Breast Cancer

Signs & symptoms

Early breast cancer usually doesn't cause pain. In fact, when breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it may cause changes that you should watch for:

• A lump or thickening in or near the breast or in the underarm area
• A change in the size or shape of the breast
• Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast
• Ridges or pitting of the breast, making the skin look like the skin of an orange
• A change in the look or feel of the skin of the breast, areola or nipple such as warmth, swelling, redness or scaliness

Diagnosis

If cancer is found in your breast, your doctor will assess the stage or extent of the disease. Staging is an effort to determine if the cancer has spread and, if so, to what parts of the body. Your doctor may use blood and imaging tests to learn the stage of the disease. Treatment decisions depend on these findings. Read Basic Facts about Breast Health to learn more about the staging system.

The first step is usually a physical exam by a doctor or nurse practitioner. Mammography and ultrasound may be part of the exam. On the basis of these evaluations, the decision may be made to perform a tissue biopsy.

Imaging

Imaging is used to diagnose breast cancer and to evaluate the stage and extent of disease. Three types of imaging are used — mammography, ultrasonography and breast magnetic resonance imaging (MRI). Based on these exams, your doctor may recommend further tests or therapy, or determine that not treatment is necessary.

• Screening mammography. A mammogram is a low-dose X-ray of the breast. This is the best test to screen for breast cancer. A screening mammogram consists of two "pictures" of each breast. If an area on the mammogram looks suspicious or is not clear, additional mammograms with different views may be needed. Annual screening mammography is recommended for all women over 40 years old.
• Diagnostic mammography. This is a mammogram used for problem-solving, rather than for screening. For instance, if a patient has a lump in her breast, a directed investigation of that area is performed. This is also done when a particular finding in the breast is being followed over time. A diagnostic mammogram is tailored to the patient's case and is carefully monitored by a radiologist, who interprets the images and determines whether there is any need for further tests.
• Ultrasonography. Using high-frequency sound waves, ultrasonagraphy can often show whether a lump is solid or filled with fluid. This exam may be used along with diagnostic mammography or MRI to answer questions about a specific area of the breast. Because it uses sound waves instead of X-rays, ultrasound provides information that is different and often complementary to the mammogram.
• Breast MRI. Magnetic resonance imaging (MRI) can be used to look specifically at the breast. Each exam produces hundreds of images of the breast, cross-sectional in all three directions (side-to-side, top-to-bottom, front-to-back), which are then read by a radiologist. It can show lesions not visible through mammography or ultrasound. The American Cancer Society recommends that certain women with an especially high risk of developing breast cancer have an MRI scan along with their yearly mammogram. Breast MRI is non-invasive and no radioactivity is involved. The technique is believed to have no health hazards in general.The hope is that such non-invasive studies will contribute to our progress in learning how to predict the behavior of tumors, and in selecting proper treatments. Breast MRI is an evolving technology and should not replace standard screening and diagnostic procedures, such as clinical and self-exams, mammograms, fine needle aspiration or biopsy.

Biopsy

One way to find out if a breast lump or abnormal tissue is cancer is by having a biopsy. During a biopsy, a surgeon, a pathologist or a radiologist removes a portion or all of the suspicious tissue. The suspicious tissue is examined under a microscope by a pathologist who checks for cancer cells and makes the diagnosis. The following are descriptions of different types of biopsies.

• Fine needle aspiration (FNA) biopsy. FNA samples a woman's lump using a thin small needle that leaves a mark no bigger than a needle stick from a blood test. FNA often allows us to diagnose a lump within two to three days.
• Stereotactic core biopsy. This procedure was developed as a less invasive way to obtain tissue samples for diagnosis. It involves removing tissue with a biopsy needle while your breast is compressed in a way similar to a mammogram. This biopsy requires less recovery time than surgery and causes no significant scarring. You and your physician and radiologist may consider this procedure if there is an abnormality on a mammogram that cannot be felt. Your radiologist decides if this procedure is technically possible for your condition and your physician decides if it's appropriate for your situation.
• Needle (wire) localization biopsy. This type of biopsy involves the use of a needle and wire to locate the abnormal tissue and surgery to remove it. Needle localization is performed when you have an abnormality on a mammogram that cannot be felt. It is an outpatient biopsy that is done in two steps on the same day.

