Breast cancer

Breast cancer is an uncontrolled growth of abnormal cells in your breast tissue. Everyone has breast tissue. Globally, more than 20 lakh breast cancer cases are detected, accounting for more than 11% of all the cancer cases. In India, breast cancer contribute to over 25% of cancer cases amongst women. The risk of breast cancer in males is low. The risk of breast cancer in transgender people isn’t yet fully understood, though research is happening.

Types of breast cancer

Breasts are made up of fat, connective tissue, and glandular tissue that’s divided into lobules. The lobules are connected to your nipple by milk ducts.

There are different types of breast cancer; they’re named according to:

• the type of cell in which the cancer first begins – usually the lining of either your milk ducts (ductal) or your lobules (lobular)
• how far the cancer has spread – either non-invasive (carcinoma in situ) or invasive

The three most common types of breast cancer are:

• invasive ductal breast cancer – this is by far the most common form of breast cancer and is also known as invasive breast cancer (no special type, NST)
• invasive lobular carcinoma (ILC).
• ductal carcinoma in situ (DCIS) – in some people, this can become invasive cancer if it isn’t treated

Cancer cells can spread to other parts of your body – this is known as metastatic cancer or secondary cancer.

Breast cancer can also be grouped by how sensitive it is to different hormones and chemical substances in your body. This helps doctors to understand how your cancer might develop, and the best way to treat it.

Most of what we know about breast cancer comes from studies in women and we’ve used these statistics below. Breast cancer may be classed as one of the following types.

• Oestrogen receptor-positive breast cancer – this means the cancer is sensitive to the hormone oestrogen. Six to seven in 10 women who have breast cancer have this type.
• HER2-positive breast cancer – this means the cancer is sensitive to a protein called HER2. Two to three in 10 women who have breast cancer have this type. These cancers can be more aggressive and more likely to spread. But there are now several medicines available that target the HER2 protein and are used in the treatment of these cancers.
• Triple negative breast cancer – one or two in 10 women who have breast cancer have this type. These cancers aren’t sensitive to oestrogen, progesterone or HER2. This means hormone and targeted treatments aren’t used for this type of cancer.

Symptoms of breast cancer

It’s important to be familiar with how your breasts normally look and feel. You may notice they change at different times of the month. If you notice a change that’s not normal for you, contact your doctor. The pictures below show you what to look out for. 

These are the most common symptoms of breast cancer.

• A lump or thickening in your breast. This will feel different from the rest of your breast tissue.
• Discharge or bleeding from your nipple. The discharge is new and isn’t milky.
• A change in the look or texture of your skin. Your skin might be red, puckered or look dimpled like the skin of an orange.
• Inflammation or a rash on or around your nipple. There may be redness, a rash or crusting on your nipple or around it.
• A change to your nipple. This might be a change to its shape or it may become sunken or inverted (turns inward).
• A lump or pain in your armpit. You might notice a lump in your armpit or feel pain there.
• A change in the size or shape of your breast. You may notice this particularly when you move your arms.

Having these symptoms doesn’t necessarily mean you have breast cancer. Breast lumps are often benign (non-cancerous) and there are many causes of breast changes. But it’s always important to get any changes checked out.

Diagnosis of breast cancer

Seeing your doctor

Your doctor will ask you about any symptoms you’ve noticed, as well as your medical and family history. They’ll also examine both your breasts for lumps and for other signs, such as changes to your skin or nipples.

If your doctor thinks you need further assessment, they'll refer you to a specialist breast clinic. How quickly you'll be seen will depend on what symptoms you have and your age.

You may also be asked to go to a breast clinic after having a screening mammogram. This does not necessarily mean that a cancer has been seen. Most people who are recalled following screening do not have breast cancer.

Triple assessment

At the specialist breast clinic, you’ll be offered triple assessment. This includes:

• an examination of your breasts by the doctor
• a scan – this may be a mammogram (X-ray of your breasts) or an ultrasound or both
• a biopsy

You may also have an ultrasound scan of your armpit. This is to look for cancer which might have spread from your breast to the lymph nodes in your armpit.

