Breast cancerCompelled by Victor Ulasi

If you or a loved one has been diagnosed with breast cancer, it's important to understand some basics: What is breast cancer and how does it happen?

In this section, you can learn about how breast cancer develops, how many people get breast cancer, and what factors can increase risk for getting breast cancer. You also can learn more about signs and symptoms to watch for and how to manage any fears you may have about breast cancer.

Breast cancer (malignant breast neoplasm) is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas.

Prognosis and survival rate varies greatly depending on cancer type and staging. Computerized models are available to predict survival. With best treatment and dependent on staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes surgery, drugs (hormonal therapy and chemotherapy), and radiation.

Worldwide, breast cancer comprises 10.4% of all cancer incidence among women, making it the most common type of non-skin cancer in women and the fifth most common cause of cancer death. In 2004, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths). Breast cancer is about 100 times more common in women than in men, although males tend to have poorer outcomes due to delays in diagnosis.

Some breast cancers are sensitive to hormones such as estrogen and/or progesterone which makes it possible to treat them by blocking the effects of this hormones in the target tissues. These have better prognosis and require less aggressive treatment than hormone negative cancers.

Breast cancers without hormone receptors, or which have spread to the lymph nodes in the armpits, or which express certain genetic characteristics, are higher-risk, and are treated more aggressively. One standard regimen, popular in the U.S., is cyclophosphamide plus doxorubicin (Adriamycin), known as CA; these drugs damage DNA in the cancer, but also in fast-growing normal cells where they cause serious side effects. Sometimes a taxane drug, such as docetaxel, is added, and the regime is then known as CAT; taxane attacks the microtubules in cancer cells. An equivalent treatment, popular in Europe, is cyclophosphamide, methotrexate, and fluorouracil (CMF). Monoclonal antibodies, such as trastuzumab (Herceptin), are used for cancer cells that have the HER2 mutation. Radiation is usually added to the surgical bed to control cancer cells that were missed by the surgery, which usually extends survival, although radiation exposure to the heart may cause damage and heart failure in the following years.

Types of Breast CancerBreast cancer can begin in different areas of the breast – the ducts, the lobules, or in some cases, the tissue in between. In this section, you can learn about the different types of breast cancer, including non-invasive, invasive, recurrent, and metastatic breast cancers.

DCIS - Ductal Carcinoma In SituDuctal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means "in its original place." DCIS is called "non-invasive" because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue. DCIS isn’t life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.

When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a recurrence are under 30%.

Women who have breast-conserving surgery (lumpectomy) for DCIS without radiation therapy have about a 25% to 30% chance of having a recurrence at some point in the future. Including radiation therapy in the treatment plan after surgery drops the risk of recurrence to about 15%. If breast cancer does come back after earlier DCIS treatment, the recurrence is non-invasive (DCIS again) about half the time and invasive about half the time. (DCIS itself is NOT invasive.)

According to the American Cancer Society, about 60,000 cases of DCIS are diagnosed in the United States each year, accounting for about 1 out of every 5 new breast cancer cases.

There are two main reasons this number is so large and has been increasing over time:

People are living much longer lives. As we grow older, our risk of breast cancer increases.

More people are getting mammograms, and the quality of the mammograms has improved. With better screening, more cancers are being spotted early.

LCIS - Lobular Carcinoma In SituLobular carcinoma in situ (LCIS) is an area (or areas) of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later on in life. Lobular means that the abnormal cells start growing in the lobules, the milk-producing glands at the end of breast ducts. Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. In situ or “in its original place” means that the abnormal growth remains

inside the lobule and does not spread to surrounding tissues. People diagnosed with LCIS tend to have more than one lobule affected.

Despite the fact that its name includes the term “carcinoma,” LCIS is not a true breast cancer. Rather, LCIS is an indication that a person is at higher-than-average risk for getting breast cancer at some point in the future. For this reason, some experts prefer the term “lobular neoplasia” instead of “lobular carcinoma.” A neoplasia is a collection of abnormal cells.

LCIS is usually diagnosed before menopause, most often between the ages of 40 and 50. Less than 10% of women diagnosed with LCIS have already gone through menopause. LCIS is extremely uncommon in men.

LCIS is viewed as an uncommon condition, but we don’t know exactly how many people are affected. That’s because LCIS does not cause symptoms and usually does not show up on a mammogram. It tends to be diagnosed as a result of a biopsy performed on the breast for some other reason.

