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Breast cancer is the most common cancer diagnosis for women. It accounts for over 30% of cancer diagnoses each year. Roughly 1 in 3 women are diagnosed with some form of breast cancer. It is estimated that in 2022, 1.9 million breast cancer cases will be diagnosed, and there will be over 609,000 deaths (American Cancer Society, 2022a). This form of cancer is the second-leading cause of death in women, second only to lung cancer. There is an increase in deaths from breast cancer in low-income countries. Developed countries see the same incidence rate but are better able to care for patients with this diagnosis due to advances in diagnosis and treatment.
Breast cancer incidence and death rates have increased in recent years. By 2030, it is estimated that 2.7 million will be diagnosed annually, and nearly 0.9 will die (American Cancer Society, 2022a). In countries with low income, these statistics could be even higher. Education and awareness are essential to early diagnosis and treatment, which could significantly reduce the risk of death from breast cancer (Łukasiewicz et al., 2021).
A combination of factors can increase the risk of breast cancer. Sex and age are the two most significant factors that increase the risk of developing this cancer (Centers for Disease Control and Prevention [CDC], 2022). Additional factors increase the risk and can be labeled as modifiable (can change) or non-modifiable (cannot change).
Breast Cancer Risk Factors
Non-modifiable risk factors for breast cancer include (CDC, 2022; Casaubon et al., 2021):
- Genetic Mutations: Genetic mutations increase a woman’s risk of developing breast cancer. Specifically, those with BRCA1 and BRCA2 genes are at a much higher risk of developing breast cancer. This risk is called a hereditary predisposition. BRCA1 and BRCA2 genes cause up to 10% of all breast cancer diagnoses and over 50% of inherited genetic risk diagnoses.
- Reproductive History: When women are exposed to hormones for longer, they are at an increased risk of developing breast cancer. Girls who start their periods before age 12 and women who start menopause after 55 years old are at an increased risk of breast cancer.
- Personal and Family History: Women with a history of breast cancer and those with a family history of relatives with breast cancer have an increased risk of diagnosis. Those who have had breast cancer once, may develop it a second time. Women who have a first-degree relative (mother, sister, or daughter) are at an increased risk of breast cancer. Women who have multiple relatives on both maternal and paternal sides with breast cancer should be screened regularly.
- Radiation Therapy: Receiving radiation therapy places women at a higher risk of developing breast cancer, especially if the woman was 30 years old and younger and received radiation to the chest.
- Diethylstilbestrol (DES): Between 1940 and 1970, many women were given DES to prevent miscarriage. Women who took DES may develop breast cancer later in life. Children whose mothers took DES while pregnant may also be at risk.
Modifiable risk factors for breast cancer include (CDC, 2022; Casaubon et al., 2021):
- Exercise: Women who do not get the recommended amount of weekly physical activity are at an increased risk of breast cancer.
- Weight: Women considered overweight or obese are at a higher risk of being diagnosed with breast cancer.
- Hormone Therapy: Estrogen and Progesterone, hormone replacement therapy, are sometimes taken during menopause. If these medications are taken longer than five years, the risk of breast cancer is increased. Some contraceptives can also contribute to this risk.
- Reproduction: There are many risk factors concerning reproduction that are associated with the development of breast cancer. Women wanting to become pregnant are advised to do so before 30 years old. There are also advised to breastfeed if possible.
- Alcohol: The more alcohol a woman consumes over her lifetime, the greater the chance of being diagnosed with breast cancer.
The United States Preventive Services Task Force (USPSTF) (2016) recommends breast cancer screening, especially mammography, every two years for women aged 50-74 who are at average risk of developing breast cancer. If women are at an increased risk of breast cancer, mammography may start at 40 years of age (U.S. Preventative Services Task Force, 2016).
Monthly self-breast exams should be performed 4-5 days after the period is started and should be done at the same time each month. The exam is encouraged to be performed after the period to ensure women are not feeling hormone-related lumps (Mount Sinai Health System, 2022).
Mammograms use low-dose x-rays to examine the breasts. For a mammogram to be performed, a patient stands in front of a machine while the breast is placed between two plastic plates. Images are then taken.
