“Just think about the many things that might cause the wear and tear that leads to abnormal cell growth—pollutants, hormones, pesticides, smoking, alcohol use, obesity, stress…. Or maybe your cells just made a mistake one day when they were making new genes to pass on to their baby cells. Perhaps there was a misprint in the genetic instruction manual that said switch growth on instead of growth off. This is a test. ”
Breast cancer is an uncontrolled growth of breast cells. To better understand breast cancer, it helps to understand how any cancer can develop.
Cancer occurs as a result of mutations, or abnormal changes, in the genes responsible for regulating the growth of cells and keeping them healthy. The genes are in each cell’s nucleus, which acts as the “control room” of each cell. Normally, the cells in our bodies replace themselves through an orderly process of cell growth: healthy new cells take over as old ones die out. But over time, mutations can “turn on” certain genes and “turn off” others in a cell. That changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumor.
A tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous). Benign tumors are not considered cancerous: their cells are close to normal in appearance, they grow slowly, and they do not invade nearby tissues or spread to other parts of the body. Malignant tumors are cancerous. Left unchecked, malignant cells eventually can spread beyond the original tumor to other parts of the body.
The term “breast cancer” refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast.
Breast Anatomy
Over time, cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body. The breast cancer’s stage refers to how far the cancer cells have spread beyond the original tumor
Breast cancer is always caused by a genetic abnormality (a “mistake” in the genetic material). However, only 5-10% of cancers are due to an abnormality inherited from your mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the “wear and tear” of life in general.
While there are steps every person can take to help the body stay as healthy as possible (such as eating a balanced diet, not smoking, limiting alcohol, and exercising regularly), breast cancer is never anyone's fault. Feeling guilty, or telling yourself that breast cancer happened because of something you or anyone else did, is not productive.
When a medication is approved by the U.S. Food and Drug Administration (FDA) for use in one way, it is generally understood that research and experience may eventually guide doctors to other uses of that medication. This is especially true with advanced cancer treatments, when it might be necessary to exhaust all reasonable options to fight the cancer. The term "off-label use" refers to the use of a drug in a way that has not been officially approved by the FDA. Doctors will usually choose to use a medication off-label to treat specific cancer situations only when there is some good evidence from research and clinical experience that the medication can be used effectively in that situation. Off-label use in this manner is considered acceptable and appropriate.
The research reviewed in this article found that about one-third of women being treated for metastatic breast cancer received a cancer medicine used in an off-label way. Most of the time the off-label use was considered appropriate to the situation. The results were presented at the 2009 American Society of Clinical Oncology (ASCO) Annual Meeting.
The researchers reviewed the treatment histories of over 2,000 women age 65 and older who were diagnosed with and treated for metastatic breast cancer.
The results:
Over one-third of the women had received an off-label treatment at some point in their overall treatment plan.
Among the women studied, the younger they were, the more likely they were to have received an off-label treatment.
In over 93% of cases when treatments were used off-label, the use was considered appropriate. This means that the treatment choice was reasonable based on research evidence and clinical experience. Only 6.7% of the women received off-label treatments that were considered medically inappropriate.
Drugs that were commonly used off-label, but appropriately, included:
vinorelbine (brand name: Navelbine)
gemcitabine (brand name: Gemzar)
carboplatin (brand name: Paraplatin)
mitoxantrone (brand name: Novantrone)
If you are being treated for breast cancer and are taking time to learn about the medications in your treatment plan, you may discover that one or more of your treatments were never approved by the FDA for use in someone with your specific situation. Even though a treatment may be off-label, it is very likely that your doctor has recommended it to you based on sound evidence and experience from use of that treatment in patients with situations similar to your own. Still, it is a good idea to talk with your doctor about the role of any off-label treatments in your overall treatment plan, and why an off-label treatment might make sense for you and your unique situation.
A third of patients with metastatic breast cancer receive off-label therapy at some point during treatment, according to a study reported here.
More than 70% of the drugs used off label lacked evidence to support their use in breast cancer, but these drugs were used in only a small percentage of patients, Sharon Giordano, M.D., of the University of Texas M.D. Anderson Cancer Center in Houston, said at the American Society of Clinical Oncology meeting.
Few patients received what was judged to be medically inappropriate therapy, she said.
"Although off-label drug use is widespread among patients with metastatic breast cancer, the vast majority of patients who received off-label drugs were treated with chemotherapy that was considered appropriate for use in treatment of breast cancer," Dr. Giordano said in an interview.
Estimates of the frequency of off-label therapy in medical practice range from 21% to 51%. Off-label use of chemotherapy drugs is thought to be widespread, but few studies have examined the issue, particularly with respect to the medial appropriateness of off-label therapy.
The last study to evaluate off-label chemotherapy practices was conducted about 20 years ago and covered cancer in general, not just breast cancer, Dr. Giordano said.
In an effort to develop a knowledge base specific to breast cancer, she and her colleagues analyzed merged data from the NCI Surveillance, Epidemiology, and End Results program and Medicare. They limited the analysis to women ages 65 and older who had a diagnosis of metastatic breast cancer from 1991 to 2002.
Investigators used the DRUGDEX drug compendium to evaluate the appropriateness of off-label therapy.
The study involved 2,082 women. Overall, 34.9% of the patients received at least one off-label therapy. Off-label treatment was least common in patients older than 80 (24.4%) and most common those ages 65 to 70 (37.7%, P=0.004).
Off-label drug therapy became less frequent over time. More than half of the therapy in 1991 (52.4%) was off label. Off-label therapy reached a nadir of 29.7% in 1997, rose to 37.6% over the next two years, and then declined again, accounting for 31.5% of treatment in 2002 (P=0.025).