IDC - Invasive Ductal CarcinomaInvasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma, is the most common type of breast cancer. About 80% of all breast cancers are invasive ductal carcinomas.

Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means that the cancer began in the milk ducts, which are the “pipes” that carry milk from the milk-producing lobules to the nipple. Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. All together, “invasive ductal carcinoma” refers to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body.

According to the American Cancer Society, more than 180,000 women in the United States find out they have invasive breast cancer each year. Most of them are diagnosed with invasive ductal carcinoma.

Although invasive ductal carcinoma can affect women at any age, it is more common as women grow older. According to the American Cancer Society, about two-thirds of women are 55 or older when they are diagnosed with an invasive breast cancer. Invasive ductal carcinoma also affects men.

ILC - Invasive Lobular CarcinomaInvasive lobular carcinoma (ILC), sometimes called infiltrating lobular carcinoma, is the second most common type of breast cancer after invasive ductal carcinoma (cancer that begins in the milk-carrying ducts and spreads beyond it). According to the American Cancer Society, more

than 180,000 women in the United States find out they have invasive breast cancer each year. About 10% of all invasive breast cancers are invasive lobular carcinomas. (About 80% are invasive ductal carcinomas.)

Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Lobular means that the cancer began in the milk-producing lobules, which empty out into the ducts that carry milk to the nipple. Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. All together, “invasive lobular carcinoma” refers to cancer that has broken through the wall of the lobule and begun to invade the tissues of the breast. Over time, invasive lobular carcinoma can spread to the lymph nodes and possibly to other areas of the body.

Although invasive lobular carcinoma can affect women at any age, it is more common as women grow older. According to the American Cancer Society, about two-thirds of women are 55 or older when they are diagnosed with an invasive breast cancer. ILC tends to occur later in life than invasive ductal carcinoma — the early 60s as opposed to the mid- to late 50s.

Some research has suggested that the use of hormone replacement therapy during and after menopause can increase the risk of ILC.

Paget's Disease of the NipplePaget's disease of the nipple is a rare form of breast cancer in which cancer cells collect in or around the nipple. The cancer usually affects the ducts of the nipple first (small milk-carrying tubes), then spreads to the nipple surface and the areola (the dark circle of skin around the nipple). The nipple and areola often become scaly, red, itchy, and irritated.

According to the National Cancer Institute, Paget's disease of the nipple accounts for less than 5% of all breast cancer cases in the United States. Being aware of the symptoms is important, given that more than 97% of people with Paget's disease also have cancer, either DCIS or invasive cancer, somewhere else in the breast. The unusual changes in the nipple and areola are often the first indication that breast cancer is present.

Doctors are not yet completely sure how Paget's disease develops. One possibility is that the cancer cells start growing inside the milk ducts within the breast and then make their way out to the nipple surface. This would appear to explain why so many people with Paget's disease of the nipple have a second area of cancer within the breast. Another theory is that the cells of the nipple itself become cancerous. This theory would explain the small number of people who: (1) only have Paget's disease in the nipple, or (2) have a second breast cancer that appears to be completely separate from the Paget's disease.

Paget's disease of the nipple is more common in women, but like other forms of breast cancer, it can also affect men. The disease usually develops after age 50. According to the National Cancer Institute, the average age of diagnosis in women is 62, and in men, 69.

Inflammatory Breast CancerInflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. According to the National Cancer Institute, about 1-5% of all breast cancer cases in the United States are inflammatory breast cancers.

Inflammatory breast cancer usually starts with the reddening and swelling of the breast instead of a distinct lump. IBC tends to grow and spread quickly, with symptoms worsening within days or even hours. It’s important to recognize symptoms and seek prompt treatment. Although inflammatory breast cancer is a serious diagnosis, keep in mind that treatments today are better at controlling the disease than they used to be.

The average age at diagnosis for inflammatory breast cancer in the United States is 57 for white women and 52 for African American women. These ages are about 5 years younger than the average ages at diagnosis for other forms of breast cancer. According to the American Cancer Society, inflammatory breast cancer is more common in African American women. A 2008 study found that being overweight makes a person more likely to develop IBC. Like other forms of breast cancer, IBC can also affect men.

Male Breast CancerBreast cancer in men is a rare disease. Less than 1% of all breast cancers occur in men. In 2005, when 211,400 women were diagnosed with breast cancer in the United States, 1,690 men were diagnosed with the disease.

