Detecting & Living with Breast Cancer For Dummies^®

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Library of Congress Control Number: 2017948467

ISBN 978-1-119-27224-3 (pbk); ISBN 978-1-119-27225-0 (ePub); ISBN 978-1-119-27226-7 (ePDF)

I am excited to write this foreword for Detecting & Living with Breast Cancer For Dummies by Drs. Marshalee George and Kimlin Tam Ashing. As a survivor, I believe that the comprehensive and easy-to-read information this book provides will help readers navigate each stage of their healthcare and personal journey from diagnosis to survivorship. In clear, concise language this book explains testing, procedures, and treatments that individuals experience. The authors understand the questions that concern patients at every stage and they deliver the answers in topical chapters.

For my fellow survivors, I encourage you to start by looking over the table of contents, which offers you an overview of the breadth and depth of coverage. This book tackles topics that we are sometimes hesitant to ask and even sometimes don’t even know to ask. For example, chapters detailing surgical procedures, chemotherapy, and radiation demystify the experiences through patient-centered teaching. This book attends to social, family, sexuality, and psychological matters and is clearly intended for the whole person. It thoughtfully addresses medical communication and improving physical, social, and emotional well-being to “live our best life possible,” as the authors put it. This empathetic, knowledge-based approach lives in each chapter and continues throughout the book.

Detecting & Living with Breast Cancer For Dummies is a powerful and compassionate resource.

—Nilaya Baccus-Hairston, JD, breast cancer survivor

Foolish Assumptions

We assume a few things about you, the reader, but not many. We assume you read at least at an eighth-grade level, have no medical background, and don’t necessarily have any knowledge of breast cancer or its treatments. You may be newly diagnosed with breast cancer, receiving active treatment, recovering from treatment, or you may be several years out from treatment.

Perhaps you’re a friend or family member who wants to support a loved one with breast cancer. Regardless of your situation, reading this book will help you discover all aspects of breast cancer treatment, including cutting edge treatments, innovations in breast reconstruction, how to live well after breast cancer, and much more.

Icons Used in This Book

The icons you see in the left-hand margins throughout the book are there to help you identify information that may be of particular interest in certain ways — or not.

This icon points out especially useful information or good practical advice for you regarding some aspect of breast cancer treatment and survivorship.

This icon highlights information you would do well to tuck into your brain’s file drawer for later use.

This icon lets you know there is something to especially watch out for or be cautious about.

This icon points out peripheral information you can safely skip, that’s not necessary to understanding the main point under discussion.

Beyond the Book

In addition to the material in the print or e-book you’re reading right now, this product also comes with some access-anywhere goodies on the web. Check out the free Cheat Sheet by going to www.dummies.com and searching for detecting and living with breast cancer. You’ll also find a downloadable, free survivorship care plan.

Breast Cancer Basics

Let’s start with the most fundamental biological unit: the cell. As you may (or may not) remember from biology class in school, the cell is the basic building block of the human body and is where life begins. A group of cells is called tissue. And a group of tissues is called an organ. The breast is considered an organ, like your kidney, spleen, and brain.

Finding your way around your breast

The breast extends from the collarbone to the underarm and across to the middle of the chest at the sternum. The breast is mostly made up of adipose tissue, which means it’s a collection of fat cells. The size and number of fat cells in the breast are influenced by many hormones, genetics, growth factors, and lifestyle behaviors — and the female hormone estrogen.

The breast is divided into 12–20 sections called lobes. In these lobes are many small glands called lobules, which produce milk in nursing mothers. Milk ducts are small channels that collect the milk that is produced in the lobules and convey milk to the nipple. Throughout the adipose tissue of the breast is a network of ligaments, fibrous connective tissue, nerves, lymph vessels, lymph nodes, and blood vessels. Figure 1-1 shows the breast and some of its parts.

Here are a few more important parts of the breast:

• Areola: Dark area around the nipple.
• Blood vessels: Help carry blood throughout the tissue.
• Connective tissue: Made up of muscles, fat, ligaments, and blood vessels. It provides support for the breast, gives shape to the breast, and separates or binds other tissues within the breasts.
• Lymph nodes: Small kidney bean shaped pieces of tissue that are connected by lymphatic vessels that are part of the immune system. They are located in various areas throughout the body and act as a filter for getting rid of abnormal cells from healthy tissue. The majority of the lymph nodes that filter the breast are in the underarm area (armpit).
• Lymph vessels: Lymph vessels are a network of vessels running throughout the body. They are part of the immune system that transports disease-fighting cells and fluids.
• Nerves: Provide sensation to the breast.