Breast tomosynthesis is a 3D version of the mammogram that takes pictures of the breasts from various angles to create a 3D image.
CEDM combines digital mammography with contrast dye. Breast tumors absorb the dye and are highlighted on imaging.
Radio waves and a magnet create detailed breast images.
Sound waves create pictures when an ultrasound is performed on the breast. A probe is placed on the breast that produces sound waves; these waves are transformed into images.
Clinical breast exams are performed by trained professionals who look for any signs of breast cancer.
Women usually find cancerous and non-cancerous lumps during a breast self-exam. However, sometimes they are discovered by healthcare professionals. Sometimes, other presenting symptoms of breast cancer warrant a visit to a healthcare provider.
Symptoms include (Koo et al., 2017):
- Change in breast size or shape
- Skin changes (thickening, swelling, or redness)
- Skin dimpling
- Nipple abnormalities (ulceration, retraction, or bloody discharge)
- Nipple inversion
If nipple discharge is present, care should be taken to determine if the discharge is spontaneous or not. The frequency and smell of the discharge should be noted. If discharge occurs in both breasts, it is usually not from a cancerous cause.
The patient being examined will have their arms upright. If the healthcare provider identifies one of these, concern is warranted (Koo et al., 2017):
- Nipple inversion
- Peau d’orange
- Dilated veins
- Skin tethering
If a lump is found, the provider should distinguish between a lump that is concerning versus one that is not. Concerns include (Koo et al., 2017):
- Focal nodularity
Symptoms of Breast Cancer
Once a breast mass or lump is identified, whether by a provider or oneself, prompt evaluation and diagnosis are necessary.
Providers should inquire about the relevant history of the patient with a breast mass. Besides characteristics of the mass (pain, duration, redness, swelling, etc.), other important factors include diet and medications, family history, medical and social history, personal characteristics, and social history.
Factors such as current medications, history of hormone treatments, breast surgeries or recent trauma, lactation status, and smoking are important considerations to consider.
Besides provider examination and mammography, other studies may be performed, depending upon the situation.
This is usually performed if the provider feels the mass/lump may be a cyst of fluid around it (American Cancer Society, 2022b). A hollow and thin needle aspirates fluid and breast tissue from the area of concern. If a biopsy is required, the needle can be used as a guide for the provider.
Two biopsies are typically used when breast cancer is of concern. Core-needle biopsy (CNB) uses a larger hollow needle guided by diagnostics (MRI, ultrasounds) to sample the area of concern. Excisional biopsy, most often used in breast cancer cases, is performed in the operating room, and the entire mass/lesion is removed.
Before biopsies occur, a mammogram is done first. Findings from the mammogram are reported using BIRADS or Breast Imaging Reporting And Diagnostic System (American Cancer Society, 2022b; Castro et al., 2017).
Table 1: Breast Imaging Reporting And Diagnostic System (BI-RADS) (Castro et al., 2017)
|BIRADS consists of Category 0 to Category 6|
|Category 0||Additional imaging and evaluation are warranted|
|Category 1||Negative findings (normal scan)|
|Category 2||Benign findings, a non-cancerous area found|
|Category 3||Findings are probably benign; follow-up is warranted|
|Category 4||Suspicious abnormality, biopsy considered|
|Category 5||Malignancy suspected, action required|
|Category 6||Cancer found, action required|
Most breast lumps are benign, which is a negative or non-cancerous result. There are many causes of benign breast lumps.
The most common cause of benign lumps in the breast is fibroadenomas (Stachs et al., 2019). They are usually painless, soft, round, with a rubber-like feel, and can be easily moved. They are typically found in women between the ages of 20-30 and are not sources of pain.
Fibrocystic changes often occur due to a hormone fluctuation, most commonly seen with a menstrual cycle. These changes cause lumps to increase in size near the cycle time and can cause mild tenderness (Stachs et al., 2019).
Fibrocystic Breast Changes
Papillomas are small wart-like growths that form near the nipple and can cause bleeding. These benign growths are often seen in females aged 30-50 (Stachs et al., 2019).