You may be thinking: Men don't have breasts, so how can they get breast cancer? The truth is that boys and girls, men and women all have breast tissue. The various hormones in girls' and women's bodies stimulate the breast tissue to grow into full breasts. Boys' and men's bodies normally don't make much of the breast-stimulating hormones. As a result, their breast tissue usually stays flat and small. Still, you may have seen boys and men with medium-sized or big breasts. Usually these breasts are just mounds of fat. But sometimes men can develop real breast gland tissue because they take certain medicines or have abnormal hormone levels.

Because breast cancer in men is rare, few cases are available to study. Most studies of men with breast cancer are very small. But when a number of these small studies are grouped together, we can learn more from them.

In this section, you can learn the basic information about male breast cancer:

The Risk Factors for Male Breast Cancer Symptoms of Male Breast Cancer Diagnosis of Male Breast Cancer The Pathology Report Treatment of Male Breast Cancer

The medical experts for Male Breast Cancer are:

Lisa Attebery, D.O., breast surgeon, assistant professor of surgery, Dept. of Surgery, Cooper University Hospital, The Cancer Institute of Surgery

Jennifer Harned Adams, Ph.D., Department of Behavioral Science, University of Texas M.D. Anderson Cancer Center, Houston, Texas

Marisa Weiss, M.D., breast radiation oncologist, Lankenau Hospital, Thomas Jefferson University Health System, Philadelphia, Pennsylvania

Less Common Subtypes of Invasive Ductal CarcinomaThere are some types of invasive ductal carcinoma that happen less commonly than others. In these cancers, the cells can look and behave somewhat differently than invasive ductal carcinoma cells usually do. If you’re diagnosed with one of these cancers, talk with your doctor about how this could affect your treatment plan.

Tubular Carcinoma of the Breast

Tubular carcinoma of the breast is a rare subtype of invasive ductal carcinoma (cancer that begins inside the milk duct and spreads beyond it). Tubular carcinoma accounts for about 1-2% of all breast cancer cases. In this type of cancer, the tumor is usually small and made up of tube-shaped cells that are low grade. “Low grade” means they look somewhat similar to normal, healthy cells and tend to grow slowly.

Tubular carcinoma of the breast is less likely to spread outside the breast than other types of breast cancer. It’s also easier to treat.

Studies have found that the average age of diagnosis for tubular carcinoma ranges from the mid-40s to late 60s.

Medullary Carcinoma of the Breast

Medullary carcinoma of the breast is a rare subtype of invasive ductal carcinoma (cancer that begins in the milk duct and spreads beyond it), accounting for about 3-5% of all

cases of breast cancer. It is called “medullary” carcinoma because the tumor is a soft, fleshy mass that resembles a part of the brain called the medulla.

Medullary carcinoma can occur at any age, but it usually affects women in their late 40s and early 50s. Medullary carcinoma is more common in women who have a BRCA1 mutation. Studies have shown that medullary carcinoma is also more common in Japan than in the United States.

Medullary carcinoma cells are usually high-grade in their appearance and low-grade in their behavior. In other words, they look like aggressive, highly abnormal cancer cells, but they don’t act like them. Medullary carcinoma doesn’t grow quickly and usually doesn’t spread outside the breast to the lymph nodes. For this reason, it’s typically easier to treat than other types of breast cancer.

Mucinous Carcinoma of the Breast

Mucinous carcinoma of the breast — sometimes called colloid carcinoma — is a rare form of invasive ductal carcinoma (cancer that begins in the milk duct and spreads beyond it). Mucinous carcinoma of the breast accounts for about 2-3% of all breast cancer cases. In this type of cancer, the tumor is formed from abnormal cells that “float” in pools of mucin, a key ingredient in the slimy, slippery substance known as mucus.

Normally, mucus lines most of the inner surface of our bodies, such as our digestive tract, lungs, liver, and other vital organs. Many types of cancer cells — including most breast cancer cells — produce some mucus. In mucinous carcinoma, however, the mucus becomes a main part of the tumor and surrounds the breast cancer cells.

Mucinous carcinoma tends to affect women after they’ve gone through menopause. Some studies have found that the usual age at diagnosis is 60 or older.

Mucinous carcinoma is less likely to spread to the lymph nodes than other types of breast cancer. It’s also easier to treat.

