Breast cancer

Forward by srinivasan rajagopalan

The breasts and lymphatic system

This page tells you about the structure of the breasts and about the lymphatic glands. There is information about

The breasts



Breast size and density
Lymph glands and the lymphatic system

The breasts:-

The breasts are made up ofFat Connective tissue Gland tissue divided into lobes. A network of ducts spreads from the lobes towards the nipple. If you have 'ductal carcinoma in situ' (DCIS), cancer cells have been found inside these ducts.


Breast size and density:-

The breasts are not usually the same size as each other. They may also feel different at different times of the month - just before a period they can feel lumpy.

You may have heard or read about 'breast density'. This changes with age. Younger women have more glandular tissue in their breasts, which makes them dense. Once a woman is past her menopause, the glandular tissue is gradually replaced by fat, which is less dense. During breast screening it is harder to read a mammogram if the breast tissue is dense. So mammograms are not as reliable for young women. Specialists have also found that older women who take hormone replacement therapy (HRT) have denser breasts than would be expected for their age. This is related to the HRT. It isn't a problem in itself, but it may make mammograms less accurate for these women.Get to know your breasts over time. Learn what natural changes take place during your periods and at other times. Look at your breasts when you change your clothes. Or feel them - for instance when you take a bath. Look for changes that seem unusual for you. If you find an unusual change, see your doctor as soon as you can.


Lymph glands and the lymphatic system:-



A 'tail' of breast tissue, under the skin, leads into the armpit (axilla). The armpits have many lymph glands, also known as lymph nodes. The diagram above shows the network of lymph glands around the breast. They are part of the body's lymphatic system. There is also a chain of lymph nodes that runs up the centre of your chest, by your breast bone. This is called the 'internal mammary chain'.

The lymphatic system is made up of a network of lymph glands, connected throughout the body by tiny tubes (vessels) called lymph vessels. Lymph glands are part of the natural drainage system of the body. Lymph is a yellow fluid that flows through the lymphatic system and eventually drains into veins. This system helps to get rid of waste products from the body.

Tissue fluid bathes the body's cells, drains into the lymphatic system and is recirculated. Lymph glands are important in cancer care because any cancer cells that have broken away from a tumour can be carried by this tissue fluid to the nearest lymph glands. This is why doctors always examine the lymph glands. If you have cancer, but no cancer cells in any of your lymph glands, your cancer is less likely to have spread.
.
.
.
.

Breast cancer symptoms:-

This page tells you about the symptoms of breast cancer. There are sections on

Breast lumps in general
What to look out for
If you spot a lump
Breast pain
More information

Breast lumps in general:-

The first symptom of breast cancer for many women is a lump in their breast. But 9 out of 10 breast lumps (90%) are benign. That means they are not cancers. Most benign breast lumps are Areas of benign breast change, causing lumpiness that is more obvious just before a period, particularly in women over 35 .Cysts - sacs of fluid in the breast tissue. These are quite common
Fibroadenoma - a collection of fibrous glandular tissue. These are more common in younger women

What to look out for:-

Changes that could be due to a breast cancer are

A lump or thickening in an area of the breast
A change in the size or shape of a breast
Dimpling of the skin
A change in the shape of your nipple, particularly if it turns in, sinks into the breast or becomes irregular in shape
A blood-stained discharge from the nipple
A rash on a nipple or surrounding area
A swelling or lump in your armpit

Like breast lumps, these signs don't necessarily mean cancer. Inverted nipples, blood stained nipple discharge or a rash can all be due to other medical conditions. But if any of these things happen to you, you should get it checked out. It may be nothing and seeing the GP will put your mind at rest. It may be a benign condition that can easily be treated. Or at the very worst, if you have a cancer you give yourself the best chance of successful treatment by going to the doctor early on.

There is a rare type of breast cancer called inflammatory breast cancer which can have different symptoms. The whole breast can look red and inflamed and can be very sore. The breast may feel hard. The skin sometimes looks like orange peel because the pores stand out in the inflamed area.

Another rare type of breast cancer shows up as a rash on and around the nipple. It is called Paget's disease. The red, scaly rash can be itchy. It looks a bit like eczema and is sometimes mistaken for that at first.