Distinguishing Different Breast Cancers

We’ve all heard the terms tumor and cancer thrown around. But is there a difference — and if so, what is it? Technically there is a difference, although many people use these terms interchangeably. A benign tumor or neoplasm is a mass that is generally harmless, as this is an overgrowth of normal tissue. An example would be a freckle or benign mole that grows on the skin, or the raised lumpy tissue that forms over a cut to create scar tissue. A malignant (cancerous) tumor is bad news, as this is an overgrowth of mutated tissue. A malignant tumor is also called a cancer (or malignant neoplasm). An example would be a mole that undergoes mutations to become a melanoma (a type of skin cancer).

When the term cancer is used, it refers to new malignant growths that have the ability to spread to surrounding tissues and organs. As cancer tissue grows it can begin to infiltrate and replace all the normal tissue which can prevent an organ, for example, from functioning. Cancer sucks the nutrients and blood supply from your body to itself through a process called angiogenesis. Angiogenesis is when new blood vessels are formed from your existing blood vessels that are necessary for cancer growth. The blood vessels carry oxygenated blood and nutrients to the cancer, causing the cancer to grow and eventually spread to other organs (metastasis), and this can lead to death if left untreated.

Understanding angiogenesis is a very important area of research. Some treatments for breast cancer, such as chemotherapy, focus on disrupting the blood supply to the cancer, causing cell death.

In medical terminology, the location of the cancer cells in the body determines what it’s called. So, if the cancer is found in the breast, it’s called breast cancer. There are different types of breast cancer that are defined by the part of the breast where the cancer is found. The different types of breast cancer are as follows:

• Ductal carcinoma (cancer of the milk ducts): When cancer is found within the milk ducts of the breast, it is called ductal carcinoma. Ductal carcinoma is the most common type of breast cancer. It affects the lining of the milk ducts that carry breast milk from the lobules, where it’s made, to the nipple. If the cancer is limited to the lining of the ducts it is called DCIS (ductal carcinoma in situ). When the cancer breaks out of the milk ducts and starts to infiltrate the rest of the breast, it is considered invasive or infiltrating ductal carcinoma. DCIS and invasive ductal carcinoma are illustrated in Figures 1-2 and 1-3.
• Lobular carcinoma (cancer of the lobules): When cancer is found within the lobules of the breast, where breast milk is produced, it is called lobular carcinoma. If the cancer is limited to a small area in the lobule it is called LCIS (lobular carcinoma in situ). When the cancer breaks out of the lobules, it is considered invasive or infiltrating lobular carcinoma.
• Inflammatory breast cancer: This is a rare, aggressive form of breast cancer that often invades the lymphatic vessels and skin of the breast. It can be confused with an infection initially, as it will often cause an area of redness and swelling on the breast. See Figure 1-4.
• Phyllodes tumor (cystosarcoma — cancer of the connective tissues): This is an even rarer type of breast cancer that doesn’t usually spread to other areas of the body. There are two main types of phyllodes tumor: benign and malignant. No one knows what causes phyllodes tumors, but they appear to be more common in women with a history of fibroadenomas (benign breast lumps) and in women who are pre-menopausal between the ages of 35 to 50.

Cancer has the unfortunate tendency to not stay put, and when it travels, it brings destruction wherever it goes. When doctors find cancer in the breast, they immediately want to know whether the breast cancer has spread to the lymph nodes, and if so, how far it has spread. If the closest lymph node to the breast is found to have cancer cells, then additional lymph nodes are usually examined to determine if cancer cells are present.

Lobular carcinoma in situ (LCIS), although it sounds like a cancer because it includes the term carcinoma, is not cancer. LCIS is a tumor that grows in the milk-producing lobules of the breast and remains inside the lobule — that is, it does not spread to other tissues. Unfortunately, having LCIS may increase your risk of developing invasive breast cancer in the future. In some people there may be a small area of malignant cancer hidden within an area of LCIS, which is why it has been recommended that LCIS be treated with surgical removal in certain people, depending on their other risk factors for breast cancer. Risk reduction treatment with endocrine therapy may be offered. See Chapter 11 for more information on endocrine therapy.

Planning Your Treatment

After the breast has been biopsied and breast cells have been examined by a pathologist, a diagnosis is usually made that lets you know what type of tumor is in your breast. Is it benign or is it malignant (cancer)? Knowing what you have is, of course, necessary for you to obtain the right treatment at the right time and at the right place.

Advanced Age

The number one risk factor of any type of cancer is age. The older people get, the more incidences of cancer will be found. In the United States, we are becoming a more aged society, with the baby boomers getting older and living longer. With advanced age, there is ample time for breast cells to be altered or mutate due to internal genetic errors. Just like an aging car, some of the parts of a cell are subject to wear and tear over time and as a result function less efficiently. Additional risk factors like environmental exposures and poor lifestyle behaviors can increase your risk, as discussed later in this chapter. Table 2-1 shows how often women get diagnosed with breast cancer (incidence rate) and the age of diagnosis.

