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"Breast cancer is treatable if caught early, and often fatal if not. Mammograms are the best tool we have to find breast cancer before it spreads and becomes much more difficult to treat." -Dr. Debbie Saslow, American Cancer Society
WHAT IS BREAST CANCER?
Breast cancer is the disease that women in the United States fear the most, and for compelling reasons. It is the most common cancer in the U.S. for women, second only to lung cancer for cancer-related deaths among American women. Over 200,000 Americans are diagnosed with the disease every year, and roughly 40,000 lose their lives annually.
Coupled with Western ideals that equate breasts with sexuality and beauty, many women feel that having breast cancer and losing part or all of their breasts as a result, means a loss of their femininity. Almost everyone can name someone close to them that has suffered from this disease, yet so many still know little about breast cancer, including diagnosis, treatment options and ways of reducing their risks.
What is breast cancer exactly? In the most simple terms, it is when cells in your breast begin growing abnormally. The most common type of breast cancer begins in the ducts of the breast designed to carry milk; other types occur in the lobules, or sacs that produce milk. These cancerous cells form a malignant tumor, which can invade surrounding breast tissue and invade the lymph nodes, or collections of immune system cells that help fight infections.
Eighty percent of women diagnosed with breast cancer have no family history of the disease. About 5-10% actually inherit breast cancer, due to defects in one of two genes, dubbed BRCA 1 (Breast Cancer 1) or BRCA 2 (Breast Cancer 2). Both men and women can inherit these genes from either one of their parents.
EARLY DETECTION IS THE KEY TO SURVIVAL
While there is still no cure for the disease, the experts and leading organizations such as the American Cancer Society, Susan G. Komen Breast Cancer Foundation and Mayo Clinic all agree that early detection is the key to surviving breast cancer. If detection is delayed, the cancer tends to spread to distant organs and becomes very difficult, often impossible, to treat effectively. Too many women delay getting regular mammograms or are not aware that they need to and--if there is a tumor--they run the serious risk of enabling it to spread beyond the breasts.
WHAT ARE THE RISK FACTORS FOR BREAST CANCER?
The American Cancer Society estimates that 75 % of breast cancer cases occur in women with no known risk factors, other than sex and age. However, the following factors increase your risk:
Sex: Being a woman is your greatest risk factor. It should be noted that while it is rare for men to get breast cancer, approximately 1,300 men are afflicted with breast cancer each year. Risk factors for men include a family history, a genetic defect, exposure to radiation or having a disease related to high levels of estrogen in the body, like cirrhosis of the liver. For more information on male breast cancer, visit the National Cancer Institute's website, www.cancer.gov.
Age: One out of every eight women will be affected by breast cancer at some point in their lives, and your chances of developing breast cancer increase as you get older. Women under 30 are rarely (but sometimes) affected, whereas most breast cancers occur in women over age 50.
Family History of Breast Cancer: Women with a mother or sister with breast cancer have a higher chance of developing it themselves, and the more relatives you have with breast cancer who were premenopausal at their time of their diagnosis, the higher your own risk.
Personal History of Breast Cancer: If you've already been diagnosed with breast cancer in one breast, you are at an increased risk for developing cancer in the other breast. Additionally, radiation therapy to the chest before age 30 also puts you at higher risk for breast cancer.
Genetic Predisposition: Defects in the BRCA 1 or BRCA 2 genes put you at greater risk of developing the disease. Usually these genes help prevent cancer by making proteins to keep cells from growing abnormally, but if they are mutated, the genes aren't as effective. Women of Eastern European Jewish ancestry (called "Ashkenazi" Jews) are especially at risk.
Excess Weight: Although the relationship between breast cancer and excess weight is complex, in general, weighing more than you should, and especially carrying weight in your abdomen, puts you at greater risk for breast cancer. Women who have gained weight after menopause are also at higher risk.
Insufficient Exercise: Women who do not exercise regularly are more susceptible to weight gain, which is linked to a higher risk of breast cancer. Women who begin exercising in their teens can help delay the onset of menstruation, and by decreasing the amount of estrogen exposure, a woman can decrease her lifetime risk of developing breast cancer.
