Breast cancer is the most commonly diagnosed cancer of women, and the second leading cause of cancer deaths among American women between 40 and 55 years of age. Regular mammography and clinical breast exams are essential for early detection of breast cancer. For women between 50 and 69 years of age, having regular mammograms can reduce the chance of death from breast cancer by one-third or more. During the most recent 5-year period, mortality rates among Caucasian women declined for all decades between 30 and 79 years of age, and for all decades among African American women from 30 to 69 years of age. Despite these numbers, only about 30% of women actually have a regular mammogram.

Important Facts:

A woman's chances of getting breast cancer changes with age: by age 40, 1 in 217 women will face breast cancer; by age 70, 1 in 14 will be diagnosed with the disease. Although death rates from breast cancer declined 4.6% between 1991 and 1995, breast cancer accounts for 31% of all cancers diagnosed among women.
Approximately 180,000 new cases of breast cancer are estimated for 1998, and about 43,500 women are expected to die from breast cancer. It is estimated that 1.5 million American women will be diagnosed with breast cancer this decade, and breast cancer will claim nearly half a million lives.
With proper early detection and treatment, the chances of surviving breast cancer are improving. Breast cancer mortality trends among African American and Caucasian women have improved markedly since the 1980s. The greatest reductions in death rates were among younger women (7.6%) and Caucasian women (5.3%), with more modest reductions among African Americans (1.6%).
Over 2 million breast cancer survivors exist in the U.S. today!

Breast Cancer Incidence
Age Range - Incidence (per 100,000 persons)
20-24   0.7
25-29   4.3
30-34   12.9
35-39   29.5
40-44   60.1
45-49   101.4
50-54   164.6
55-59   193.1
60-64   223.9
65-69   223.9
70-74   267.2
75-79   306.5
80-84   306.5
85+     282.6
Ethnic Group
Whites 115.5
Blacks 101.5
White Hispanics 72.9
Nonwhite Hispanics 68.5
Asian/Pacific Islanders 78.1
American Indians/Alaska Natives 50.5

Breast cancer is a disease in which cancer (malignant) cells are found in the tissues of the breast. Each breast has 15 to 20 sections called lobes that have many smaller sections called lobules. Thin tubes called ducts connect the lobes and lobules. The most common type of breast cancer is ductile cancer. It is found in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma. Lobular carcinoma more often is found in both breasts than other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer. In this disease, the breast is warm, red, and swollen.

You should see your doctor if you notice changes in your breast. Women older than 50 years of age should also have a special x-ray called a mammogram that may find tumors that are too small to feel. Check with your doctor on how often you should have this x-ray. When breast cancer spreads outside the breast, cancer cells are often found in the lymph nodes under the arm (axially lymph nodes). If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body. Cancer that spreads is the same disease and has the same name as the original (primary) cancer. When breast cancer spreads, it is called metastatic breast cancer, even though the secondary tumor is in another organ.

Q. How is breast cancer treated?
A. There are treatments for all patients with breast cancer. Four types of treatment are used:

Surgery (taking out the cancer in an operation)
-Radiation therapy (using high-dose x-rays to kill cancer cells)
-Chemotherapy (using drugs to kill cancer cells)
-Hormone therapy (using hormones to stop the cells from growing).
-Biological therapy (using your body's immune system to fight cancer) and bone marrow transplantation are being tested in clinical trials.
Treatment depends on the size and location of the tumor in the breast, the results of lab tests, and the stage (or extent) of the disease. The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are, how successful the treatment is expected to be, and how much it is likely to cost.

Q. What are the risk factors for developing breast cancer?
A. The two most important risk factors are getting older and being a woman. In fact, almost 75 percent of women with breast cancer are over 50 years of age. The risk also is increased if a woman:

Has a history of breast cancer in her family
Has never had children
Has had her first child after age 30
Began menstruating before age 12
Completed menopause after age 55
It is important to keep in mind that these factors do not cause cancer but are merely associations that may increase cancer risk. Having one or more of the risk factors does not mean a woman is certain to develop breast cancer.

There is no proven way to prevent breast cancer, so finding the disease as early as possible is the goal. Used on a regular basis, a mammogram (with or without a breast exam by a doctor or nurse) offers the best chance of saving lives. Studies have shown that, for women 50 to 69 years of age, having a regular mammogram (with or without breast exams by a doctor or nurse) could reduce deaths from breast cancer by one-third or more.

