Saint Louis University Cancer Center

BREAST CANCER

What youshould knowabout breast cancer.Saint Louis University Cancer Center

3655 Vista AvenueSt. Louis, Missouri 63110

1-800-268-5880 or (314) 268-5880www.sluhospital.com or www.slucare.edu

SAINT LOUIS UNIVERSITY CANCER CENTEROur standing as an academic medical center putsthe Saint Louis University Cancer Center at theforefront in developing and providing the latestmedical treatment and procedures for breast cancerpatients. Our cancer services are accredited by theAmerican College of Surgeons Commission onCancer. Radiologists, oncologists and surgeons whoare part of the Saint Louis University CancerCenter offer all the recommended tests andtreatment for breast cancer. In addition, we providepersonalized information to help patients throughthe difficulties in dealing with this disease. Formore information about the programs availablethrough the Saint Louis University Cancer Center,call (314) 268-5880 or toll-free 1-800-268-5880.

SOME FACTS ABOUTBREAST CANCERBreast cancer is the most common form of canceramong American women. More than 190,000women are diagnosed with breast cancer each yearand almost everyone knows at least one personwho has been treated for it.Three-fourths of thecases of breast cancer occur in women ages 50 andolder, but it also affects younger women as well asabout 1,400 men a year.

More women are getting breast cancer, but noone yet knows all the reasons why. Some of theincrease can be traced to better ways of recognizingand detecting cancer in an early stage.The increasealso may be the result of changes in the way welive – postponing childbirth, taking replacementhormones and oral contraceptives, eating high-fatfoods, or drinking more alcohol. However, eventhough the incidence of breast cancer is increasing,the death rate is decreasing due to medical andsurgical intervention.

The encouraging news is that breast cancer isbeing detected earlier while the tumor is very smalland limited to the breast. Currently, two-thirds ofnewly diagnosed breast cancers show no signs thatthe cancer has spread beyond the breast.

WHAT ARE THE RISKS FORDEVELOPING BREAST CANCER?Simply being female and getting older puts awoman at average risk for developing breast cancer.The older she is, the greater her chance of gettingbreast cancer.This disease is very uncommon inwomen under the age of 35 and most breastcancers occur in women over the age of 50.Therisk is especially high for women over the age of60. No woman should consider herself too old toneed regular screening mammograms.

Research has also shown that the followingconditions increase a woman’s chance of gettingbreast cancer:

• Personal history of breast cancer. Womenwho have had breast cancer face an increased riskof getting breast cancer in their other breast.

• Genetic alterations. Changes in certain genes(BRCA1, BRCA2 and others) increase the riskof breast cancer. In families in which manywomen have had the disease, genetic testing cansometimes show the presence of specific geneticchanges that increase the risk of breast cancer.Doctors may suggest ways to try to delay orprevent breast cancer, or to improve thedetection of this disease in women who havethese changes in their genes.

If you know that one or more types of cancer seem torun in your family, you may wish to contact the geneticeducation program offered by the SLUCare Division ofHematology and Oncology.This comprehensive,confidential program can help you and your familymembers identify your cancer risks, take steps that mayhelp reduce the risk and undergo screenings to detectcancer in its early stages. Intensive education andcounseling are important parts of the program.

• Family history of breast cancer. A woman’srisk for developing breast cancer increases if her

THE BREASTSEach breast has 15 to 20 sections called lobes.Within each lobe are many smaller lobules. Lobulesend in dozens of tiny bulbs that can produce milk.The lobes, lobules and bulbs are all linked by thintubes called ducts.These ducts lead to the nipple inthe center of a dark area of skin called the areola.Fat surrounds the lobules and ducts.There are nomuscles in the breast, but muscles lie under eachbreast and cover the ribs.These normal features cansometimes make the breasts feel lumpy, especially inwomen who are thin or who have small breasts.

Each breast also contains blood vessels and lymphvessels.The lymph vessels carry colorless fluid, calledlymph, and lead to small bean-shaped organs calledlymph nodes. Clusters of lymph nodes are foundnear the breast under the arm (in the axilla), abovethe collarbone, and in the chest. Lymph nodes arealso found in many other parts of the body.

Over her lifetime, a woman can encounter abroad variety of breast conditions.These includenormal changes that occur during the menstrualcycle as well as several types of benign (noncancerous)lumps.What they have in common is that they arenot cancer. Even for breast lumps that require abiopsy, some 80 percent prove to be benign.

Lobe

Lobules

Ducts

Nipple

Ribs

Lymp nodes

Muscle

mother, sister, or daughter had breast cancer,especially at a young age.

• Certain breast changes. Having a diagnosis ofatypical hyperplasia or lobular carcinoma in situ(LCIS) may increase a woman’s risk fordeveloping cancer.