Exposure to Estrogen: If you have a late menopause, or began menstruating before age 12, you have a slightly higher risk of developing breast cancer. The same is true for women who have never had children, or waited until after age 30 to have children.
Race: Caucasian women are more likely to develop breast cancer than African American or Hispanic women, but minorities are more likely to die of the disease. They tend to be diagnosed at a later stage than white women, mostly due to lack of regular mammograms.
Hormone Therapy: Recent studies show that there are some health risks with hormone therapy, especially at higher doses and/or when taken for an extended time. Some menopausal women need and may benefit from hormone therapy due to difficult symptoms. Before starting, it is important to discuss your risk factors for breast cancer and other diseases with your doctor to determine whether hormone replacement is right for you - and, if so, in what doses, combinations and for what time period. According to the National Cancer Institute, women who take hormone therapy for five or more years after menopause seem to be at greater risk. Taking estrogen plus progesterone puts women at a slightly higher risk, and hormone therapy may make tumors harder to detect on mammograms. If you are on hormone therapy, it is important to let the doctor ordering your mammogram know as well as the radiologist, so that they will know that the test will be a bit less sensitive.
Birth Control Pills: The American Cancer Society says that women currently using the pill may have a slightly increased risk, whereas women who stopped using oral contraceptives 10 years ago probably don't have this risk. Most women who use oral contraceptives take them at a young age, when their risk of breast cancer is very low.
Exposure to Carcinogens: Polycyclic aromatic hydrocarbons (PAHs), chemicals found in cigarettes and charred meat, can increase your chances of developing breast cancer. Exposure to pesticides may also increase your risk.
At present, there is no evidence that residues of pesticides at the low doses found in foods increase the risks.
Excessive Consumption of Alcohol: Regular consumption of even a few drinks per week is associated with an increased risk of breast cancer in women.
Over-use of antibiotics: More studies need to be conducted to determine the reason why excessive antibiotic use may be associated with an increased risk of breast cancer. One theory, provided on the National Cancer Institute's website, is that antibiotics affect a body's immune function. It needs to be emphasized that antibiotics are an important weapon to combat bacterial infections, but gratuitous or excessive use may increase breast cancer risk as well as making a person potentially less responsive to antibiotic treatments in the future.
THE SIGNS OF BREAST CANCER
Identifying the signs and symptoms of breast cancer is a crucial step in saving your life, because the five-year survival rate of those affected is 97 % when the cancer is detected in the early stages.
Breast cancer is most effectively detected in the early stages by a mammogram, before signs are present. The most common sign of breast cancer is a lump, but spontaneous clear or bloody discharge from your nipple, a retraction or indentation of your nipple, a change in the size or shape of your breast, a flattening or redness or pitting of the skin around the breast are also indications of this type of cancer. If a woman ignores these signs, she may eventually experience pain if the tumor compresses a nerve or spreads to the bone.
Upon discovering a lump, many women avoid seeing a doctor because they fear a diagnosis of breast cancer, but it should be known that about 80% of lumps are non-cancerous; they can also be caused by trauma to the breast, a cyst, infection, or fibrocystic changes. If you do feel a lump and you have not gone through menopause, you may want to wait through one menstrual period before having it checked out, but afterwards, be sure to report this lump to your doctor.This important recommendation applies to all women, but especially those who have previously had breast cancer.
SCREENING FOR BREAST CANCER
Listed below are the most common methods of screening for breast cancer, administered by a doctor or nurse.
• Mammogram Annually beginning at age 40, earlier if you have a strong family history or genetic predisposition for the disease. A mammogram is a series of X-rays designed to detect tumors before they can be felt.
• Clinical Breast Exam Once every three years, administered by your doctor or nurse, until age 40. After that, it is recommended that women have a yearly clinical exam, where your breasts will be examined for lumps and changes.
• Breast Self Exam (BSE) Beginning in their 20s, women should be told about the benefits and limitations of BSE. Women should be aware of how their breasts normally feel and report any new breast change to a health professional as soon as they are found.
There are several tests being used in order to detect and diagnose breast cancer. Some of these include Magnetic Resonance Imaging (or MRI), ultrasound and digital mammography. Since early detection is key, all women should know about as many options as possible, and should practice the screening options listed above.