Q. Is breast cancer inherited?
A. The genes in your cells carry the hereditary information that you got from your parents. Sometimes, a test can be done to look for a gene that may be associated with a certain hereditary trait. Recently, a gene was found to be defective in 5% of breast cancer patients. Hereditary breast cancer makes up approximately 5 to 10% of all breast cancer cases. Relatives of breast cancer patients who carry this defective gene may be more likely to develop breast or ovarian cancer. Tests are being developed to determine who has the genetic defect long before any cancer appears.

Q. If I do not have a family history of breast cancer, am I still at risk for developing it?
A. Yes. In fact, 80% of women who develop breast cancer have no family history of the disease. While chances of getting breast cancer increase if a family member also has had it, this does not mean that a woman is free from risk if no one in her family has had breast cancer.

Q. What about estrogen (hormone replacement therapy) and breast cancer?
A. A major issue surrounding hormone replacement therapy and estrogen replacement therapy is the influence of estrogen on breast cancer. Researchers believe that the longer a woman is exposed to naturally occurring estrogen, the greater risk of developing breast cancer. It has not been proven, however, that estrogen administered at menopause has the same effect. There is disagreement because of wide variations in the populations studied, as well as the doses, timing, and types of estrogen used. An analysis of previous studies suggests that low-dose estrogen taken on a short-term basis (10 years or less) does not pose increased risk of breast cancer. Long-term use (more than 10 years) at a high dose may significantly increase the risk. By how much is still a matter of heated debate. At the very most, researchers think long-term use could possibly increase the risk of getting breast cancer by 30%. This means that incidence would rise from 10 women per 10,000 each year to 13 women per 10,000 each year.

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The WHI is a large-scale study of estrogen and combination estrogen plus progestin as preventive therapies for postmenopausal women, designed to access the long-term risks and benefits of estrogen replacement therapy (ERT) and combination HRT. It enrolled 27,000 women between 1993 and 1998, scheduled to conclude in 2005. A total of 16,608 women were randomized to combination HRT and placebo.

The combination HRT arm of the study was discontinued, citing as the main factor an increased risk of invasive breast cancer in the group receiving continuous combined HRT compared with the placebo group after an average follow-up of 5.2 years. This, combined with an increase in cardiovascular events in women and active drug vs. those on placebo that began in the first year and persisted, outweighed the benefits, which included a reduced incidence of colon cancer and hip fractures.

The fear of cancer is one of the most common reasons that women are unwilling to use hormone replacement therapy. Interestingly, actual death rates for breast cancer have not risen at all. This may be because estrogen users have more frequent medical visits and obtain more preventive care including yearly mammograms. The WHI study conitnues to monitor women who are on estrogen alone and do not take progestin (progesterone).

While no one can determine who will eventually develop breast cancer, there are certain risk factors you should be aware of when considering hormone replacement therapy. A family history of breast cancer (sister or mother) is probably the most important risk factor of all. You may also be at an increased risk if: you menstruated before age 12; delayed motherhood until later in life; or have a late menopause (after age 50). Also, the older you are, the higher the risk.

To use or not use hormone replacement therapy is a personal decision to be made by each woman with help from her doctor. Regular breast examinations by a health care professional and self-examination are recommended for women receiving estrogen therapy, as they are for all women.

Best Bet For Detection and Survival
Breast Self Examination - Breast Self Examination (BSE) takes just a few minutes and you only need to do it once a month. If you are menstruating, perform BSE 7 to 10 days after the first day of your period when your breasts are least tender. If you no longer menstruate, choose the same day each month to remind yourself to do BSE. As you do your examination, keep in mind that your goal is to become acquainted with how your breasts normally look and feel. Look for:

A lump or thickening in or near the breast or underarm area
A change in the size or shape of the breast
A puckering, dimpling, or redness of the breast skin

Screening - Regular mammogram screening and breast examinations by a medical professional. More than 20% of breast cancers are diagnosed in women over age 50 after a regular mammogram. Mammograms are recommended annually for women age 50 and older. The age that initial mammogram screening is recommended depends upon personal history and a doctor's recommendation. Some women start as early as age 30. Most start around age 40.

Tissue sampling - The sampling of a lump by performing a biopsy (removal of a small sample by a very thin needle inserted into the lump) has proven to be a very effective method of determining breast cancer. Over 80% of breast biopsies prove to be benign (non-cancerous). Advancement in technique allows for most procedures to be done in the doctor's office or as an outpatient procedure.

Early detection is the key to beating breast cancer. Advances in surgery, medications, and radiation therapy have allowed more and more women to leave their breast tissue in tact with little scarring. The 5-year survival rate when the cancer is detected early is more than 97%.