• Estrogen. Evidence suggests that the longer awoman is exposed to estrogen (estrogen made bythe body, taken as a drug, or delivered by apatch), the more likely she is to develop breastcancer. For example, the risk is somewhatincreased among women who beginmenstruation before age 12, experiencemenopause after age 50, never have children, ortake hormone replacement therapy for longperiods of time. Each of these factors increasesthe amount of time a woman’s body is exposedto estrogen.

DES (diethylstilbestrol), a synthetic form ofestrogen, was used between the early 1940s and1971.Women who took DES during pregnancyto prevent certain complications are at a slightlyhigher risk for breast cancer.This does notappear to be the case for their daughters whowere exposed to DES before birth. However,more studies are needed as these daughters enterthe age range when breast cancer is morecommon.

• Late childbearing. Women who have their firstchild after about 30 have a greater chance ofdeveloping breast cancer than women who havetheir children at a younger age.

• Radiation therapy. Women whose breasts wereexposed to radiation during radiation therapybefore age 30, especially those who were treatedwith radiation for Hodgkin’s disease, are at anincreased risk for developing breast cancer.Studies show that the younger a woman was

when she received treatment, the higher her riskfor developing breast cancer later in life.

• Alcohol. Some studies suggest a slightly higherrisk of breast cancer among women who drinkalcohol.

• Diet and dietary factors. Some evidenceexists that a diet high in animal fat may increasethe risk of breast cancer and a diet high in fruitsand vegetables may decrease the risk.

Most of the women who develop breast cancerhave none of the risk factors listed above, otherthan the risk that comes with growing older.Scientists are conducting research into the causes ofbreast cancer to learn more about risk factors andways of preventing this disease.

WHAT ARE THE SYMPTOMS OFBREAST CANCER?Early breast cancer usually does not cause pain. Infact, when breast cancer first develops, there maybe no symptoms at all. But as the cancer grows, itcan cause changes that women should watch for:

• A lump or thickening in or near the breast or inthe underarm area.

• A change in the size or shape of a breast.

• Nipple discharge or tenderness, or the nipplepulled back (inverted) into the breast.

• Ridges or pitting of the breast (the skin lookslike the skin of an orange).

• A change in the way the skin of the breast,areola, or nipple looks or feels (for example,warm, swollen, red or scaly).

A woman should see her doctor about anysymptoms like these. Most often, they are notcancer, but it’s important to check with the doctorso that any problems can be diagnosed and treatedas early as possible.

HOW IS BREAST CANCERDETECTED?From age 20 on, monthly Breast Self-Examination(BSE) is recommended seven to 10 days after awoman’s period begins.After menopause, BSEshould be performed on the first day of the month.BSE only takes a few minutes, costs nothing, andhelps find tumors at a smaller size.Ask your healthcare provider or a Saint Louis University CancerCenter health professional for simple BSEinstructions.

To help find the cause of any signs or symptoms,your doctor does a careful physical exam and asksabout personal and family medical history. Inaddition, your doctor may recommend one ormore of the following breast exams.

• Clinical breast exam. The doctor can tell a lotabout a lump by carefully feeling it and the tissuearound it. Benign lumps often feel different fromcancerous ones.The doctor can examine the sizeand texture of the lump and determine whetherthe lump moves easily.A clinical breast examshould be performed by a trained health careprofessional annually beginning at age 20 as apart of an annual wellness examination.

• Mammography. A mammogram is a safe low-dose X-ray picture of the breast.A screeningmammogram is a quick, easy way to detect breastcancer early when treatment is more effectiveand survival rates high. Usually two X-raypictures are taken of each breast.A physiciantrained to read X-ray pictures, a radiologist,examines them later. If you have sensitive breasts,try having your mammogram at a time of themonth when your breasts will be least tender.Tryto avoid the week right before your period tohelp lessen any discomfort.A screeningmammogram should begin by age 40 and shouldbe performed annually.

A diagnostic mammogram is used if there maybe a problem. It is also used if it is hard to get agood picture because of special circumstances, forinstance, when a woman has breast implants.Diagnostic mammography takes a little longerthan screening mammography because more X-ray pictures usually are taken.A radiologistmay check the X-ray pictures while you wait.

A lump should never be ignored just because it isnot visible on a mammogram. Breasts of youngerwomen contain many glands and ligaments.Because their breasts appear dense onmammograms, it is difficult to see tumors or todistinguish between normal and abnormal breastconditions.As a woman grows older, theglandular and fibrous tissues of her breastsgradually give way to less dense fatty tissues.Mammograms can then see into the breast tissuemore easily to detect abnormal changes.

Tumor sizes found by BSE and Mammography

• Ultrasonography. Using high-frequency soundwaves, ultrasonography can often show whether alump is a fluid-filled cyst (not cancer) or a solidmass (which may or may not be cancer).Thisexam may be used along with mammography.

Based on these exams, the doctor may decidethat no further tests are needed and no treatment is

Average-sizelump foundby womenuntrained inBSE

Average-sizelump foundby womenpracticingoccasionalBSE

Average-sizelump foundby womenpracticingregular BSE

Average-sizelump foundby firstmammogram

Average-sizelump foundby repeatmammogram

necessary. In such cases the doctor may need tocheck your breasts more regularly to watch for anychanges.