Necrosis occurs when there is trauma to the breast. Fat in the breast forms into a small lump or mass that is often painless. They may disappear over time and usually do not cause problems (Stachs et al., 2019).
Types of Breast Cancer
The most common form of breast cancer diagnosed is invasive ductal carcinoma (IDC). (Cleveland Clinic, 2021b). It makes up over 80% of breast cancers diagnosed. This form of cancer arises in the milk glands but invades surrounding tissue, meaning metastasis is more likely to be seen in this cancer. Survival rates are high when it is caught early. It is often detected on a mammogram and can be visibly seen on an MRI or ultrasound. Treating IDC involves surgery, lumpectomy, or mastectomy, followed by chemotherapy or radiation (Cleveland Clinic, 2021b).
The second most common type of breast cancer diagnosed is invasive lobular carcinoma (Luveta et al., 2020). It is commonly seen in post-menopausal women who have received hormone therapy. It can be clinically challenging to diagnose as there may be no presenting masses/lumps and its margin is typically poorly defined. BCS is often used to treat this cancer along with adjuvant therapies, dependent on if there is metastasis (Luveta et al., 2020).
It is estimated that 1 in 5 women diagnosed with breast cancer will be diagnosed with ductal carcinoma in situ (DCIS) (American Cancer Society, 2021b). This form of breast cancer is very curable and is considered non-invasive. It is rated as a Stage 0 breast cancer. It usually does not metastasize to other parts of the body, increasing the success of treating it. If the tumor spreads out of the breast duct, there is potential metastasis. To treat DCIS, women often elect to have breast-conserving surgery (BCS) or a simple mastectomy. If BCS is used, radiation is usually performed after the surgery for some time (American Cancer Society, 2021c).
Lobular carcinoma in situ (LCIS) is a rare form of neoplasia that develops in the milk glands. Most often, it is painless with no symptoms. In rare cases, women may notice a lump that was not there before. It is usually not seen on a mammogram and requires a biopsy for diagnosis. As this neoplasia is not considered cancerous, no treatment is performed. It places a patient at higher risk of developing breast cancer.
Inflammatory breast cancer (IBC) is the rarest form of breast cancer and comprises only 5% of diagnoses (Moulder-Thompson & Mitri, 2016). With IBC, swelling and redness (inflammation) are caused by cells and vessels in the breast being blocked by cancer or a tumor. It is also challenging to diagnose as there is no lump, and it is often not seen on a mammogram. IBC is more common in younger Caucasian females who are overweight or obese. It can be an aggressive form of breast cancer as it can grow and metastasize at a quick rate, decreasing the success rate of treatment (Moulder-Thompson & Mitri, 2016).
Paget’s breast disease is a rare form of breast cancer that accounts for up to 3% of cases (Dubar et al., 2017). This form of breast cancer is generally associated with invasive glandular carcinoma in nearly 90% of cases. The presentation includes inflammation, bleeding, and/or erosion of the nipple. There are no identified risk factors. However, it usually affects post-menopausal women (Dubar et al., 2017).
There are many treatment options after one is diagnosed with breast cancer. Local treatments are directed at the tumor itself. Systemic treatments affect the tumor and the entire body. Treatment options and approaches depend on the type of breast cancer and the stage in which it is diagnosed. Surgery, chemotherapy, and radiation are common approaches to treating breast cancer. If cancer has metastasized, more aggressive treatment will be required.
Sentinel node biopsy is often used to determine if breast cancer has spread into the lymphatic system. It is named after the sentinel nodes, the lymph nodes that the tumor drains into. After the sentinel nodes are removed, they are analyzed to determine if cancer is present. If cancer is present, the breast cancer has metastasized. Pain and bruising can be seen after this biopsy is performed.
Chemotherapy is often used alongside surgery when treating breast cancer. There are two classes that chemotherapy can be divided into.
Neoadjuvant chemotherapy is administered before surgery (Rocky Mountain Cancer Centers, 2021). The goal is to make surgery easier by shrinking the tumor and decreasing the chance of metastasis before the surgery. This form of chemotherapy is often started quickly after diagnosis.