Papillary Carcinoma of the Breast

Invasive papillary carcinomas of the breast are rare, accounting for less than 1-2% of invasive breast cancers. In most cases, these types of tumors are diagnosed in older women who have already been through menopause. An invasive papillary carcinoma usually has a well-defined border and is made up of small, finger-like projections. Often it is Grade 2, or moderate grade, on a scale of 1 to 3 — with Grade 1 describing cancer cells that look and behave somewhat like normal, healthy breast cells, and Grade 3 describing very abnormal, fast-growing cancer cells. In most cases of invasive papillary carcinoma, ductal carcinoma in situ (DCIS) is also present. (DCIS is a type of cancer in which the carcinoma cells are confined to the breast duct.)

Cribriform Carcinoma of the Breast

In invasive cribriform carcinoma, the cancer cells invade the stroma (connective tissues of the breast) in nestlike formations between the ducts and lobules. Within the tumor, there are distinctive holes in between the cancer cells, making it look something like Swiss cheese. Invasive cribriform carcinoma is usually low grade, meaning that its cells look and behave somewhat like normal, healthy breast cells. In about 5-6% of invasive breast cancers, some portion of the tumor can be considered cribriform. Usually, some ductal carcinoma in situ (DCIS) of the cribriform type is present as well.

Breast Cancer Statistics About 1 in 8 women in the United States (between 12 and 13%) will develop invasive

breast cancer over the course of her lifetime. In 2010, an estimated 207,090 new cases of invasive breast cancer are expected to be

diagnosed in women in the U.S., along with 54,010 new cases of non-invasive (in situ) breast cancer.

About 1,970 new cases of invasive breast cancer will be diagnosed in men in 2010. Less than 1% of all new breast cancer cases occur in men.

From 1999 to 2006, breast cancer incidence rates in the U.S. decreased by about 2% per year. One theory is that this decrease was partially due to the reduced use of hormone replacement therapy (HRT) by women after the results of a large study called the Women’s Health Initiative were published in 2002. These results suggested a connection between HRT and increased breast cancer risk.

About 39,840 women in the U.S. are expected to die in 2010 from breast cancer, though death rates have been decreasing since 1991. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness.

For women in the U.S., breast cancer death rates are higher than those for any other cancer, besides lung cancer.

Besides skin cancer, breast cancer is the most commonly diagnosed cancer among U.S. women. More than 1 in 4 cancers in women (about 28%) are breast cancer.

Compared to African American women, white women are slightly more likely to develop breast cancer, but less likely to die of it. One possible reason is that African American women tend to have more aggressive tumors, although why this is the case is not known. Women of other ethnic backgrounds — Asian, Hispanic, and Native American — have a lower risk of developing and dying from breast cancer than white women and African American women.

In 2010, there are more than 2.5 million breast cancer survivors in the U.S. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative

(mother, sister, daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer have a family history of breast cancer.

About 5-10% of breast cancers can be linked to gene mutations (abnormal changes) inherited from one’s mother or father. Mutations of the BRCA1 and BRCA2 genes are the most common. Women with these mutations have up to an 80% risk of developing breast cancer during their lifetime, and they are more likely to be diagnosed at a younger age (before menopause). An increased ovarian cancer risk is also associated with these

genetic mutations. In men, about 1 in 10 breast cancers are believed to be due to BRCA2 mutations and even fewer cases to BRCA1 mutations.

About 70-80% of breast cancers occur in women who have no family history of breast cancer. These occur due to genetic abnormalities that happen as a result of the aging process and life in general, rather than inherited mutations.

The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).

nitially, breast cancer may not cause any symptoms. A lump may be too small for you to feel or to cause any unusual changes you can notice on your own. Often, an abnormal area turns up on a screening mammogram (x-ray of the breast), which leads to further testing.

Symptoms of Breast Cancer

In some cases, however, the first sign of breast cancer is a new lump or mass in the breast that you or your doctor can feel. More than 80% of breast cancer cases are discovered when the woman feels a lump. A lump that is painless, hard, and has uneven edges is more likely to be cancer. But sometimes cancers can be tender, soft, and rounded. So it's important to have anything unusual checked by your doctor.

According to the American Cancer Society, any of the following unusual changes in the breast can be a symptom of breast cancer:

swelling of all or part of the breast skin irritation or dimpling breast pain nipple pain or the nipple turning inward redness, scaliness, or thickening of the nipple or breast skin a nipple discharge other than breast milk a lump in the underarm area

These changes also can be signs of less serious conditions that are not cancerous, such as an infection or a cyst. It’s important to get any breast changes checked out promptly by a doctor.

Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge. Pain ("mastodynia") is an

unreliable tool in determining the presence or absence of breast cancer, but may be indicative of other breast health issues.[14][15][16]

When breast cancer cells invade the dermal lymphatics—small lymph vessels in the skin of the breast—its presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC). Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast, as well as an orange-peel texture to the skin referred to as peau d'orange.

Another reported symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Approximately half of women diagnosed with Paget's also have a lump in the breast.

In rare cases, what initially appears as a fibroadenoma (hard movable lump) could in fact be a phyllodes tumor. Phyllodes tumors are formed within the stroma (connective tissue) of the breast and contain glandular as well as stromal tissue. Phyllodes tumors are not staged in the usual sense; they are classified on the basis of their appearance under the microscope as benign, borderline, or malignant.

Occasionally, breast cancer presents as metastatic disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. Common sites of metastasis include bone, liver, lung and brain.[19] Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms. These symptoms are "non-specific", meaning they can also be manifestations of many other illnesses.[20]

Most symptoms of breast disorder do not turn out to represent underlying breast cancer. Benign breast diseases such as mastitis and fibroadenoma of the breast are more common causes of breast disorder symptoms. The appearance of a new symptom should be taken seriously by both patients and their doctors, because of the possibility of an underlying breast cancer at almost any age.

Stages of Breast Cancer

Cancer stage is based on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast.

The purpose of the staging system is to help organize the different factors and some of the personality features of the cancer into categories, in order to:

best understand your prognosis (the most likely outcome of the disease) guide treatment decisions (together with other parts of your pathology report), since clinical

studies of breast cancer treatments that you and your doctor will consider are partly organized by the staging system

provide a common way to describe the extent of breast cancer for doctors and nurses all over the world, so that results of your treatment can be compared and understood

Stage 0

Stage 0 is used to describe non-invasive breast cancers, such as DCIS and LCIS. In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or of getting through to or invading neighboring normal tissue.

Stage I

Stage I describes invasive breast cancer (cancer cells are breaking through to or invading neighboring normal tissue) in which:

the tumor measures up to 2 centimeters, AND no lymph nodes are involved

Stage II

Stage II is divided into subcategories known as IIA and IIB.

Stage IIA describes invasive breast cancer in which:

no tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm), OR

the tumor measures 2 centimeters or less and has spread to the axillary lymph nodes, OR the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to

the axillary lymph nodes

Stage IIB describes invasive breast cancer in which:

the tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes, OR

the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

Stage III

Stage III is divided into subcategories known as IIIA, IIIB, and IIIC.

Stage IIIA describes invasive breast cancer in which either:

no tumor is found in the breast. Cancer is found in axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone, OR

the tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped together or sticking to other structures, OR

the tumor is larger than 5 centimeters and has spread to axillary lymph nodes that are clumped together or sticking to other structures

Stage IIIB describes invasive breast cancer in which:

the tumor may be any size and has spread to the chest wall and/or skin of the breast AND may have spread to axillary lymph nodes that are clumped together or sticking to other

structures, or cancer may have spread to lymph nodes near the breastbone Inflammatory breast cancer is considered at least stage IIIB.

Stage IIIC describes invasive breast cancer in which:

there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast, AND

the cancer has spread to lymph nodes above or below the collarbone, AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Stage IV

Stage IV describes invasive breast cancer in which:

the cancer has spread to other organs of the body -- usually the lungs, liver, bone, or brain

"Metastatic at presentation" means that the breast cancer has spread beyond the breast and nearby lymph nodes, even though this is the first diagnosis of breast cancer. The reason for this is that the primary breast cancer was not found when it was only inside the breast. Metastatic cancer is considered stage IV.

Information on how to Lower Your RiskA tremendous amount of promising research is under way to determine the cause of breast cancer and to establish effective ways to prevent it. Still, doctors can't always explain why one woman develops breast cancer and another doesn't.

Everyone seems to know someone with breast cancer, and we wonder whether we, too, will be affected during our lifetime. All of us want to do everything we can to reduce the risk of ever getting the disease. Right now, though, we just don't know enough about what causes breast

cancer and we haven't yet figured out how to keep it from happening — so we can't say that we can “prevent” it.

