High-Risk Breast Cancer
Breast cancer is the most common type of cancer in the United States, other than skin cancer. While the rate of breast cancer has gone down in recent years, a woman's chance of getting breast cancer during her life is about 1 in 8, and her chance of dying from breast cancer is about 1 in 35.
Most breast cancer starts in the lobes in a woman's breasts that produce milk and the ducts that carry milk to the nipple. In women who have cancer, the growing mass of cells will form a lump. That's why women should perform regular breast self-exams to check for lumps. When it is found early, the five-year survival rate for women with breast cancer is 98 percent.
However, not all lumps in the breast are cancerous. Some may be fluid-filled cysts or caused by fibrosis, which is scar-like tissue. Such lumps are non-cancerous (benign), but may still cause swelling or pain.
There are many types of breast cancer, though some are very rare. Sometimes a breast tumor can be a combination of types. Among the most common:
Ductal carcinoma in situ (DCIS) – This is the most common type of non-invasive breast cancer. DCIS means that the cancer is only in the ducts and has not spread through the walls of the ducts into the tissue of the breast. Nearly all women with cancer at this stage can be cured. Often the best way to find DCIS early is with a mammogram.
Lobular carcinoma in situ (LCIS) – This condition begins in the milk-making glands but doesn't go through the wall of the lobules. Although not a true cancer, having LCIS increases a woman's risk of getting cancer later. For this reason, it's important that women with LCIS follow the screening guidelines for breast cancer.
Invasive (infiltrating) ductal carcinoma (IDC) – This is the most common type of invasive breast cancer. It starts in a milk passage or duct, breaks through the wall of the duct and invades the tissue of the breast. From there it can spread to other parts of the body. It accounts for about 8 out of 10 invasive breast cancers.
Invasive (infiltrating) lobular carcinoma (ILC) – This cancer starts in the milk glands or lobules. It can spread to other parts of the body. About 1 out of 10 invasive breast cancers are of this type.
Inflammatory breast cancer (IBC) – This uncommon type of invasive breast cancer accounts for about 1 to 3 percent of all breast cancers. Usually there is no single lump or tumor. Instead, inflammatory breast cancer (IBC) makes the skin of the breast look red and feel warm. It also gives the skin a thick, pitted appearance that looks a lot like an orange peel. Doctors now know that these changes are not caused by inflammation or infection, but by cancer cells blocking lymph vessels in the skin. The breast may become larger, firmer, tender or itchy. IBC is often mistaken for an infection in its early stages. Because there is no defined lump, it may not appear on a mammogram, which may make it even harder to catch it early. It usually has a higher chance of spreading and a worse outlook than invasive ductal or lobular cancer.
Men can get breast cancer, too. Until they reach puberty, the breast area in boys and girls develops in the same way. By the time boys reach their teens, however, hormones keep the breasts from developing. Like women, men have ducts and lobes in their breast area but in far smaller numbers.
Although we still do not know what causes cancer, there are new and powerful options available today to successfully detect and fight breast cancer. The most important factor is catching cancer early, when it is most treatable—or closely monitoring women who may be at increased risk.
As the region’s only NCI-designated cancer center, UVA brings you the region’s most comprehensive cancer detection and treatment options, as well as personal support for you and your family.
These are the risk factors for breast cancer:
- Age—Risk increases with age, especially after age 50
- Gender—Women are 100 times more likely to get breast cancer than men, but men can get it, too
- Race—White, non-Hispanic women have the highest overall rate for breast cancer in the United States. African-American women who are ages 40 to 50 have a higher incidence than white women.
- Personal history of cancer (this may be caused by both heredity and environmental factors)
- Family history of breast cancer
- Early onset of menstrual periods (before the age of 12)
- No children or children born later in life
- Use of (combined) hormone replacement therapy (estrogen and progesterone)
- Alcohol use, especially excessive use
- Overweight and lack of physical activity
What You Should Know About BRCA1 and BRCA2
The mutations that most often cause breast cancer are changes in the BRCA1 and BRCA2 genes ("Breast cancer 1 gene" and "Breast cancer 2 gene").
Women with inherited mutations in the BRCA1 or BRCA2 genes are three to seven times more likely to develop breast cancer than those who do not have the mutations, and at an earlier age.
According to the National Cancer Institute (NCI), the women who are mostly likely to have BRCA1 or BRCA2 mutations are those of Eastern European (Ashkenazi) Jewish heritage and/or those with family members who have had:
- Multiple cases of breast cancer
- Cases of both breast and ovarian cancer, or
- One or more family members with two primary cancers (original tumors at different sites)
However, the NCI also notes that not every woman in such families carries an alteration in BRCA1 or BRCA2, and not every cancer in such families is linked to alterations in these genes.
For many women, a genetic evaluation performed by the genetic counselors at the UVA High-Risk Breast and Ovarian Cancer Program can provide valuable insight into inherited risk. For women who are at higher inherited risk for breast cancers, the high-risk program offers many options for proactive, watchful management.
Hereditary versus Sporadic Cancer
We all have 20,000 to 25,000 genes in the cells of our body. These genes determine all of our characteristics—hair color, height, body type and so on. Cancer is caused by uncontrolled growth of cells as the result of mutations in genes.
Because the mutated genes that cause hereditary cancer are inherited from a person's parents, every cell in the body of a person with such a mutation contains the mutation.
It usually takes more than one mutation to cause cancer, but people who inherit a cancer-causing mutation are that much more likely to get cancer in their lifetimes. For example, only about 5 to 10 percent of breast cancers are considered to be the result of inherited mutations.