You should be able to have all these tests, including the biopsy, during a single clinic visit. The results can help your doctor decide if you need any more investigations or treatment.

Further tests

If cancer cells are found, these will be tested further in the laboratory. These tests will show whether or not your cancer is sensitive to certain hormones and chemical substances. For more information about this, see our section on types of breast cancer. Depending on the results, you may be offered genetic testing for the BRCA1 and BRCA2 genes. Your doctor can explain what the results of all the tests mean for you and your treatment.

Treatment for breast cancer

If you have breast cancer, you'll be under the care of a multidisciplinary team of breast cancer specialists. You should also have a specialist nurse to support you.

What treatment you have will depend on a number of things. These include the type of cancer you have, if it's spread and if it’s sensitive to certain medicines. Your wishes and preferences will be taken into account.

The main treatment options for breast cancer are discussed below.

Surgery

Surgery is usually the first treatment you'll be offered for breast cancer. There are two main types of breast surgery that you may have.

• Breast conserving surgery (also known as lumpectomy or wide local excision). This means that you keep your breast but have the lump or, sometimes, a larger part of your breast removed. Your surgeon will usually need to remove a small area of surrounding healthy tissue at the same time. If examination of the removed tissue shows that not enough healthy tissue was taken, you may need more surgery. Lumpectomy will leave a scar and may affect how your breast looks. Talk to your surgeon about what to expect.

• Mastectomy. In a mastectomy, your surgeon removes the whole of your affected breast. If you’re having a mastectomy, you’ll be offered surgery to have a breast reconstruction. It’s your choice whether or not to have a breast reconstruction. Not everybody wants one. You can choose to have a reconstruction at the same time as the mastectomy or to wait until later.

Sentinel lymph node biopsy

If you have invasive breast cancer, this can spread to the lymph nodes in your armpit. To check if this has happened, your doctor will usually recommend you have a sentinel lymph node biopsy. The sentinel nodes are the first nodes that a cancer would spread to. They can be removed during your breast surgery and checked for cancer cells.

If your sentinel nodes contain cancer cells, your surgeon may recommend you have a further operation to remove more lymph nodes. This is called axillary clearance.

Radiotherapy

Radiotherapy is a treatment to destroy cancer cells with radiation. You’ll usually be offered it after surgery in order to destroy any remaining cancer cells. This aims to reduce the risk of your cancer coming back.

Chemotherapy

Chemotherapy uses medicines to destroy cancer cells. You may have two or three different chemotherapy medicines as part of your treatment.

You may have chemotherapy before surgery to shrink your cancer and make it easier to remove. Or you may have it after surgery, to destroy any remaining cancer cells in your body.

Hormone therapy

Hormone (endocrine) therapy may be a treatment option for you. Your doctor may offer this if you have breast cancer that's sensitive to oestrogen. Hormone therapy includes medicines such as tamoxifen, and aromatase inhibitors. Tamoxifen blocks the effects of oestrogen on your cancer. Aromatase inhibitors stop your body from making oestrogen.

You may be offered hormone therapy after you’ve had surgery and finished chemotherapy. You'll usually need to take it for at least five years. Sometimes, you may be advised to have this type of therapy before surgery to shrink the cancer.

If you’re already taking hormone treatments, your cancer team will discuss this with you.

Biological therapy

This is also known as targeted therapy because these medicines work by targeting cancer cells and affecting their growth. There are several different types but the medicines you’re most likely to be offered are called trastuzumab (Herceptin) and pertuzumab (Perjeta). Your doctor will only offer these if your cancer is sensitive to the protein HER2.

You might have biological therapy before or after surgery and it may be combined with chemotherapy. You’ll generally need to have this therapy every three weeks for a year.

Bisphosphonates

Your doctor may also offer you treatment with medicines called bisphosphonates. These are medicines which work to prevent bone thinning. They’re often prescribed if you have bone pain due to your breast cancer spreading. Bisphosphonates may also help stop breast cancer spreading or coming back.