A Diagnosis of Cancer - LOOK FORWARD WITH HOPE

As we live longer lives, more and more people are likely to get cancer. There are, however, millions of Americans who have been diagnosed and successfully treated for cancer. Today, they are alive and well.

Better, and regular, screening tests have helped detect cancer at its earliest and most treatable stages. Treatment methods have also improved over the years. As a result, many people go into remission and also become long-term survivors. About 60 percent of the 1.2 million people diagnosed with cancer this year will live cancer-free for five years or more. For many cancers, these people have the same life expectancy as people who never had cancer.

The American Institute for Cancer Research strongly believes that being an informed, involved patient is an important factor in overcoming cancer. In this section, we discuss the initial questions and emotions nearly all cancer patients face upon first learning that they may have cancer.

WHAT IS CANCER?

"What can I do to fight cancer?"

Although the term "cancer" is often used as if it were one disease, cancer is actually a group of over 100 different diseases affecting various parts of the body. They all have one common characteristic, however –– the uncontrolled growth and spread of abnormal cells that can invade and damage healthy body tissues and organs. Most cancers are named for the body tissue in which they begin, such as the breast, colon or skin.

Normally, cells divide to produce new cells only when the body needs them. If cells keep dividing when new cells are not needed, a mass of extra tissue, called a tumor, forms. Tumors can be benign, meaning noncancerous, or malignant, meaning cancerous. Cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. This is how cancer spreads, or metastasizes, to other parts of the body.

Scientists don’t know for sure why some people develop cancer and others don’t, but advancing age increases the risk of nearly all types of cancer. Cancer is rarely caused by a single factor; rather, it is the result of a complex interaction between carcinogens, or cancer-causing substances in the environment, and heredity.

The process begins with the many thousands of genes found in each cell of the human body. Made up of DNA, genes carry instructions for making the proteins that regulate all body processes, including how efficiently we process foods, metabolize toxins, and fight infections.

Genes are activated, or switched on and off, by signals in the body or by environmental influences. For instance, an unhealthy diet, cigarette smoke, too much sun, or high levels of certain chemicals, can damage the DNA and cause genes to mutate, or change. Most of the time, regulator genes in the cells can recognize when the DNA is damaged and fix the problem so that it is not copied into new "daughter" cells. When the repair mechanism doesn’t work properly, because of an inherited or environmentally-caused mutation, the damaged cell continues to grow and multiply abnormally, and can eventually lead to cancer.

It is generally believed that cancer is triggered by defective genes. However, most people who get cancer do not inherit altered, or mutated, genes. In fact, only about five to ten percent of all cancers are caused by an inherited "cancer gene." Even if there is a strong family history of a particular cancer, it does not mean that cancer is inevitable. Dietary and lifestyle factors can interact with the genes to influence whether a person at risk for cancer actually gets the disease.

Researchers are making great progress in their understanding of cancer and its causes. As they continue to find better ways to diagnose and treat cancer, the chances of recovery keep improving. Many individuals who have been successfully treated for cancer are able to lead normal, active lives. The road to recovery begins with an understanding of your diagnosis and what it means to you and your family.

UNDERSTANDING YOUR DIAGNOSIS

It is very important to understand the diagnosis you are receiving from your doctor or health care provider. Powerful emotions are a natural response to even a potential diagnosis of cancer, but getting the facts about your situation will help you make the right decisions in the days ahead.

If you are nervous or don’t think you’ll remember what you are being told, then bring someone with you, ask your doctor to write out the information you need, or take notes yourself. Don’t be afraid to ask questions. Make sure you understand what the doctor is saying. If medical jargon is confusing you, then ask the doctor to explain the answer in a different way.

It’s in your best interest to be an involved and informed patient. So, let your doctor know you want to be an active participant in your health care. Try to build a relationship with your doctor and health care team. A good doctor will not only have exceptional medical knowledge about your condition, but will also offer support, listen to your concerns, and explain medical procedures and options to your satisfaction.

Below are some questions you’ll want answered, to help you take charge of your health and medical care.

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QUESTIONS TO ASK YOUR PHYSICIAN AND OTHER HEALTH CARE PROVIDERS ABOUT YOUR DIAGNOSIS

Exactly what type of cancer do I have?
What stage is the cancer in? What does that mean?
How does my stage affect what I am supposed to do?
What other health professionals do I need to speak with? How can they help me?
How was my diagnosis determined?
What tests were taken and what did they show?
Are more tests planned?
What is my prognosis? (You should ask your doctor to give you an honest answer, neither minimizing nor maximizing your chances. How likely are you to survive? How likely are you to have a good quality of life?)
What are the next steps to take? (If your doctor is not an oncologist, or cancer specialist, you should be advised to see one for further tests or for treatment. If your doctor is an oncologist, treatment options will be recommended.)