About 90 percent of all cases of cancer are sporadic cancers. Unlike hereditary cancer, in which mutations are passed on from parents, in cases of sporadic cancer, the mutation occurs spontaneously—often from unknown origins and reasons.
Doctors believe that these mutations are caused through exposure to risk factors for cancer during a person's lifetime.
Risk Factors for Breast Cancer in Men
In men, risk factors for breast cancer may include the following:
- Exposure to radiation
- Use of estrogen in medical treatment
- Diseases associated with excessive estrogen production, such as cirrhosis or Klinefelter's syndrome—a genetic condition that can result in infertility and less body hair and muscle mass
- Heavy alcohol intake
- Female family members who have history of breast cancer
- Family members in which the BRCA2 mutation has been identified
The following are the most common symptoms of breast cancer. However, each individual may experience symptoms differently. Early breast cancer usually doesn't cause pain and may cause no symptoms at all. And some breast cancers never cause symptoms or other indications of a problem.
As the cancer grows, however, it can cause changes that women and men should watch for, such as:
- A lump or thickening (a mass, swelling, skin irritation or distortion) in or near the breast or in the underarm area
- A change in the size or shape of the breast
- A change in the color or feel of the skin of the breast, areola or nipple (dimpled, puckered or scaly)
- Nipple discharge, erosion, inversion (pointing inward) or tenderness
Symptoms of Breast Cancer for Men
For men, symptoms of breast cancer are similar to those in women and include:
- Breast lumps
- Nipple inversion (pointing inward)
- Discharge from the nipples (sometimes bloody)
- Pain or pulling sensation in the breast
Our advanced diagnostics include today’s most sophisticated tools for the detection of even the smallest cancers. You also have the security of knowing that if you should need further treatment, you have one of the nation’s top cancer centers and a whole team of caring, dedicated specialists and professionals ready to help you.
Among the diagnostic tools we offer:
- Tomosynthesis, or 3D mammography, detects very small cancers that can’t be found with traditional mammograms. It also helps doctors rule out false positives, reducing the number of follow-up screenings.
- Screening MRI is a sensitive imaging technique that can find breast cancers that mammograms might miss.
- Digital mammography uses computer-generated images to provide finer images than traditional mammography. Results are usually available within seconds.
- Ultrasound-guided biopsy uses a computer and a transducer that sends out ultrasonic sounds waves to create images of the breast lump or mass.
- Stereotactic biopsy finds the exact location of a breast lump or suspicious area by using a computer and mammogram results to create a three-dimensional (3D) picture of the breast.
If your family or personal history indicates a significant level of risk, our team will work with you to design a treatment plan that's right for you. We can offer several strategies to help keep you healthy while aggressively monitoring for the development of any cancer. These include:
- Personal risk assessment and close observation
- Chemoprevention, which uses powerful, FDA-approved medications, including tamoxifen and raloxifene, to help prevent cancer from developing
If you need medical intervention for a diagnosed cancer, UVA also provides:
- Radiation therapy, using some of the most advanced radiation technology available anywhere
Our high-risk program is led by talented, board-certified breast surgeons who specialize in the removal of breast cancers. In fact, we see more high-risk patients than anyone in the region. We offer the full complement of innovative and minimally invasive surgery including:
- Breast reconstruction
In extremely high-risk women, we also offer preventive surgery for breast cancer, including bilateral prophylactic mastectomy.
Treatment for Breast Cancer in Men
Treatment can include removal of breast tissue (mastectomy). Other treatment may be considered in the same way it is for a woman with breast cancer, since there is no evidence that the prognosis is different for men or women.
To reduce your risk of breast cancer, and to keep yourself healthy overall, you should eat a balanced diet, get regular exercise and try to keep yourself relaxed and stress free. You should also avoid risk factors that are under your control and known to cause cancer.
What is Chemoprevention?
Chemoprevention is the use of natural or synthetic substances to reduce the risk of getting cancer or of having cancer recur. Chemoprevention works in several different ways. First, it can prevent the mutations that can cause cancer. It can also help stop the process that makes the mutated, damaged cells grow out of control.
Chemoprevention is not the same as chemotherapy. Chemotherapy is used to kill cells that have already mutated and become cancerous. Chemoprevention is done to try to stop cells from becoming cancerous.
The News About Tamoxifen and Other Preventive Medications
Doctors in our High-Risk Breast and Ovarian Cancer Program use two different chemopreventive drugs—tamoxifen and raloxifene. These are the only two chemopreventive drugs approved by U.S Food and Drug Administration for reducing the risk of breast cancer.
Your doctor will work with you to help determine which chemopreventive agents might help lower your risk of cancer or help keep you from developing cancer.
“It runs in the family.” How many times have we said it about a family member’s wavy hair or wide-open smile? We don’t like to think about cancer as a family trait but here’s why we should: Thanks to remarkable advances in our understanding of the role of genetics, a woman can learn if she’s at higher inherited risk, enabling her to take action to stay healthy.
Genetic mutations and other inherited risk factors are a factor in less than 10 percent of all breast and ovarian cancers. But if a woman does carry an inherited mutation, specifically the BRCA1 or BRCA2 gene, our genetic counselors can help you understand what it means to you. Because genetic risk is complex, our genetic counselors are an integral part of the high-risk program’s interdisciplinary team, whose primary purpose is helping you manage your risk of developing cancer.