Decision-making consultation

If you are diagnosed with breast cancer, Collaborative Care services at the UCSF Carol Franc Buck Breast Care Center can help you effectively communicate with your doctors as you navigate the series of complex decisions surrounding your treatment options. To learn more, please read about our Patient Support Corps.

Treatments

Treatments for breast cancer include surgery as well as radiation, chemotherapy and hormonal therapy. These treatments are either local or systemic. Local treatments, such as surgery and radiation therapy, remove, destroy or control cancer cells in specific areas. Systemic treatments, such as chemotherapy and hormonal therapy, destroy or control cancer throughout the body. Depending on your condition, you may receive one treatment or a combination at the same time or in succession.

Surgery

Surgery is a common treatment for cancer. Several procedures may be used, from lumpectomy to breast reconstruction:

• Lumpectomy. In this procedure, a surgeon removes the cancer and some normal tissue around it. Lumpectomy usually results in little change in breast appearance. Some lymph nodes may be removed from under your arm to determine if cancer has spread. Radiation therapy is typically performed to destroy any cancer cells that may remain.
• Partial or segmental mastectomy. Depending on the size and location of the cancer, this procedure can conserve much of the breast. The surgeon removes the cancer, some breast tissue, the lining over the chest muscles below the tumor and usually some of lymph nodes under the arm. In most cases, radiation therapy follows.
• Sentinel lymph node dissection. One or more of your sentinel lymph nodes are removed in this procedure. To locate a sentinel node, the surgeon injects a blue dye (isosulfan blue) into the skin where the breast cancer is or was. The blue dye is picked up by the lymphatic vessels and travels to a sentinel node. A lymph node is removed and sent to pathology, where it is examined. The sentinel lymph node is believed to most likely contain disease if the cancer has spread from the breast to the lymph nodes. Other lymph nodes may or may not be removed, depending on your situation. This procedure typically takes about an hour.
• Modified radical mastectomy. In this type of mastectomy, a surgeon removes the breast, some of the lymph nodes under the arm, and the lining over the chest muscles, and sometimes part of the chest wall muscles.
• Radical mastectomy. The surgeon removes the breast, chest muscles and all the lymph nodes under the arm in a radical mastectomy. This was the standard operation for many years, but now is performed only when a tumor has spread to the chest muscles.
• Breast reconstruction. Breast reconstruction, or surgery to rebuild a breast, is often an option after the removal of a breast. Health insurance plans in California pay for this surgery, including surgery to make both breasts similar in shape and size. A reconstructed breast will not have natural sensation, but can have a natural appearance. The best cosmetic results are achieved with immediate reconstruction, performed at the same time as the mastectomy. The choice regarding reconstruction is based on personal preferences and will not affect outcome.

Radiation therapy

Radiation therapy is the use of high-energy rays or particles to treat disease. It works by killing tumor cells or inhibiting their growth and division. Years of study by radiation oncologists have led to the widespread use of effective, tolerable doses of radiation. It is used to treat early stage breast cancer along with surgery. It may be used in more advanced breast cancer to control the disease or to treat symptoms such as pain.

To learn more, read Radiation Therapy for Breast Cancer.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. For breast cancer, it is usually administered as a combination of drugs given orally or by injection. Chemotherapy enters the bloodstream and travels throughout your body. The treatment is most commonly used to decrease the chance that cancer will recur after surgery, shrink breast cancer after surgery when the tumor is large or if it is inflammatory, and to control metastatic breast cancer which has spread to other organs in the body.

Hormonal therapy

Hormonal therapies change the hormonal environment in your body, which impacts the growth and behavior of some breast cancers. If your breast cancer produces one of the hormone receptors — estrogen receptor (ER) or progesterone receptor (PR) — then hormonal therapy is effective in treating early-stage, metastatic or advanced breast cancer and preventing recurrence.