HOW DOES IT FEEL TO HAVE A MAMMOGRAM?
As a woman interviewed by CBS Cares put it, "Having a mammogram isn't any more uncomfortable than the rest of the rituals women undergo willingly on a daily basis. Like shoving your feet into too-small heels, or squeezing into your skinny jeans when it was apparent they didn't fit five pounds ago. And you wear those jeans all day - at least the mammogram's over in half an hour!" Another woman said, "It's like a big pinch. If you've been pinched before you know the little ones are even worse. But slight discomfort is nothing compared to the reward of knowing you're healthy or knowing you've caught something sooner rather than later."
Good points. What specifically happens when you have a mammogram? First, your breasts are compressed between plastic plates while X-rays are taken. The entire process takes about thirty minutes; the actual compression takes only a few minutes. You may find the procedure somewhat uncomfortable, but scheduling a mammogram after your menstrual period and avoiding caffeine for two days prior to the exam should alleviate too much discomfort. It should be emphasized that any minor discomfort is heavily outweighed by the opportunity to detect breast cancer at an early stage when it is far more treatable.
Although mammograms aren't perfect - about 10-15% of breast cancers don't show up on X-rays - they are still highly effective. Sixteen percent of all breast cancer-related deaths would be avoided if all women got regular mammograms; women who have yearly mammograms have a 20-50% reduced chance of dying of breast cancer compared to those who don't. The American Cancer Society points to alarming evidence that many women are still not getting these life-saving tests done for a variety of reasons, among them being that women are afraid of the procedure or its results, or are embarrassed, or that their doctors simply aren't conveying the importance. Minority women are especially among those not getting tested, although this is due mostly to socio-economic reasons. Most importantly, women with no health insurance should not let that keep them from getting regular mammograms, as many state health departments, as well as Planned Parenthood clinics offer low-cost or free screenings. To find out about free or low-cost screenings in your area, visit the American Cancer Society website, www.cancer.org, or call toll-free at 1-800-ACS 2345.
Additionally, during National Breast Cancer Awareness month each October, women should make a special point of utilizing helpful resources in their area that will help protect them against breast cancer.
WHAT IF I'M DIAGNOSED WITH BREAST CANCER?
A diagnosis of breast cancer is a very difficult experience to go through, because you are faced with a life-threatening illness and must make complex decisions about treatment. Since no one "right" treatment exists for everyone, it is important to know your options. Make sure that you are in the hands of a doctor who is very experienced in the treatment of breast cancer. Don't be afraid to ask your doctor questions or ask for a second opinion. Learn as much as you can from books, websites and information available from such organizations as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talk to other women who are sharing similar experiences, read as much as you can and take charge of your health. Make sure that your relationship with your doctor is a true partnership and that s/he is taking the time to answer your questions.
There are treatments for every one of the five stages of breast cancer. According to the Mayo Clinic's website, most women will have surgery and additional therapy such as radiation, chemotherapy or hormone therapy.
BREAST CANCER SURGERY - WHAT ARE THE OPTIONS?
Lumpectomy This operation removes only the lump plus a surrounding area of normal tissue, saving as much of your breast as possible. The surgeon will probably do a lymph node dissection to check for the spread of cancer. In most cases, women will undergo radiation therapy following their operation, usually every weekday for six to seven weeks. Many women choose the lumpectomy plus radiation instead of a mastectomy because they are more satisfied with their appearance after a lumpectomy, and the survival rates for both operations are similar. However, a lumpectomy may not be an option if a tumor is very large or deep within your breast; it may also not be possible if you've had radiation therapy, are pregnant or have had two or more areas of cancer in the same breast.
Mastectomy A mastectomy involves removing breast cancer as well as the surrounding breast tissue. There are different types of mastectomies, which include the following: partial mastectomy, which is considered to be a breast-sparing operation, as it only removes the tumor as well as some breast tissue around the tumor, the lining of the chest muscles and some lymph nodes under your arm; simple mastectomy, where all the breast tissue is removed, including lobules, ducts, fatty tissue and the nipple and areola area; and the modified radical mastectomy, which is a procedure where the surgeon removes your entire breast and some underarm lymph nodes, but leaves the chest muscles intact. Depending on the results of all of these mastectomies, you may need further treatment.
