; we would be happy to provide your yearly mammogram and any needed follow-up imaging, such as an ultrasound and MRI. 

If your biopsy results are abnormal, you may need a biopsy. Our surgeons from the Yale School of Medicine Department of Surgery can perform your biopsy and review your biopsy results with you, in detail, and answer all your questions and concerns. Should your biopsy results show that you have a malignancy, our nationally recognized surgeons are highly experienced in treating all types of cancer, including the most complex cases. We will create a detailed treatment plan based on your specific condition and your concerns, while offering heartfelt, comprehensive care to help you through every step of your surgery and treatment process.

Stages of Breast Cancer

Stage 0 cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.

Stage I cancer is two centimeters or less and is confined to the breast (lymph nodes are clear). No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm)
OR
Stage IIA: the tumor measure two centimeters or smaller and has spread to the axillary lymph nodes. The tumor is larger than two centimeters but no larger than five centimeters and has not spread to the axillary lymph nodes
OR
Stage IIB: the tumor is larger than five centimeters but has not spread to the axillary lymph nodes. No tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in the lymph nodes near the breastbone.
OR
Stage IIIA: the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone. The tumor may be any size and has spread to the chest wall and/or skin of the breast. 
AND
Stage IIIB: may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone.
Inflammatory breast cancer is considered at least Stage IIIB. There may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast.
AND
Stage IIIC: the cancer has spread to the lymph nodes either above or below the collarbone.
AND
the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.

Stage IV: the cancer has spread, or metastasized, to other parts of the body.