National Breast Cancer Foundation, Inc.

Risk Factors

No one knows the exact causes of breast cancer, but research has shown that women with certain risk factors are more likely than others to develop the disease.

Risk factors for breast cancer include:

• Older age - Half of all women diagnosed are over age sixty-five
• Early onset of menses or late menopause
• Diets high in saturated fat
• Older age at birth of first child or never having given birth
• A personal history of breast cancer or benign (noncancer) breast disease
• A family history, particularly a mother or sister
• Treatment with radiation therapy to the breast/chest
• Breast tissue that is dense on a mammogram
• Taking hormones such as estrogen and progesterone
• Obesity
• Moderate alcoholic intake - more than 2 drinks per day
• Gene changes - including BRCA1, BRCA2, and others

Symptoms

Generally, early breast cancer does not cause pain. Even so, a woman should see her health care provider about breast pain or any other symptom that does not go away.

Common symptoms of breast cancer include:

• A change in how the breast or nipple feels
  You may experience nipple tenderness or notice a lump or thickening in or near the breast or in the underarm area.
• A change in how the breast or nipple looks
  This could mean a change in the size or shape of the breast or a nipple that is turned slightly inward. In addition, the skin of the breast, areola or nipple may appear scaly, red or swollen or may have ridges or pitting that resembles the skin of an orange.
• Nipple discharge

Early Detection Plan

An Early Breast Cancer Detection Plan should include:

• Clinical breast examinations every three years from ages 20-39, then every year thereafter.
• Monthly breast self-examinations beginning at age 20. Look for any changes in your breasts.
• Baseline mammogram by the age of 40.
• Mammogram every one to two years for women 40-49, depending on previous findings.
• Mammogram every year for women 50 and older.
• A personal calendar to record your self-exams, mammograms, and doctor appointments.
• A low-fat diet, regular exercise, and no smoking or drinking.

How to do a Breast Self-Examination

In the Shower

Fingers flat, move gently over every part of each breast. Use your right hand to examine left breast, left hand for right breast. Check for any lump, hard knot or thickening. Carefully observe any changes in your breasts.

Before a Mirror

Inspect your breasts with arms at your sides. Next, raise your arms high overhead.

Look for any changes in contour of each breast, a swelling, a dimpling of skin or changes in the nipple. Then rest palm on hips and press firmly to flex your chest muscles. Left and right breasts will not exactly match - few women's breasts do.

Lying Down

Place pillow under right shoulder, right arm behind your head. With fingers of left hand flat, press right breast gently in small circular motions, moving vertically or in a circular pattern covering the entire breast. Use light, medium and firm pressure. Squeeze nipple; check for discharge and lumps. Repeat these steps for your left breast.

Inflammatory Breast Cancer

By Dr. Jeff Patton of Tennessee Oncology

Inflammatory breast cancer is a unique and uncommon type of breast cancer. It is unique in that inflammatory breast cancer does not produce a distinct mass or lump that can be felt within the breast. The lack of a lump or mass also makes inflammatory breast cancer difficult to detect by mammograms. Inflammatory breast cancer cells infiltrate the skin and lymph vessels of the breast. When the lymph vessels become blocked by the breast cancer cells the breast typically becomes red, swollen, and warm. The skin changes associated with inflammatory can cause the breast skin to look like the skin of an orange a finding called peau d'orange. The appearance of the breast is similar to other inflammatory conditions such as cellulitis or mastitis. Other possible associate symptoms include enlarged lymph nodes under the arm or above the collar bone on the affected side.

Inflammatory breast cancer is diagnosed based upon the results of a biopsy and the clinical judgment of the treating physician. Typically, inflammatory breast cancer grows rapidly and requires aggressive treatment. There are two aspects to treating all breast cancer, local treatment and systemic or total body treatment. Because inflammatory breast cancer is aggressive, most oncologists recommend both systemic and local treatment. The typical sequence of treatment is to start with chemotherapy, systemic treatment, followed by surgery and radiation therapy, which are the local treatments, often followed by additional chemotherapy and possibly hormone treatments. With aggressive treatment using this multimodality approach, the 5 year survival for inflammatory breast cancer has improved significantly from an average survival of 18 months to an approximately 50% survival rate at 5 years.