If you spot a lump:-

See your doctor straight away. If you notice anything unusual about your breast, have it examined. Even though most breast lumps are benign, they need to be checked to rule out cancer. Our page on breast awareness shows how to learn what is normal for you.

Your doctor will examine you and if necessary, send you to a specialist breast clinic for further checks. At the clinic, they will be able to see on your mammogram or ultrasound if the lump is a fluid-filled cyst or a solid lump.

If it is a cyst, they may get rid of it by draining the fluid out through a fine needle. If it is a solid lump, they will stick a very fine needle into it and take a tissue sample to test for cancer cells.

Some women prefer to have benign lumps removed to relieve their worry. They may be concerned that they will confuse them with any other lumps they may get in the future. But if you and your doctor are confident that the lump is benign, you do not have to have it removed if you do not want to. Benign lumps don't turn into cancer.

If your lump is a cancer, the earlier you have breast cancer treatment, the better your chance of cure.


Breast pain:-

Pain doesn't usually mean cancer. Many healthy women find that their breasts feel lumpy and tender before a period. And some benign breast lumps are painful. Many women get pain in their breasts for a while, which goes after a time. There may be no obvious reason for the pain, even with lots of tests. Most breast pain is not caused by cancer, but some breast cancers do cause pain, so if you are worried, see your GP.


More information:-

Look at screening for breast cancer for information about
Examining your own breasts
Having a mammogram
How cancer is diagnosed
Why it's important to find out about it as early as possible

If you would like more information about anything to do with the symptoms of breast cancer, contact one of the breast cancer organisations.


Breast cancer risks and causes:-

This section of CancerHelp UK tells you about the possible risks and causes of breast cancer. You can choose from the following menu


Definite breast cancer risks
Breast cancer genes
Possible breast cancer risks
Breast cancer protective factors

Definite breast cancer risks :-

This page tells you about things that can affect your risk of breast cancer. You can find information on
What you can do
How common breast cancer is
Getting older
Ethnic group
A previous breast cancer
Significant family history
Breast cancer genes
Sex hormones
When you start and stop having periods
Having children or having them early in life
Hormone replacement therapy

Breast cancer genes:-
This page is about inherited faulty genes that can increase the risk of breast cancer. You can find information on

Why carrying inherited faulty genes increase risk
How much breast cancer genes increase your risk
What 'lifetime risk' means
How genetic tests work
Who should be tested
About the test
How reliable the test is
The result
What to do if you have a positive test result
More information on breast cancer genes

Why carrying inherited faulty genes increase risk:-

There have to be a number of mistakes in a cell's genetic code before it becomes cancerous. Doctors call these mistakes 'mutations'. Most of these gene mutations develop during our lifetime - either because of substances we come into contact with that cause cancer. Or because of mistakes cells make when copying their genetic code before dividing into two new cells. Most of these abnormal cells die or are killed off by your immune system. It usually takes many years to gather enough genetic mistakes so this is one of the reasons cancer is generally more common as we get older.

But it is possible to be born with a gene fault that may cause cancer. This doesn't mean you will necessarily get cancer. But it will mean that you are more likely to than the average person. Faults in some breast cancer genes increase your risk of cancer because they are genes that normally protect cells from cancerous changes.

How much breast cancer genes increase your risk:-

The first breast cancer gene faults to be found were BRCA1 and BRCA2. These faults don't mean you have cancer, or you definitely will get cancer but women with these genes have a 50 to 80% chance of getting breast cancer in their lifetime. We now know of other genes that significantly increase a woman's risk of breast cancer. They are called TP53 and PTEN. Genetic tests are available to women with a high risk of having changes in their BRCA1, BRCA2, TP53 or PTEN genes.

Researchers have found other common genes that can slightly increase a woman's risk of developing breast cancer. These are called CASP8, FGFR2, TNRC9, MAP3K1 and LSP1. No tests are available to find these genes yet.

Rare genes that can also increase breast cancer risk slightly include CHEK2, ATM (ataxia telangiectasia mutated), BRIP1 and PALB2. No tests are available for these genes yet.

What lifetime risk means:-

Lifetime risk can be quite difficult to understand. 1 in 9 women in the UK will develop cancer during their lifetime. But the risk is small in younger women and and increases as they get older. Women with a faulty breast cancer gene will have a higher risk of developing breast cancer than people of the same age. But if you are 30, your risk of breast cancer is going to be much lower than if you are 80, whether or not you carry a breast cancer gene.