THE EMOTIONAL IMPACT OF A CANCER DIAGNOSIS

YOUR PERSONAL REACTIONS

Powerful feelings, both positive and negative, are part of living with cancer. For many people, the most intense emotional upheaval comes right after diagnosis. Feelings change rapidly in the first few days and weeks, and may include such emotions as denial, anger, fear, stress, loneliness and depression. Family members and friends may also go through similar feelings. Or, they may try to hide their sadness and worry, and "distance" themselves emotionally.

All these emotions are natural reactions to a diagnosis of cancer. Most are temporary. Cancer experts recommend confronting these feelings directly, although methods and timetables will differ from person to person.

Denial

At first, denial can help soften the impact of the diagnosis and give you time to process the information. Denial can be a problem, however, if it keeps you from getting treatment. Most cancer patients are able to work through these feelings before they begin treatment.

Anger

Once you accept the diagnosis, anger may set in. You might ask yourself, "Why me?" Being angry at the disease or at healthy people you know could be a way of expressing other feelings, like fear or helplessness. Letting your feelings be known can help you accept the diagnosis.

Fear

A cancer diagnosis frightens many people. It may be the fear of pain or dying, the physical effects and costs of treatment, or the burden it could place on your family. Not knowing what to expect can cause more fear than the facts. Learning as much as you can about your diagnosis and treatment may make you feel less afraid and more in control of the situation. Read through CancerResource for helpful information.

Stress

The stress that comes from learning of your diagnosis can cause a variety of physical symptoms, including a faster heart rate, headaches, trembling, loss of appetite and sleeping problems. Stress may also affect your immune system and how well your body fights disease. To help reduce stress and anxiety, try to exercise, listen to relaxing music, talk about your feelings, and keep involved in activities you enjoy. Counseling or joining a support group may also help.

Loneliness

Cancer patients may feel isolated when they don’t feel like socializing or if friends stay away because of the diagnosis. If you are lonely or feel like no one you know understands what you’re going through, try to get in touch with other cancer patients or a support group of people who are facing issues similar to yours. Ask your health care team for referrals or look through the AICR brochure "Cancer Information—Where to Find Help" for information on finding an appropriate support group.

Depression

You may feel depressed about a cancer diagnosis. If symptoms become more serious, like strong feelings of sadness and despair, helplessness, and loss of interest or ability to do activities that were a normal part of your life, then let your doctor know, so you can get appropriate help or treatment.

Hope

Once the shock of a cancer diagnosis passes, most people are able to look forward with a feeling of hope. Since each cancer case is unique, it is not possible to exactly predict the outcome of your cancer. However, improved treatment methods and knowing that so many cancer survivors are leading full, productive lives may help you and your family feel more optimistic about the future.

Often, people living with cancer find that support groups can help them cope with some of the emotions described above. If you are interested in joining a support group, check with your hospital or treatment center for information about groups in the community. You may also be interested in joining AICR’s "Pen Pals Cancer Support Network." The program gives cancer patients and survivors the opportunity to share support through letter writing. Call AICR toll-free at 1-800-843-8114 for more information.

HANDLING FAMILY ISSUES

"I'm so concerned about how my family will handle this cancer diagnosis."

A diagnosis of cancer can present new challenges and stresses for many families. Adjusting to new roles and responsibilities can cause upheavals in the way family members interact. Children may need special attention and guidance at times of disruption in their routine. They need to know that nothing they said or thought caused you to get cancer and that their help and support means so much to you and the family. Sharing your feelings and needs with your spouse or partner is also very important.

If family members are unable to help each other or are having difficulty adjusting to the diagnosis, check with your physician, hospital social services department or library for referrals to local support and service organizations that can help you cope with the emotional stresses of the disease.

FINDING EMOTIONAL SUPPORT

"My friends and family were just so helpful."

People with cancer and their families often find a great deal of help and support by making contact with others who are in similar circumstances. Cancer support groups can be a wonderful source of strength, hope and practical ideas for everyday life. Attending a support group can give needed structure and focus to your week, as well as emotional support from individuals who can empathize with you.

Some patients find that the support of the medical social worker in a local hospital, local mental health or health care facility is invaluable. For others, it might be a member of the doctor's staff, a relative who has experienced cancer therapy or a neighbor who can run a few errands if you're feeling tired.

The AICR brochure "Cancer Information—-Where to Find Help" contains resources that can connect you with other cancer patients and provide you with additional forms of emotional support. To order this brochure, call AICR toll-free at 1-800-843-8114.