However, researchers are working to learn how our “external” and “internal” environments may work separately and together to affect our health and possibly the risk of developing breast cancer. “Internal environment” means the things inside our bodies that influence our health, such as genetics (the genes you got from your mother and father), hormones, illnesses, and feelings and thoughts. “External environment” refers to the things outside of our bodies that influence our health, such as air, water, food, danger, music, noise, people, and stress. Also, the external environment enters our internal environment every day — think of the food you eat, water you drink, air you breathe (including whether you smoke or not), and medicines you take. More subtlely, there's the way you “breathe in” or absorb your environment, such as your home or workplace, and the way you take in energy from the people you spend time with.

Some of these factors, such as your genetic makeup and the medicines that you take, have a very direct effect on your breast health. The impact of other, indirect factors, such as air quality, exercise, meditation, and spending time with friends, is less well understood.

Anything that INCREASES your chance of developing breast cancer is called a risk factor. Anything that REDUCES your risk of developing breast cancer is called a protective factor.

You can control some risk factors. For example, if you are overweight, you can seek to lose excess pounds, which may reduce your risk of breast cancer. You can also make informed choices about the medicines you take.

But other factors are beyond your control. For instance, you can't change your gender. Women are much more likely than men to have breast cancer. This is mostly because women have more estrogen and progesterone in their bodies. These hormones stimulate breast cell growth — both normal and abnormal. Also, you can't stop growing older. Aging is the biggest risk factor for breast cancer (besides being a woman).

Risk reduction means making choices to avoid or minimize any possible risk factors that you can. It also means increasing the protective factors in your life so your chances of developing breast cancer are lower.

Although you can control many risk factors, remember that doing so does not guarantee zero risk. It is also important to keep in mind that many women who have a particular risk factor for breast cancer never develop it.

Knowledge is power. Instead of living under the shadow of myths and misunderstandings, KNOW your own realistic level of risk. Then you can talk to your doctor about ways to lessen controllable risk factors and boost your protective factors.

In the following pages of the Lower Your Risk section, you can learn about:

Understanding Breast Cancer Risk

What do the statistics about breast cancer risk mean? What are relative and absolute risk? The facts and figures can help you understand risk.

Genetics and Breast Cancer RiskRead Conference Transcripts and summaries of research on BRCA1 and BRCA2 gene abnormalities, including how they affect breast cancer risk, as well as reports on the treatment options of removing ovaries and breasts.

Lowering Risk for EveryoneLifestyle and environmental factors can either increase or reduce your risk for breast cancer. Learn what you should know and what action you can take.

Lowering Risk for People at High RiskIf you have a family history of breast cancer or have the abnormal BRCA1 or BRCA2 gene, you may have a higher risk of developing breast cancer and may want to consider more advanced protection methods. Also, if you have an abnormal BRCA1 or BRCA2 gene, your risk of developing ovarian cancer is increased. Protect yourself with information.

Lowering Risk for People with a Personal HistoryIf you already have been diagnosed with breast cancer, your risk of developing it again is higher than if you had never had the disease. Treatment options are available to help you reduce that risk. Your risk of developing ovarian cancer also may be higher. Understand your options.

Ovarian Cancer and Breast CancerHere we examine the link between ovarian cancer and breast cancer.

The medical experts for Lower Your Risk are:

Carol Cherry, R.N., O.C.N. , oncology nurse, Fox Chase Cancer Center, Philadelphia, PA. Anne McTiernan, M.D., Ph.D. , member of the Cancer Prevention Program at the Fred

Hutchinson Cancer Research Center in Seattle, where she is Director of the Prevention Center, and Research Professor at the University of Washington School of Public Health and Community Medicine Department of Epidemiology, and School of Medicine Division of Geriatrics.

Marisa C. Weiss, M.D. , breast radiation oncologist, Thomas Jefferson University Health System, Philadelphia, PA.

By now you may be familiar with the statistic that says 1 in 8 women will develop invasive breast cancer. Many people misinterpret this to mean that, on any given day, they and the women they know have a 1-in-8 risk of developing the disease. That’s simply not true.

In reality, about 1 in 8 women in the United States — 12.7%, or about 12-13 out of every 100 — can expect to develop breast cancer over the course of an entire lifetime. In the U.S., an average lifetime is about 80 years. So, it’s more accurate to say that 1 in 8 women in the U.S. who reach the age of 80 can expect to develop breast cancer. In each decade of life, the risk of getting breast cancer is actually lower than 12-13% for most women.