How many cases of IBC are diagnosed each year?
The numbers vary, but approximately 1% to 2% of newly diagnosed invasive breast cancers (that have spread beyond the breast) in the United States are described as inflammatory breast cancers.

What are the symptoms of IBC?

Symptoms may include:

• One breast larger than the other
• Red or pink skin
• Swelling
• Rash (entire breast or small patches)
• Orange-like texture (peau d' orange)
• Skin hot to the touch
• Pain and/or itchiness
• Ridges or thickened areas of breast
• Nipple discharge
• Nipples that appear inverted or flattened
• Swollen lymph nodes under the armpit
• Swollen lymph nodes of the neck (sometimes)

What should people do if they have IBC symptoms?
If one or more symptoms continue for more than a week, look for information and talk to a physician with experience with this particular type of breast cancer.

The resources below may help guide you to physicians and centers with this expertise.

How old are typical IBC patients at diagnosis?
The median age range is between 45 and 55 years old, but there may be patients either younger or older. The symptoms must guide the diagnosis, and age should not be used to exclude it.

How well do diagnostic tests work in identifying IBC?
IBC typically cannot be identified through:

Mammogram - Because IBC usually does not occur in the form of a lump (the cancer is spread throughout breast tissue), it is difficult to detect with a mammogram. The most characteristic mammography findings consist of swelling of the skin.

Ultrasound - This test confirms the swelling (edema) of the skin and can better identify breast nodules (if present). It also is the most appropriate test for the evaluation of lymph nodes.

Magnetic Resonance Imaging (MRI) - This is probably the most sensitive test because it includes a functional description of the abnormal findings. It should be included among the diagnostic tests once the pathological diagnosis is confirmed. It is extremely useful in evaluating the clinical response to chemotherapy.

Core biopsy - Typically, fine-needle aspiration or a core biopsy (removal of tissue with a needle) is performed to obtain a pathological diagnosis of invasive disease, but these diagnostic procedures are not appropriate for IBC because of the peculiar growth pattern in the breast lymphatic system.

What diagnostic tests identify IBC?
Surgical biopsy - Most of the time a skin biopsy or a surgical biopsy is necessary. These procedures are able to collect larger samples that include the skin and underlying tissue with higher chances to identify the cancer cells. PET Scan - In the near future, this could be one of the most important diagnostic/staging tests for IBC, though it still is under study. We have found that with the PET scan we can see more disease.

We can see lymph nodes far from the breast, which tells us we have a metastatic cancer already at the time of diagnosis. If we limit staging to mammogram, CT (computed tomography - computerized X-rays) and bone scans we may miss different components of this inflammatory spreading, which may have significant consequences in the way we treat the cancer and the way we process patients.

What is the survival rate for IBC?
The five-year median survival rate for inflammatory breast cancer is approximately 40%. The main reasons for such a disappointing outcome are multiple and include: a delay in diagnosis, the lack of expertise in treating IBC because it is so rare and the relative resistance the disease has to standard chemotherapeutic agents.

With regard to the first critical issue, it is important to keep in mind that IBC is a fast-growing cancer (it can spread within weeks), and it is often mistaken for something other than breast cancer, such as a rash or infection.

What are common mistakes in treating IBC?
A surgeon might want to remove the breast too early, which would increase the chance of local recurrence (return of the disease).

A radiation oncologist with experience in treating IBC also is important. IBC might require a different schedule than most breast cancers. You might need two treatments a day, instead of one, because this is a highly aggressive tumor. Patients also need a specific chemotherapy dose.

A particular challenge with treating IBC is that it is difficult to measure response since a nodule or mass is usually not present.

If patients have had incorrect treatment, it may be hard to go back and improve the prognosis (outcome).

How is IBC currently treated?
We typically treat IBC with chemotherapy before surgery, and we also are using drugs like Herceptin® (trastuzumab) or Tykerb™ (lapatinib) in a subset of IBC patients who have the HER-2 gene. One of our challenges is to improve our current treatments. We are focused on finding ways to eliminate microscopic disease to prolong survival.