There is more about definite risk factors for breast cancer, including what is meant by having a family history, in this section of CancerHelp UK.


How genetic tests work:-

It is only possible to have a test for BRCA1, BRCA2, TP53 or PTEN if you have a strong family history of breast cancer. Most people also need to have a living relative with breast cancer. This is because looking for a gene fault is a bit like looking for a single spelling mistake in a very long book. Your relative has to be tested first to try to find out which fault on the breast cancer genes might run in your family. Then the researchers look for that same gene fault in you. They are more likely to find the fault if they know what to look for.

Some labs can do a test on the genes without having blood from a living relative, but this is less likely to find the fault. It is important to remember that no test is 100% accurate and genetic tests can miss the fault. So, if your relative with breast cancer’s test is negative, this only means they didn’t find a gene mutation – not that there definitely isn’t one there. There is more about the reliability of gene testing further down this page.

With particular groups of women, there are very common specific gene faults. Ashkenazi Jewish women tend to have one of 3 very particular gene mutations. Specialists in breast cancer gene testing know where they are in the gene. So it is much easier to check to see if you carry one of them. If you are Ashkenazi Jewish, you can be tested for one of these mutations. Because the testers know what to look for, it is possible to have this test without a living relative with breast cancer.


Who should be tested:-

In the UK, guidelines published by NICE (the National Institute for Health and Clinical Excellence) say that women should only be referred to a specialist genetics services for gene testing if they have a high risk of developing breast cancer. They define a 'high risk' as having a 1 in 3 chance of getting breast cancer at some point in your life. Or a greater than 1 in 12 chance of getting breast cancer before the age of 50. There are many different family situations they outline that could mean you are at high risk. Generally, they look at

The age your relatives were diagnosed with breast cancer (the younger they are, the more likely there is to be a faulty gene in the family)
Whether anyone had cancer in both breasts
If there are men in your family who've had breast cancer
If there is also ovarian cancer in the family
The affected family members you are 'counting' towards your risk must be close, blood relatives of yours and must all be from the same side of the family (so either your mother's relatives OR your father's). You can download the public information on familial breast cancer from NICE or ask them to send you a copy in the post.

To get a genetic test, you need to ask your GP for a referral to a specialist breast clinic. If they think you probably do have a high risk of breast cancer, they will refer you on to a specialist genetics service. There, they will talk to you about your risk and discuss the test with you. The test result takes a few weeks, sometimes longer, to come back.

Before you decide whether or not to go ahead with the test, the staff in the clinic will make sure that you have good information to take away, read and think about. Having a test can have a big impact on you and other members of your family. The clinic staff will try to answer all the questions you have about the test. There’s no rush and you can take as long as you need to make up your mind whether to go ahead or not.

Even if you know it is possible, finding out that you have a high risk of breast cancer is still likely to come as a shock. You need to be sure that you want to know the test result before you go ahead. And that you will be able to decide whether you are going to do anything about it or not if you get a positive result. Everyone is different and there is no right or wrong way to feel about this. The important thing is that you feel you have been given enough information to make the right choice for you about the test. Talk it over with a good friend or relative. Or if you feel you need to talk with your genetics specialist again, get back in touch with them.


About the test:-

There are one or two things to think about before asking for a test

How do you feel about being tested
What does the result really mean?
What would you do if the result was positive?
Before you ask for gene testing, think about what it may mean for you. What will you do about the result? How will you feel? Would you rather not know? Would you consider having both breasts removed to prevent breast cancer?

There are also one or two things to know about the test. If you haven't had breast cancer, in order to be tested in the first place, you usually need to have a relative with a known gene mutation. The lab staff can then look for exactly the same gene fault in your genetic code and tell you whether you have inherited it or not.

If you haven't had a relative tested already, but you have a living relative with breast cancer, they usually have to be tested before you can be tested. But unfortunately, this still isn't straightforward. There are many different gene mutations. The genetic code is very long and a gene fault could be in many different places. Having a living realtive who can be tested makes it much more likely that the genetic fault will be found. But even this is not 100% accurate.

How reliable the test is:-

As we’ve said, it is best if a woman in your family who already has breast cancer is tested first to try to find a gene fault. Then, if they find one, they will look for the same fault in you.