AFTER THE SURGERY
A big part of dealing with breast cancer is what happens after the surgery. There may be changes in your physical appearance, especially if you undergo a mastectomy. Many women choose to have breast implants to restore not only their shape, but also their self-esteem. Many women will have chemotherapy, which involves receiving drugs in a combination that will kill cancer cells that have spread outside the breast. There are medications like Tamoxifen, which reduce the effect of estrogen in your body. Side effects associated with chemotherapy may include hair loss and nausea, though nausea is often helped by other drugs.
Want to know about treatment options? The most common treatment option is chemotherapy, which is highly effective. It does pose some risks and doesn't work for everyone. But, the sooner breast cancer is detected, the more likely it is to respond to treatment with chemotherapy drugs. It is important to note that a number of new approaches to treating breast cancer are being studied in clinical trials, emphasizing methods that could prolong women's lives, with minimal side effects.
WHAT TO DO IF YOU OR SOMEONE YOU KNOW IS DIAGNOSED WITH BREAST CANCER
All of this information about breast cancer, and certainly a diagnosis, can be overwhelming. But remember, you are not alone! Find a strong support system of other survivors, friends, family or doctors whom you can turn to in times of need. Links to important websites are provided below and they can help you to find support groups, which include other women with breast cancer.
Remember that everyone wants you to get better, so don't be afraid to ask for help. Focus on getting better and improving the quality of your life one day at a time. Certainly having breast cancer will change your life, as well as the lives of your family and those close to you. But, with advances and medical breakthroughs on the horizon, there is always good reason to hope for the best. Read stories of inspiration from survivors and continue to do things that you enjoy; after all, improving the quality of your life never hurts, with or without a disease like breast cancer.
WHAT'S NEW IN BREAST CANCER RESEARCH?
While the importance of getting mammograms and knowing your body well enough in order to detect breast cancer in its earliest possible stage cannot be stressed enough, advancements in medical technology are allowing doctors to research new ways to increase chances of survival for women who have already been diagnosed. Research is ongoing, and there are many experimental drugs being tested in clinical studies by organizations like the National Cancer Institute ( www.cancer.gov). Listed below are the options that are currently the most commonly investigated.
Aromatase inhibitors. Currently, Tamoxifen is the drug most widely being used to treat breast cancer. However, medical studies have shown Tamoxifen to interfere with antidepressants and increase the risk of cancer of the uterus and blood clots in women who are bed-ridden; thus, it may not be the best treatment option for everyone.
In new clinical studies, aromatase inhibitors, or drugs that reduce estrogen levels in your body, are being tested for effectiveness in conjunction with, or over Tamoxifen alone. Three aromatase inhibitors - anastrozole, letrozole and exemestane - were tested in various combinations (for example, some women received anastrozole instead of Tamoxifen as an initial adjuvant therapy). The New England Journal of Medicine reported a study using 5,000 postmenopausal women; half of which took Tamoxifen for two to three years and then switched to an aromatase inhibitor, while the other half continued the typical five-year course of Tamoxifen. After nearly three years, the women who combined Tamoxifen and an aromatase inhibitor had 32% fewer spreading or recurrences of their breast cancer, and half as many new cancers develop in their other breast.
It is important to note that there are side effects associated with aromatase inhibitors; bone loss, joint pain and hot flashes may occur, and vaginal bleeding, discharge and endometrial cancer - while less commonly reported in women using aromatase inhibitors than in those using Tamoxifen - can occur as well. More trials have to be done in order to learn about how effectively these aromatase inhibitors reduce breast cancer risk for all women, and if they should replace Tamoxifen entirely or be paired with this widely used drug.
Lapatinib. The American Society of Clinical Oncology is experimenting with a new drug called Lapatinib, which is being tried out on women who don't respond to traditional therapies. The drug works by helping to block the action of two growth factors that stimulate breast cancer. In trials, 46% of those who took Lapatinib experienced tumor shrinkage or a halting of their tumor's growth, and 24% of those who took the drug for four weeks experienced this as well.