People tend to have very different ways of viewing risk. For you, a 1-in-8 lifetime risk may seem like a high likelihood of getting breast cancer. Or you may turn this around and reason that there

is a 7-in-8, or 87.5%, chance you will never get breast cancer, even if you live to age 80. How you view risk often depends on your individual situation — for example, whether you or many women you know have had breast cancer, or you have reason to believe you are at higher-than-normal risk for the disease — and your usual way of looking at the world.

Even though studies have found that women have a 12.7% lifetime risk of developing breast cancer, your individual risk may be higher or lower than that. Individual risk is affected by many different factors, such as family history, reproductive history, lifestyle, environment, and others.

This section is designed to help you better understand breast cancer risk and some of the factors that can increase risk.

A “risk factor” is anything that increases your risk of developing breast cancer. Many of the most important risk factors for breast cancer are beyond your control, such as age, family history, and medical history. However, there are some risk factors you can control, such as weight, physical activity, and alcohol consumption.

Be sure to talk with your doctor about all of your possible risk factors for breast cancer. There may be steps you can take to lower your risk of breast cancer, and your doctor can help you come up with a plan. Your doctor also needs to be aware of any other risk factors beyond your control, so that he or she has an accurate understanding of your level of breast cancer risk. This can influence recommendations about breast cancer screening — what tests to have and when to start having them.

Risk factors you can controlWeight. Being overweight is associated with increased risk of breast cancer, especially for women after menopause. Fat tissue is the body’s main source of estrogen after menopause, when the ovaries stop producing the hormone. Having more fat tissue means having higher estrogen levels, which can increase breast cancer risk.

Diet. Diet is a suspected risk factor for many types of cancer, including breast cancer, but studies have yet to show for sure which types of foods increase risk. It’s a good idea to restrict sources of red meat and other animal fats (including dairy fat in cheese, milk, and ice cream), because they may contain hormones, other growth factors, antibiotics, and pesticides. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer, and studies show that eating a lot of red and/or processed meats is associated with a higher risk of breast cancer. A low-fat diet rich in fruits and vegetables is generally recommended. For more information, visit our page on healthy eating to reduce cancer risk in the Nutrition section.

Exercise. Evidence is growing that exercise can reduce breast cancer risk. The American Cancer Society recommends engaging in 45-60 minutes of physical exercise 5 or more days a week.

Alcohol consumption. Studies have shown that breast cancer risk increases with the amount of alcohol a woman drinks. Alcohol can limit your liver’s ability to control blood levels of the hormone estrogen, which in turn can increase risk.

Smoking. Smoking is associated with a small increase in breast cancer risk.

Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are under your control, such as:

taking combined hormone replacement therapy (estrogen and progesterone; HRT) for several years or more, or taking estrogen alone for more than 10 years

being overweight regularly drinking alcohol

Recent oral contraceptive use. Using oral contraceptives (birth control pills) appears to slightly increase a woman’s risk for breast cancer, but only for a limited period of time. Women who stopped using oral contraceptives more than 10 years ago do not appear to have any increased breast cancer risk.

Stress and anxiety. There is no clear proof that stress and anxiety can increase breast cancer risk. However, anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction can have a major effect on your quality of life. So-called “mindful measures” (such as meditation, yoga, visualization exercises, and prayer) may be valuable additions to your daily or weekly routine. Some research suggests that these practices can strengthen the immune system.

Risk factors you can’t controlGender. Being a woman is the most significant risk factor for developing breast cancer. Although men can get breast cancer, too, women’s breast cells are constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risk for breast cancer.

Age. Simply growing older is the second biggest risk factor for breast cancer. From age 30 to 39, the risk is 1 in 233, or .43%. That jumps to 1 in 27, or almost 4%, by the time you are in your 60s.

Family history of breast cancer. If you have a first-degree relative (mother, daughter, sister) who has had breast cancer, or you have multiple relatives affected by breast or ovarian cancer (especially before they turned age 50), you could be at higher risk of getting breast cancer.

Personal history of breast cancer. If you have already been diagnosed with breast cancer, your risk of developing it again, either in the same breast or the other breast, is higher than if you never had the disease.

Race. White women are slightly more likely to develop breast cancer than are African American women. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer.