Some NHS labs in the UK don’t check the whole gene. Generally, they check about 60% of it, although this varies between labs. To keep the ‘spelling mistake’ example, this is like looking for a single spelling mistake in the first 12 chapters of a 20-chapter book, but ignoring the last 8 chapters. So a negative result means they haven't found a gene fault, but it doesn’t mean there definitely isn’t one there. Across the country, the labs find a gene fault in about 2 out of 10 women having this test. So in 8 out of 10, the test is inconclusive. Some labs check the whole gene and this is much more accurate. You can find information about NHS gene testing labs on the UK genetic testing network website. You can look on their database to see which services are offered by labs close to you.

You can have 100% gene testing privately. You have to send a blood sample to the USA. It is still best to have a living relative with breast cancer so that they can be checked for all the commonest gene faults first. You can have a test without having a living relative with breast cancer tested, but the result won't be as reliable. If it comes back negative, they won't be able to tell you whether there is a gene mutation in your family or not. So you will have paid out a couple of thousand pounds and won't know any more than you did before.

Do be careful when finding private medical services on the web. There are some charlatans out there, particularly advertising on the internet. One reliable company is called 'Myriad' - they developed the test originally. Even if you are sure the company you've picked is reliable, you really need to talk this over with a breast specialist or genetics specialist before going ahead. Do remember that most women who get breast cancer do not have breast cancer gene faults. And you must be sure you've thought about how the result will affect you.

The 2004 NICE guidelines said the UK should aim for 100% gene testing instead of 60%. The UK Government has said it will put more resources into improving gene testing in this country and in time all labs should be doing 100% testing on the NHS. But we don't know when that will happen just yet.


The result:-

The most accurate way to find a faulty gene is to have a test after a faulty gene has already been found in one of your relatives who has breast cancer. The genetics lab will then look for this specific gene fault in you and can say definitely whether it is there or not.

A positive result means you carry a known breast cancer gene. As we have seen, this means about a 50 to 80% chance of developing breast cancer by the end of your life.

A negative result means you do not carry the same gene fault as was found in your relative. A very rare possibility is that you could carry a different breast cancer gene mutation, but this isn't very likely.

Remember - if you are the first person in your family to ask for a breast cancer gene test, you must usually have a relative with breast cancer tested first. If that relative has a negative result, that means the lab didn’t find a gene fault in their sample. Unfortunately, that doesn't mean there isn’t one - just that they didn’t see one in the bit of the gene sequence they examined.


What to do if you have a positive test result:-

There are 3 options if you carry a known breast cancer gene

Have regular breast cancer screening
Have surgery to remove your breasts
Join a prevention trial

Screening will increase the chance of a breast cancer being picked up early enough to cure it. Having surgery is an option. Some women choose to have both breasts removed and immediate breast reconstruction. But it does not completely rule out the risk of breast cancer. It is possible that there are cells somewhere else in your body that could develop into breast cancer, although this is relatively rare.

You may also be advised to have your ovaries removed. Unfortunately, some breast cancer gene faults increase the risk of ovarian cancer too. As many as 2 out of 3 women who carry the BRCA1 or 2 genes will get ovarian cancer by age 75. This is the maximum risk. The actual risk will vary from family to family, depending on how often the gene fault shows up (called gene penetrance).

A clinical trial called IBIS1 has been looking into using tamoxifen to prevent breast cancer starting in women with a strong family history. The women in this trial took tamoxifen for 5 years. The results show that tamoxifen lowers breast cancer risk by about a third in high risk women. And we now know that the benefit carries on for at least another 5 years after women stop taking tamoxifen. Tamoxifen does have side effects, but these nearly all go as soon as women stop taking the drug.

A further development of this trial, IBIS2 started in 2003. This trial is looking at whether another type of hormone drug, anastrozole (Arimidex) can prevent breast cancer in women at high risk. While this trial is recruiting, it will be on our clinical trials database. Pick 'breast' from the drop down menu to find it. Or you can type 'ibis' in the free text search box on the clinical trials page.