AICR - American Institute for Cancer Research

The American Institute for Cancer Research is the nation's third largest cancer charity and focuses exclusively on the link between diet and cancer. The Institute provides a wide range of consumer education programs that have helped millions of Americans learn to make dietary changes for lower cancer risk. AICR also supports innovative research in cancer prevention and treatment at universities, hospitals and research centers across the U.S. The Institute has provided over $50 million in funding for research in diet, nutrition and cancer. Visit the Institute online at www.aicr.org

American Institute for Cancer Research
1759 R Street NW
Washington, DC 20009
1.800.843.8114

Breast Cancer and Pregnancy

Breast cancer is the most common cancer in women who are pregnant or have just had a baby, occurring in about 1 in 3,000 pregnancies. The average patient is between 32 and 38 years old and, since many women are having children later in life, the numbers of pregnant women with breast cancer will probably increase.

Women who are pregnant or nursing usually have tender, swollen breasts, making small lumps hard to detect and possibly leading to a delay in diagnosing (finding) breast cancer. These delays are common, with an average reported delay of 5 to 15 months between the start of symptoms and the diagnosis. Because of this delay, cancers are usually detected at a later stage than they are in women who are not pregnant.

To detect breast cancer, pregnant and nursing women should examine their breasts and undergo a breast examination as part of the routine prenatal examination by a doctor. If an abnormality is found, ultrasound (a test that uses sound waves to find tumors) and a mammogram (a special x-ray of the breast that may find tumors that are too small to feel) can be performed with little risk to the developing fetus. Twenty-five percent of mammograms in women who are pregnant may be negative even though cancer is present. Therefore, a biopsy (the removal of cells or tissues for examination under a microscope) is important for the diagnosis of any mass that can be felt.

STAGE EXPLANATION
Once breast cancer has been found, more tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, a doctor needs to know the stage of the disease.

The usual procedures that are used to stage breast cancer can be changed slightly to be safer for pregnant women. Blood tests may also be used.

Overall survival of pregnant women with breast cancer may be worse than in nonpregnant women at all stages. However, this may be due to the delayed diagnosis. Ending the pregnancy does not seem to affect the outcome of the breast cancer, and is not usually considered as a treatment option. It may be considered, however, depending on the age of the developing fetus, if the treatment options for the mother, such as chemotherapy and radiation therapy, are severely limited by continuing the pregnancy.

TREATMENT OPTION OVERVIEW

How breast cancer is treated
Early stage cancer (stages I and II)
Surgery is recommended as the first treatment of breast cancer in pregnant women. Since radiation therapy may be harmful to the fetus, modified radical mastectomy is the treatment of choice. Conservative surgery with radiation therapy after the baby is delivered has been used in order to keep the breast intact. If chemotherapy is needed after surgery, it should not be given during the first 3 months of the pregnancy. Chemotherapy given after this time does not usually lead to birth defects, but may cause early labor and low birth weight. The risk of using hormones after surgery, either alone or with chemotherapy, is not known. Radiation therapy should not be used during pregnancy, due to the risk to the fetus.

Late stage disease (stages III and IV)
Radiation therapy during the first three months of pregnancy should be avoided. Chemotherapy may be given after the first three months as discussed under early stage disease. Because the mother may have a limited time to live (only 10% of women with stage III or IV disease live 5 years), and since there is a risk of damage to the fetus during treatment, continuing the pregnancy should be discussed with the mother and her family. Abortion as a treatment option does not improve survival for the mother.

Breastfeeding
Stopping milk production does not improve survival of the mother. However, if surgery is planned, breastfeeding should be stopped to make the breasts smaller and lessen the blood flow in them. It should also be stopped if chemotherapy is planned, since many drugs, especially cyclophosphamide and methotrexate, may occur in high levels in breast milk, which would effect the nursing baby. In general, women receiving chemotherapy should not breastfeed.

Effects of cancer on the fetus
Breast cancer does not appear to damage the fetus since breast cancer cells do not seem to be transferred to the fetus from the mother.

Effect of pregnancy in patients who have previously had breast cancer
Pregnancy does not seem to affect the survival of women who have had breast cancer in the past, and the fetus does not seem to be affected, either. Some doctors recommend that a woman should wait two years before trying to have a baby, so that any early return of the cancer would be detected, which may affect the woman's decision to be a parent. The risks of pregnancy after a woman has received bone marrow transplantation and high-dose chemotherapy with or without total body irradiation are unknown, but may result in early labor and low birth weight.

National Cancer Institute
Office of Cancer Communications
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580
1-800-4-CANCER (1-800-422-6237)