Adjuvant chemotherapy is administered after surgery (Rocky Mountain Cancer Centers, 2021). The goal is to kill any cancer cells that are left after surgery. It also decreases the chances of breast cancer coming back. Treatment with adjuvant chemotherapy treatment usually occurs within 30 days after surgery (Rocky Mountain Cancer Centers, 2021).
Radical mastectomies were commonly used in the past but have decreased in incidence in the last few decades. It is most most often used when the breast cancer is in the chest wall. The lymph nodes in the armpit, the muscles in the chest wall, and the entire breast are removed during a radical mastectomy. This procedure almost always removes axillary lymph nodes and supraclavicular lymph nodes. The surgery generally is performed under general anesthesia and usually takes a few hours. A diagonal or horizontal incision is made to reach all of these areas.
A modified radical mastectomy removes the entire breast (skin, nipple, areola, etc.) and most of the axillary lymph nodes. The chest wall or pectoralis muscle is spared in this surgery. It is often indicated when there is a focally positive margin, and the tumor is larger than 5 cm. The most common complications seen with a modified radical mastectomy include infection and skin necrosis.
BCS is often used in breast cancer and is commonly referred to as a lumpectomy or partial mastectomy (Cleveland Clinic, 2021a). A lumpectomy removes cancer in the breast and a small sample of healthy tissue. A lumpectomy is used to preserve as much of the breast as possible. Two procedures associated with a lumpectomy include wedge resection and quadrantectomy (Cleveland Clinic, 2021a):
- A wedge resection removes a larger portion or wedge of breast tissue.
- With a quadrantectomy, only a quarter of the breast is removed.
- A portion of healthy tissue is removed to be examined to ensure the breast cancer has not invaded any surrounding tissue.
- A sentinel lymph node biopsy is often performed alongside a lumpectomy to ensure the cancer is not in the lymph nodes.
Radiation therapy is a standard adjuvant treatment used for breast cancer (American Cancer Society, 2021c). High-energy particles and rays are used to destroy cancer. Sometimes radiation is used after BCS to prevent reoccurrence. Other times, it is used after a mastectomy or if there is metastasis. Brachytherapy and external beam radiation therapy (EBRT) are the two most common forms of radiation (American Cancer Society, 2021c).
There are different stages of radiation used to treat breast cancer. Whole breast radiation means the entire breast receives radiation. Hypofractionated radiation therapy is where the whole breast receives radiation, but it is in larger doses. This way, women only receive 3-4 weeks of radiation instead of receiving it for a prolonged time (American Cancer Society, 2021c).
Hormone therapy is used in women to prevent breast cancer from spreading and re-occurring (American Cancer Society, 2021a). It can help treat metastasized breast cancer. Selective estrogen receptor modulators prevent hormones from attaching themselves to cancer cells. These medications can also be used to avoid hormone production in the ovaries.
Typically, breast cancer affects women. However, there are incidences of men being diagnosed with breast cancer. In fact, 1 out of every 100 men will be diagnosed with breast cancer (CDC, 2021). DCIS, invasive lobular carcinoma, and invasive ductal carcinoma are the three forms of breast cancer most commonly diagnosed in men.
Risk factors for breast cancer in men include age (over 50), genetic mutations, obesity, liver disease, family history of breast cancer, Klinefelter syndrome, and previous trauma to the testicles (CDC, 2021).
In men, breast cancer symptoms include a mass or lump near or on the breast, swelling, irritation, and nipple discharge (CDC, 2021).
The breast undergoes many changes while a woman is pregnant (Lee & Bae, 2020). Lactation can also cause hormonal fluctuations. These changes can make diagnosing pregnancy-associated breast cancer (PABC) difficult (Lee & Bae, 2020). Breast enlargement is common in pregnancy and can decrease a mammogram's sensitivity by up to 90%. Pregnant patients with a palpable mass should alert their provider of the mass immediately. Mammograms are safe in pregnancy if warranted. However, ultrasounds are the best diagnostic tool to use in pregnancy as there is no exposure to radiation, and it is more sensitive in identifying a mass in a pregnant woman's breast.