Possible breast cancer risks :-

This page tells you about factors that researchers are looking into to see if they could possibly increase the risk of getting breast cancer. There is information below about

Diet
Having uneven breasts
Injury to the breast
Diabetes
There is also information on factors that have been researched, but don't seem to increase risk. They are
Pesticides
Smoking
Having a pregnancy terminated
Stress
Diethylstilboestrol (DES)

Diet:-

What you eat may increase your breast cancer risk. Recent research indicates that fat in the diet may play a small part in breast cancer risk. There is more about this in the 'foods we all eat' section of diet and preventing breast cancer.


Having uneven breasts:-

A recent study showed that women who have one breast larger than the other may be at a slightly increased risk of developing breast cancer. But any increase in risk is small compared to other risk factors. For most women it is normal to have slightly uneven (asymmetrical) breasts. More research needs to be done before we know for sure how this may affect breast cancer risk. The important thing is to check your breasts regularly and be aware of how they usually look and feel. And to let your doctor know if you notice any changes, including unevenness.


Injury to the breast:-

Some women wonder if a past injury could have caused their breast cancer. Scientific research has not identified this as a risk factor but one study did suggest a link. We need more studies to prove or disprove this. There is more information about this injury and breast cancer study in our breast cancer questions section.


Diabetes:-

A meta-analysis of 20 individual studies reported that women with diabetes have a small increase in their risk of breast cancer. This may be due to higher levels of insulin during the initial phase of diabetes. But people with diabetes often have a higher body mass index (BMI) and a high BMI increases the risk of breast cancer for some people. So it is not clear why women with diabetes may have an increased risk.


Diethylstilboestrol (DES):-

Diethylstilboestrol (DES) is a drug that is no longer used in medicine. It was used between 1945 and 1970 as a treatment for pregnant women, to stop them having a miscarriage. Researchers are still gathering information about its effects. Some research studies have shown that women who took DES during pregnancy have a slightly increased risk of breast cancer.

One American research study found that daughters of women who took DES during their pregnancy have an increased risk of breast cancer after the age of 40. But we need more research before we can be really sure there is a link.


Pesticides :-

Some people think that pesticides increase the risk of breast cancer. But there is no convincing scientific evidence for the role of any pollutants in breast cancer risk, including pesticides. If pollutants were a major risk factor, this would be very likely to have shown up in the research that has been done so far. The fact that there is no clear evidence shows that if pollutants do have any role in causing breast cancer, it is only likely to be a very small one. So you don't need to be alarmed about any suggested link between them.


Smoking:-

There has been quite a bit of research into this. Smoking does not seem to be linked to breast cancer. But smoking is bad for your health, so if you do smoke, you'd be well advised to stop!


Having a pregnancy terminated:-

Pregnancy termination, or abortion, has been looked into in several different studies. It doesn't seem to increase breast cancer risk. Researchers thought it might, because of the effect of pregnancy on breast cells.


Stress:-

Research has been done into the effects of stress on breast cancer. A study of women with breast cancer, led by Cancer Research UK's London Psychosocial Group, found that stress did not make breast cancer more likely to come back. Another study called the Nurses' Health Study found no link with breast

Breast cancer protective factors:-

This page tells you about factors that can help to protect people against breast cancer. There is information about

Being physically active:-
Breastfeeding
Diet
Aspirin and other non-steroidal anti-inflammatory drugs
Using medicines to prevent breast cancer
Coeliac disease

Being physically active:-

We know from research that physical activity can help to prevent breast cancer. Studies have found a protective effect of about 30 to 40%. So being active may lower your risk by about a third. This is probably because physical activity lowers oestrogen and testosterone levels and can delay the start of periods.


Breastfeeding:-

Statistics show that if you breastfeed (particularly if you have your children when you are younger) you are less at risk of developing breast cancer. The longer you breastfeed your baby, the more you lower your risk. We don't know exactly why this is. It may be because you don't ovulate so often when you are breastfeeding. Or because breastfeeding changes the cells in the breast and may make them more resistant to the changes that lead to cancer.


Diet:-

A healthy diet may help prevent breast cancer. Look at the CancerHelp UK section on diet and preventing breast cancer for more information.


Aspirin and other non-steroidal anti-inflammatory drugs:-

Research has shown that women regularly using aspirin or other non-steroidal anti-inflammatory medicines probably have a small reduction in their risk of breast cancer. Remember though that aspirin can be dangerous and you should talk to your own GP before starting to take it regularly. It can irritate the lining of your stomach and cause bleeding. You certainly shouldn't take it if you have any history of stomach ulcer.