Radiation therapy to the chest. Having radiation therapy to the chest area as a child or young adult as treatment for another cancer significantly increases breast cancer risk. The increase in risk seems to be highest if the radiation was given while the breasts were still developing (during the teen years).

Breast cellular changes. Unusual changes in breast cells found during a breast biopsy (removal of suspicious tissue for examination under a microscope) can be a risk factor for developing breast cancer. These changes include overgrowth of cells (called hyperplasia) or abnormal (atypical) appearance.

Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are not under your control, such as:

starting menstruation (monthly periods) at a young age (before age 12) going through menopause (end of monthly cycles) at a late age (after 55) exposure to estrogens in the environment (such as hormones in meat or pesticides such as

DDT, which produce estrogen-like substances when broken down by the body)

Pregnancy and breastfeeding. Pregnancy and breastfeeding reduce the overall number of menstrual cycles in a woman’s lifetime, and this appears to reduce future breast cancer risk. Women who have never had a full-term pregnancy, or had their first full-term pregnancy after age 30, have an increased risk of breast cancer. For women who do have children, breastfeeding may slightly lower their breast cancer risk, especially if they continue breastfeeding for 1 1/2 to 2 years. For many women, however, breastfeeding for this long is neither possible nor practical.

DES exposure. Women who took a medication called diethylstilbestrol (DES), used to prevent miscarriage from the 1940s through the 1960s, have a slightly increased risk of breast cancer. Women whose mothers took DES during pregnancy may have a higher risk of breast cancer as well.

Managing Breast Cancer FearsSo many women you know may have had breast cancer — friends and neighbors, coworkers, relatives. It seems as if every time you turn around, breast cancer is being talked about in the newspaper or on TV. You may be fearful of developing breast cancer for the first time or of receiving a diagnosis after a mammogram or other testing. If you’ve had breast cancer, you may be fearful of a possible recurrence or even of the possibility that breast cancer could take your life.

Even though you may have some of these fears, you are not necessarily going to get breast cancer. If you have had breast cancer before, it doesn’t mean that the cancer will recur. Still, it's normal to have concerns about a disease that you hear about and see around you relatively often — and that you may have experienced yourself or through a loved one. Don't let the discussion of fear in this section feed into your own fears. Throughout Breastcancer.org, the information our

medical experts provide and the support offered by our community members can help you manage the fears, instead of letting them manage you.

The fear of breast cancer is unlike any other — psychologists and other experts agree on that. The fear can take many different forms, depending upon where you are in the breast cancer experience. Understand that many of your fears are shared by others. While fears are normal, they are uncomfortable to live with. We'll help you figure out how you can manage fear so you can focus on living a happy and healthy life.

10 Ways to Manage Fear after Diagnosis Find a doctor who communicates with you in a way that is comfortable for you, who invites your questions and takes your concerns seriously, who gives you as much or as little information as you feel comfortable with at any given moment. Find out what to expect from tests, procedures, and treatments. Minimize surprises. Make plans with your doctor about how to receive test results in a prompt way. If possible, try to schedule important tests early in the week, so you don't have to wait over a long weekend when lab work may slow down or doctors aren't communicating with each other. Find a mammography center where the radiologist will talk with you about the results before you go home, so you don't have to wait for a letter or a call from your doctor. When you know you're going to have a challenging week (a mammogram coming up or a round of chemotherapy), don't plan to do things that are stressful for you (for example: balance the checkbook, cook dinner for 20, or run a big meeting at work). Use your support systems — friends, movies, yoga, prayer — to help you get through it. If well-meaning people try to tell you stories about others struggling with cancer, stop them right away and say, "I only listen to stories with happy endings!" If you reach a point where difficult emotions are getting in the way of your functioning or taking care of yourself, speak with your doctor about the role of medications that might help ease your anxiety, depression, or sleeping problems. Join a breast-cancer-related group. This can be a support group or online discussion board — a place to share your breast cancer experience openly with people who understand. If you are more action-oriented, look for a breast-cancer-related athletic group, an organization that holds breast cancer education programs, or an advocacy group that lobbies for more research funding or free mammograms. Do whatever makes you feel connected to others in a positive way as a person who is moving beyond breast cancer.

Work on ways to feel more positive about your life. Seek out productive, life-enhancing experiences; accept yourself for who you are; and spend time with positive people who affirm who you are and how you've chosen to deal with this disease.