Some benign masses and lumps may cause problems in pregnancy (Lee & Bae, 2020). A galactocele is a milk-filled cyst that blocks a lactating duct. It is most common in women who recently stopped lactating. A lactating adenoma develops due to the hormonal shift seen in pregnancy. It is closely related to fibroadenoma and often goes away after the woman gives birth and is no longer lactating (Lee & Bae, 2020).
PABC is a severe diagnosis that occurs in pregnant women or within 1 year of delivery. It usually starts as a painless mass in the breast. It is often mistaken for regular breast changes that occur with pregnancy and can be difficult to see on diagnostic imaging, leading to a delay in diagnosis. Usually, when it has been found, it has already been growing for a long time, and 50% of women have metastasis to the lymph nodes (Lee & Bae, 2020). Ultrasonography is the best option for visualizing PABC (Lee and Bae, 2020).
There are no strong indicators that breast implants cause breast cancer. Some manufacturers, Allergan’s manufactured textured breast implants, have been linked to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). BIA-ALCL usually develops in the tissue or fluid around the implant (U.S. Food and Drug Administration [FDA], 2019).
There are ways to decrease the risk of breast cancer. Alcohol intake should be limited. A healthy weight should be maintained. If one is overweight or obese, care should be taken to lose weight and increase exercise. One hundred and fifty minutes a week of moderate aerobic activity is recommended for adults. If possible, breastfeeding has been shown to prevent the development of breast cancer.
Hormone therapy has been associated with breast cancer. Two specific medications, tamoxifen and raloxifene are selective estrogen receptor modulators (SERMs). Tamoxifen is often used as an adjuvant treatment and has been shown to reduce the risk of contralateral breast cancers. Raloxifene is another SERM often used.
For women at risk of developing breast cancer, mammography can be started earlier.
Men and women should be counseled on the risks of developing breast cancer. Awareness is key to prevention.
When found, an abnormal lump should be monitored and screened for cancer. A mammogram is usually performed to determine if the lump is cancerous. Ultrasounds and MRIs may also be used as diagnostic tools. If these tools are not definitive, a breast biopsy may be performed. If breast cancer is diagnosed, there are treatment options. Treatment depends on the stage and grade of the tumor. It also depends on whether the breast cancer has metastasized to other body parts.
There are treatment side effects that patients should be aware of. The side effects depend on whether the patient is having surgery or receiving chemotherapy or radiation. Though side effects may occur, additional therapies can be used to minimize the effects.
Routine screening, including monthly self-exams for women, are essential to normalizing oneself with the breast to find an abnormality earlier.
A 49-year-old post-menopausal woman had her annual mammogram, which revealed an abnormality in the left breast. There were no palpable masses on the clinical breast exam. A biopsy revealed a small (0.9 cm) invasive ductal carcinoma with some associated DCIS. The surgical margins were not clear. What are the next steps?
Local control of the tumor can be achieved by mastectomy. It can also be achieved with a lumpectomy or partial mastectomy. BCS is used if the margins are clear. There must be a unifocal tumor only, not multiple tumors. If there are multiple tumors, the patient should have a mastectomy. Following healing from surgery, radiation to the remaining breast tissue is often used as an adjuvant therapy administered 5 days a week for 6 weeks. Side effects may include fatigue, local swelling, and minor soreness of the breast with associated erythema. If chemotherapy is required, it is performed first, followed by radiation.
Breast cancer is a common cancer diagnosis for women. It is the second deadliest cancer for women. Breast cancer screening is indicated for all women at average risk. Those at high risk include women and men with a family history of breast cancer, those over age 50, and women exposed to hormone therapy. Screening may start earlier for those at increased risk of breast cancer. Men and women should watch for signs and symptoms, including a mass or lump in the breast or chest wall, nipple drainage, redness, swelling, and inflammation. Prompt diagnosis and treatment are essential to increase the chances of survival.
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Implicit Bias Statement
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
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