Using medicines to prevent breast cancer:-

Research is looking into drugs that may prevent breast cancer.

Tamoxifen is a drug that has been used to treat breast cancer for more than 20 years. It works by stopping oestrogen from getting to hormone receptors on breast cancer cells. Oestrogen works on some types of breast cancer by triggering the cells to divide and multiply, so the cancer grows. Some women who are at high risk of breast cancer have been taking tamoxifen to see if it can stop them developing the disease. Trials have been carried out worldwide. Cancer Research UK have looked at the results of all these trials together. They show that tamoxifen can lower your risk of breast cancer if you are at high risk of the disease.

Tamoxifen seems to help to prevent breast cancers that have oestrogen receptors. It does not protect against oestrogen receptor negative cancers. There are also concerns about side effects for otherwise healthy women. The trials show clearly that there is an increased risk of blood clots and of womb cancer for women taking tamoxifen.

The latest results from one of these trials, IBIS1, show that the benefits of tamoxifen in preventing breast cancer seem to last for at least another 5 years after the 5 years of tamoxifen treatment has ended. But the side effects mostly go once you stop taking the drug. A small number of women were diagnosed with womb cancers after the treatment period, but these can be successfully treated. The risk of clots only lasted while women were taking tamoxifen.

Other hormone drugs are being investigated for preventing breast cancer. Doctors hope that these other drugs may have fewer side effects than tamoxifen. These are raloxifene, exemestane and anastrozole.

Raloxifene is a drug used to treat bone thinning (osteoporosis) in women who have had their menopause. Some doctors think it may help prevent breast cancer too and recent research has shown it may help prevent breast cancer in post menopausal women.

Anastrozole (Arimidex) is a drug that has mostly been used to treat secondary breast cancer. It is also licensed in the UK to treat early breast cancer. Anastrozole is being tested for preventing breast cancer in a trial called IBIS 2. While it is open, this trial will be listed on our clinical trials database. Choose 'breast' from the drop down menu. Or type 'ibis' into the freetext search.


Coeliac disease:-

Coeliac disease is a disease of the small bowel. People with coeliac disease have an immune or allergic reaction to gluten, a protein found in rye, wheat and barley. This causes inflammation., which over time can damage the lining of the small bowel. This makes it difficult for the bowel to absorb the nutrients we need from our food. Symptoms of coeliac disease include bloating and discomfort in the tummy (abdomen), diarrhoea, low red blood cell count (anaemia) and tiredness. People with coeliac disease have to stick to a gluten-free diet.

Some research suggests that people with coeliac disease have a lower risk of getting breast cancer. There is a study looking into why this might be the case. There is information about this on our clinical trials database. But there is also evidence that coeliac disease can slightly increase the risk of some other cancers, such as non Hodgkin's lymphoma.

Breast cancer protective factors:-

This page tells you about factors that can help to protect people against breast cancer. There is information about

Being physically active
Breastfeeding
Diet
Aspirin and other non-steroidal anti-inflammatory drugs
Using medicines to prevent breast cancer
Coeliac disease

Being physically active:-

We know from research that physical activity can help to prevent breast cancer. Studies have found a protective effect of about 30 to 40%. So being active may lower your risk by about a third. This is probably because physical activity lowers oestrogen and testosterone levels and can delay the start of periods.


Breastfeeding:-

Statistics show that if you breastfeed (particularly if you have your children when you are younger) you are less at risk of developing breast cancer. The longer you breastfeed your baby, the more you lower your risk. We don't know exactly why this is. It may be because you don't ovulate so often when you are breastfeeding. Or because breastfeeding changes the cells in the breast and may make them more resistant to the changes that lead to cancer.


Diet:-

A healthy diet may help prevent breast cancer. Look at the CancerHelp UK section on diet and preventing breast cancer for more information.


Aspirin and other non-steroidal anti-inflammatory drugs:-

Research has shown that women regularly using aspirin or other non-steroidal anti-inflammatory medicines probably have a small reduction in their risk of breast cancer. Remember though that aspirin can be dangerous and you should talk to your own GP before starting to take it regularly. It can irritate the lining of your stomach and cause bleeding. You certainly shouldn't take it if you have any history of stomach ulcer.