Often, fluid or tissue must be removed from thebreast so the doctor can make a diagnosis.Areferral for further evaluation may be made to asurgeon or other health care professional who hasexperience with breast diseases.These doctors mayperform:

• Fine-needle aspiration. A thin needle is usedto remove fluid and/or cells from a breast lump.If the fluid is clear, it may not need to bechecked by a lab.

• Needle biopsy. Using special techniques, tissuecan be removed with a needle from an area thatlooks suspicious on a mammogram but cannotbe felt.Tissue removed in a needle biopsy goes toa lab to be checked by a pathologist for cancercells.

• Mammotome® Breast Biopsy. Performedunder local anesthesia, stereotactic (X-rayimaging from two angles) or ultrasound(inaudible sound waves that produce an outlineof tissue) guidance is used to locate the breastabnormality and position a small probe that usesa vacuum system to draw tissue into a samplechamber.The samples are then cut and sent tothe pathology lab for examination.

• Surgical biopsy. In an incisional biopsy, thesurgeon removes a sample of a lump orsuspicious area. In an excisional biopsy, thesurgeon removes all of a lump or suspicious areaand an area of healthy tissue around the edges.Apathologist then examines the tissue under amicroscope to check for cancer cells.

• High Risk Clinic. Surgeons in the Saint LouisUniversity Cancer Center conduct a weeklyclinic for women at high risk for developing

breast cancer. Genetic counseling, MRI testing,preventive chemotherapy and other innovativeprograms for the early detection of breast cancerare included as part of the extensive surveillanceprovided in this highly specialized clinic.

BREAST CANCER SCREENINGRECOMMENDATIONSRecommended Breast ScreeningAges 20 to 40

• Monthly breast self-examination.

• Exam by a trained professional every year.

Recommended Breast Cancer ScreeningAges 40 and Over

• Monthly breast self-examination.

• Exam by a trained professional every year.

• Mammogram every year after age 40.

Screening recommendations are for women whodo not have signs or symptoms of breast cancer.Those women who are at higher risk for breastcancer or who have breast abnormalities should asktheir physician for specific guidelines.

BREAST SELF-EXAMINATIONBreast Self-Examination (BSE) is aneasy and painless way to screen forbreast cancer. Beginning at age 20,every woman should perform BSEmonthly.This 5 minute, 16-step self-exam could detect breast cancer earlywhen it is most treatable.1. Every woman’s breasts are different, so

you must learn what is normal foryou.Any small change in the way yourbreast looks or feels could be animportant early sign. BSE should bedone about one week after yourmenstrual period begins. If you nolonger have periods, it should be doneat the same time of the month.Youshould begin BSE in front of a mirrorundressed to the waist with your armsrelaxed at your sides. Be careful tolook for any skin color changes,dimpling, or puckering of the skin orchange in breast size or shape.Alsolook at the nipple for changes such asscaliness or pulling to one side or achange in the direction in which itpoints.

2. The next step is to place your handson your waist and press inward. Bytightening these muscles, changes maybe easier to see. Look for any changesas in Step 1.

3. The third step involves placing yourhands behind your head and pressingforward. Once again, look for changesas in Steps 1 and 2.

4. Next, place your hands on your waistand allow your breasts to fall forward.Look for any change in shape orpuckering.

5. Take your hand and find yourcollarbone and rub your hand firmlydown the breast, feeling for lumps,thickenings, or changes from previousexams.

6. Repeat Step 5 on the other breast.

7. Next, use one hand to support thebreast and with the other hand press

firmly, feeling for lumps, thickeningsor changes.

8. Repeat Step 7 on the other breast.

9. Any nipple discharge could be a signof a breast problem.To check fornipple discharge, firmly squeeze thebreast tissue around the nipple usingyour thumb and middle finger.

10. Repeat Step 9 on the other breast.

11. Use your hand to check for anychanges or lumps in the armpit.

12. Repeat Step 11 on the other side.

13. You should lie down in bed tocomplete the breast exam.Take apillow and place it under your leftshoulder and put your left handbehind your head.This spreads thebreast tissue out, making it easier toexamine and find changes. Use yourright hand to examine your leftbreast. Many women find it easer tofeel changes by putting lotion ontheir fingers. Hold the fingers of yourright hand together, keeping themflat, and use firm pressure to move incircles around your breast.

14. Move your fingers in smaller circlesuntil you have felt the entirebreast.

15. Place your finger on the nippleand push it in, feeling beneathfor any changes.

16. Finally, reverse your hands andpillow to repeat Steps 13, 14and 15 on the right breast.

Nine out of every 10 breastlumps are found by womenthemselves.Although eight outof every ten lumps are NOTcancerous, it is important toseek medical help immediatelywhen a change or lump isdetected. Early detection is thebest defense against breastcancer.

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