Your doctor may offer you treatment with bisphosphonates if you’ve gone through the menopause. They’ll talk to you about the benefits and risks involved in taking the medicine first.

Treating advanced cancer

If breast cancer has spread to other areas of your body, treatment won’t be able to cure your cancer. But it can reduce your symptoms, help you to feel better and may help you to survive your cancer for longer. Your doctor may offer you treatment with hormone therapy, chemotherapy and biological therapy. There are various other treatments that can help with symptoms you may have such as bone pain, breathlessness and tiredness. Your healthcare team will support you and advise you on the best ways to manage your symptoms.

Causes of breast cancer

We don’t know for sure why some people get breast cancer. But it’s likely to be due to a combination of genetic, hormonal and lifestyle factors.

You’re more likely to develop breast cancer if you:

• are over 50 – your risk of breast cancer increases as you get older
• have a parent or sister who’s had breast cancer or ovarian cancer
• started your periods early or the menopause late
• have never had children or didn't have children until after age 30
• take a contraceptive pill that contains oestrogen
• take hormone replacement therapy (HRT), depending on the type of HRT and how long you take it
• are overweight once you've passed the menopause
• drink alcohol – the more you drink, the greater your risk

The risk of breast cancer in transgender people isn’t yet fully understood. We know that HRT increases the risk of breast cancer in postmenopausal women. But doctors don’t know if trans women taking hormone therapy will experience the same increase in risk. One study has found that taking hormone treatment might increase trans women’s risk of breast cancer, but more research is needed.

Research has also found that trans men who take hormone treatment might have a reduced risk of developing breast cancer. If you’ve had a mastectomy (removal of both breasts) as part of gender affirming surgery, your risk of getting breast cancer is reduced by around 95%.

Prevention of breast cancer

Healthy lifestyle

There are some risk factors for breast cancer that you can't change – for example, getting older or having a family history of breast cancer. But around a quarter of all breast cancers may be linked to lifestyle factors. This means they could be prevented.

You can help reduce your risk of breast cancer by:

• losing any excess weight you have, then keeping to a healthy weight
• being active
• only drinking alcohol in moderation

Breastfeeding is also known to help protect against breast cancer.

Higher risk of breast cancer

You may have a higher risk of getting breast cancer if members of your close family have had breast or ovarian cancer. If you're concerned about your risk, talk to your doctor. They may refer you to a breast clinic, family history or specialist genetics clinic.

The health professionals at the clinic will talk to you about your risk and exactly what this means for you. You may be offered a genetic test to see if you carry a gene for breast cancer. You won’t be offered this until you’ve talked it all through with a genetic counsellor first.

Depending on how high your risk of breast cancer is, your doctor will give you advice on how to lower this risk. This might include:

• being especially aware of any changes in your breasts
• making lifestyle changes such as losing weight, being active and reducing alcohol
• having breast screening from an earlier age or more frequently than usual
• having yearly MRI scans of your breasts
• taking medicines such as tamoxifen
• considering surgery (mastectomy)

Living with breast cancer

Follow up after treatment

After your treatment for breast cancer, you'll have regular check-ups with the breast care team. Your doctor will talk to you about where these will happen, how often you’ll have them, and for how long. Your doctor or nurse will ask how you are and may examine you. They’ll ask if you have problems with any ongoing treatment. It’s a chance for you to share any problems or concerns you have.

You'll be asked to return for a mammogram every year for five years. If you’re under 50, you’ll have yearly mammograms until you’re called for routine breast screening.  

Help and support

Being diagnosed with breast cancer and facing treatment can be distressing for you and your loved ones. An important part of cancer treatment is having support to deal with the emotional aspects and practical issues, as well as the physical symptoms. Specialist cancer doctors and nurses are experts in providing the support you need. Make sure you talk to them if you have any concerns.

Talking to people close to you can help them to understand what you’re going through and how you’re feeling. Organisations and support groups that specialise in breast cancer can also be a great source of information and support. For more information, see our section: Other helpful websites.