Gender

It’s surely not surprising that women are far more at risk than men for developing breast cancer. Males and females are both born with breast tissue, but the naturally elevated testosterone levels in males prevents the growth of mature breast tissue. This leaves males with a small amount of underdeveloped breast tissue. Male breast cancer makes up about 1 percent off all breast cancer. Chapter 17 talks more about men and breast cancer.

About 12 percent of women in the general population have a lifetime risk for developing breast cancer. That’s around one in eight women. For men, the lifetime risk for breast cancer is much lower: around one in a thousand.

Besides females having higher levels of estrogen than men, other risk factors can increase breast cancer in both male and females. Male risk factors for breast cancer are similar to risk factors in females, and although estrogen increases breast cancer risk for women, when women have certain diseases or are exposed to environmental toxins, their risk for breast cancer is much higher. Factors that might increase estrogen levels in males can also increase their risk of developing breast cancer.

The following are shared risk factors for breast cancer in both men and women:

• Being older: The average age when men get breast cancer is between 68 and 71 years. For women, it’s 50 to 69 years.
• Inherited gene mutations: The mutation defect in BRCA 1 or BRCA 2 can increase the lifetime risk of getting breast cancer to 6 in 100. Both men and women may carry the gene. We talk more about genetics later in this chapter.
• Liver disease: Cirrhosis of the liver can cause male hormones to be reduced, which can ultimately increase female hormones. In females, liver disease causes estrogen levels to surge to significantly higher levels.
• Alcohol: Heavy drinking can affect the liver, increasing the risk of breast cancer.
• Radiation exposure: If a man or woman has received radiation to the chest wall for cancer (for example, for lymphoma) they may develop breast cancer later in life.
• Obesity: Fat cells convert androgens to estrogens in men when they are overweight, especially in the abdomen. In women, the fat cells may convert to estrogen, placing the body in estrogen overload.

Here are risk factors for men only:

• Testicular disease or surgery: If his testicle is diseased or has been removed, then the man is more at risk for developing breast cancer.
• Occupation: Working in industries that require men to work in a heated or hot environment, such as steel mills, or in jobs with increased exposure to gasoline fumes, can affect testicles, thus increasing risk for breast cancer.
• Klinefelter syndrome: This occurs if a boy is born with more than one copy of the X chromosome, causing him to have more female hormones.

Race and Ethnicity

Even though White women (Caucasian and of European heritage) have a slightly higher risk for developing breast cancer over age 45, Black women — those of African American, African, and Afro-Caribbean descent — are more likely to die from the disease. The reasons for this are very controversial. Research in past years has shown that Black women have a higher incidence of triple negative breast cancers (see Chapter 5), though in clinical practice, cancer providers may observe differently. We provide care to equal numbers of both races of women with triple negative disease; the only common denominator is that the women are younger (under the age of 50). The verdict is still out on the true incidence according to ethnicity with triple negative disease. Several ongoing studies at the National Cancer Institute and NCI-designated cancer centers should help inform us in the near future.

Black women are also more likely to have higher grades and stages of breast cancer — in other words, they tend to have breast cancer that has spread to the lymph nodes under the arm and elsewhere, in comparison to White women. Research has shown that the driving factors in the higher incidence of breast cancer in Black women under 45 years are genetic mutation, family history, environment, lifestyle, socioeconomic status, cultural factors, and barriers to care. Lack of access to mammograms, delay in follow-up of abnormal mammogram results, denial of breast symptoms, competing priorities (single mother, other illnesses, and so on), lack of trust in the medical system, and financial limitations are all concerns for higher rates of breast cancer in Black women under 45 years.

Asian, Hispanic, and Native American women have a very low risk of developing breast cancer and dying from the disease.

For men, breast cancer is more common in White men than in Black men and least common in Asian men.

Information on breast cancer risk factors for Hispanic women is limited, even though they are the fastest-growing minority in the U.S. Hispanic women are quite often diagnosed with advanced breast cancer in comparison to non-Hispanic white women. The most perceived risk factor for breast cancer in Hispanics is less use of mammography screening in comparison to Black and White women.

Hispanics can have a lower risk of breast cancer if they have the gene ESR1. Research has shown that Hispanics are a heterogeneous population because they often have American Indian and European ancestry. When postmenopausal Hispanic women were tested in a U.S./Mexican breast cancer health disparities study, many Hispanic women were found to have the gene ESR1, which is typically found in Native Americans and which lowers the risk for breast cancer.

Overall, the risk of breast cancer typically increases in women who migrate to countries with high breast cancer incidence rates (such as the United States) from other countries with low incidence rates.

Use of Birth Control Pills

If you take oral birth control pills, you may have a slightly higher risk of developing breast cancer in comparison to women who have not used them. However, when you stop taking or have discontinued birth control pills for at least ten years, your risk for breast cancer decreases and eventually returns to baseline (no increased risk).