COX-2 inhibitors. These nonsteroidal anti-inflammatory drugs are typically used to treat pain, but researchers believe they may help protect against breast cancer as well. These drugs include medications like Celebrex and Bextra. COX-1 and COX-2 are genes that indirectly stimulate estrogen production, and blocking this activity may keep tumors from forming. The COX-2 inhibitors may also be an effective treatment for existing cancers.
Paclitaxel plus cyclophosphamide and doxorubicin. In clinical trials conducted by the National Institue of Health (www.nih.gov), findings have show that paclitaxel, a chemotherapy drug that is extracted from the bark of the Pacific Yew tree, can help women with tumors that have spread to other parts of the body when it is combined with other drugs (namely cyclophosphamide and oxorubicin).
Retinoids. These natural or synthetic forms of vitamin A may be able to destroy or inhibit the growth of cancer cells, and may also be effective in premenopausal women and in women whose tumors aren't estrogen-positive.
Flax seed. Flax seed is high in the phytoestrogen lignan, which may inhibit estrogen production and stop the growth of breast cancer tumors. These phytoestrogens are naturally occurring compounds that lower circulating estrogens in your body, which would make it an encouraging development, as it is a natural food rather than a drug.
THE FUTURE OF BREAST CANCER TREATMENT
The results of an important study released in late April 2005, suggest that the breast cancer treatment drug, Herceptin, typically used to treat advanced-stage breast cancer patients, may be beneficial to many early-stage patients as well.
The five-year clinical trials on over 3,300 HER-2 (a particularly aggressive form of the cancer which causes cells to reproduce at a highly rapid rate) has found that when taking Herceptin, as well as receiving chemotherapy, patients were 52 percent less likely to experience tumor recurrence. In a statement released by the study sponsor, National Cancer Institute (NCI), Dr. Edward Romand, a study chair stated, "For women with this type of aggressive breast cancer, the addition of trastuzumab (Herceptin) to chemotherapy appears to virtually reverse prognosis from unfavorable to good." NCI Director Dr. Andrew C. von Eschenbach added, "These results are one more example that we are at a major turning point in the use of targeted therapies to eliminate suffering and death from cancer."
HER-2 affects approximately 20 to 30 percent of all breast cancer patients and makes the illness more difficult to treat. Herceptin is especially effective in women with HER-2 because of its ability to target cancerous cells, while leaving healthy cells unaffected. More detailed results of the study are to be released during the American Society of Clinical Oncology annual meeting on May 16, 2005.
According to the National Health Institute's website (www.nih.gov), several new technologies are making the future of breast cancer treatment easier and more streamlined. Doctors will be able to insert a miniature camera through the nipple and into a milk duct in order to examine the area for cancer. Also being tested is a technique involving the insertion of a catheter into the breast to deliver tiny radioactive beads to the place where the cancerous tissue was removed in an effort to reduce radiation therapy time to a matter of days.
In January, 2005, a potentially exciting advancement in the treatment of breast cancer occurred with the approval of the drug Abraxane by the FDA.
After a decade of clinical trials were conducted to study the effects of this nanoparticle drug, researchers were finally able to determine that using Abraxane instead of Taxol doubled the response rate and slowed the rate of tumor growth in patients with metastastic breast cancer.
Abraxane combines the drug paclitaxel with a natural protein called albumin, which turns into a nanoparticle when injected into the bloodstream, allowing a greater concentration of the drug in the tumor and starving the malignant cells of the nutrients they need to grow. The drug was developed in order to combat the toxicity associated with drugs like Taxol, which contain solvents Cremophor-EL and alcohol.
Additional resources used for research:
The American Cancer Society: www.cancer.org
The American Cancer Society cancer information hotline can be reached from the United States, 24 hours a day, 7 days a week, by simply dialing: 1-800-ACS-2345
CBS Cares would like to thank Dr. Debbie Saslow of the ACS for her expertise and time and Susan Raphael of the ACS for facilitating those discussions.
The Mayo Clinic: www.mayoclinic.com
Susan G. Komen Foundation: www.komen.org
National Institute of Health: www.nih.gov
National Cancer Institute: www.cancer.gov
Journal of the American Medical Association, 2004