The frequency of off-label therapy varied geographically, from 42.7% in Connecticut to 12.5% in rural Georgia (P=0.019).
The analysis uncovered off-label use of 36 different chemotherapeutic agents. Used most frequently were vinorelbine (Navelbine), 15.98%; gemcitabine (Gemzar), 8.37%; carboplatin, 7.03%; and mitoxantrone, 6.83%.
All four drugs had supporting evidence for breast cancer.
Dr. Giordano said 71% of the drugs lacked evidence for use in breast cancer, making the use medically inappropriate. However, only 6.7% of the patients received medically inappropriate therapy.
Because the study was limited to women 65 and older, the findings may understate the extent of off-label therapy, the researchers acknowledged.
Dr. Giordano has plans for additional studies of off-label therapy across a spectrum of tumor types and stages. She also hopes to examine off-label use in younger breast cancer patients.
Dr. Giordano and her coinvestigators reported no disclosures.
Primary source: Journal of Clinical Oncology Source reference: Dean-Colomb W et al. "Off-label drug use in women with breast cancer" J Clin Oncol 2009; 27(15 suppl): Abstract 1016.
The study reviewed here found that many women being treated for breast cancer are taking at least one antioxidant supplement, often at levels much higher than recommended in a healthy diet. The researchers looked at four antioxidant supplements:
vitamin C
vitamin E
selenium
beta carotene
Because the effects of antioxidant supplements on specific breast cancer treatments hasn't been thoroughly studied, this suggests that more research is needed.
Antioxidants are compounds found in fruits, vegetables, nuts, grains, and some meats, poultry, and fish. Antioxidants may help protect cells from substances called free radicals. Free radicals are produced when you're exposed to some pollution such as tobacco smoke. Your body also produces free radicals when it breaks down food. Free radicals can damage cells and may contribute to certain diseases, including cancer. Some research has suggested that antioxidants may help reduce the risk of cancer, heart disease, and age-related changes in the body. Still, it's not clear if taking antioxidant supplements at higher-than-recommended levels offers more benefits than getting the recommended amount of antioxidants from the foods you eat. Taking certain supplements at higher-than-recommended levels can cause health problems.
There are some concerns that taking antioxidant supplements during cancer treatment can interfere with certain treatments. For example, radiation therapy and certain chemotherapy medicines work by producing free radicals that attack cancer cells. Since antioxidants destroy free radicals, some doctors think taking antioxidant supplements might reduce the effectiveness of the treatment. Many oncologists tell patients not to take antioxidant supplements during treatment.
More than 760 women diagnosed with non-invasive and invasive breast cancer in 1996 and 1997 were asked about their use of four antioxidant supplements during adjuvant treatment. Adjuvant treatments are given after surgery to reduce the risk of the cancer coming back. Almost 87% (663 women) received one or more of the following adjuvant treatments:
chemotherapy
radiation therapy
tamoxifen
More than 60% of the women took at least one antioxidant supplement while on adjuvant treatment.
39% of women getting chemotherapy took one or more antioxidant supplement during treatment
42% of women getting radiation therapy took one or more antioxidant supplement during treatment
62% of women taking tamoxifen took one or more antioxidant supplement during treatment
Most of the women (69%) who took antioxidant supplements during treatment took higher-than-recommended doses. The researchers considered a higher-than-recommended dose to be more of the antioxidant than in a Centrum multivitamin.
If you're being treated for breast cancer, you may be thinking about taking or are already taking supplements such as antioxidants to do all that you can to fight the cancer and keep it from coming back. It might be fine to do this, but it's very important to tell your doctor about ALL the supplements and medicines you take, including over-the-counter medicines and vitamins. Make sure you tell your doctor the exact dose of each supplement, vitamin, or medicine you take or are thinking about taking. Your doctor may have concerns about how these medicines and supplements may interact with your treatments or how they may affect your health. Just because you can buy a medicine, vitamin, or supplement without a prescription doesn't mean it's safe for you to take. Together, you and your doctor can decide what's best for you and your unique situation.
TORONTO, June 8 (MedPage Today) -- A majority of the women in a breast cancer study who were questioned during follow-up said they used antioxidants during treatment, researchers said.
The finding suggests that research is needed into how the use of antioxidants such as vitamin C and beta-carotene affects treatment outcomes, Heather Greenlee, N.D., Ph.D., of Columbia University Mailman School of Public Health in New York, and colleagues, reported online in Cancer.
"Given the common use of antioxidant supplements during breast cancer treatment, often at high doses and in conjunction with other complementary therapies, future research should address the effects of antioxidant supplementation on breast cancer outcomes," they argued.
Their Long Island Breast Cancer Study Project was a case-control endeavor to examine the role of environmental influences on breast cancer among women living in New York's Nassau and Suffolk counties.
Between Aug. 1, 1996 and July 31, 1997, 1,508 women with a first primary in situ or invasive breast cancer were enrolled in the study. Between 2002 and 2004, the researchers conducted follow-up interviews among case participants.
All told, 764 women completed a full interview and gave information on antioxidant use, Dr. Greenlee said.
The interviews asked about four antioxidants -- vitamin C, vitamin E, selenium, and beta-carotene -- as well as daily dose.
Intake of each supplement was categorized as none, low, or high, with high doses defined as more than 60 milligrams of vitamin C, more than 30 IU of vitamin E, more than 20 micrograms of selenium, and more than 5,000 IU of beta-carotene.
The researchers created a nine-point "antioxidant index" to summarize total intake, based on scoring the intake of each antioxidant as zero for never, one for low, and two for high.
The antioxidant index itself was divided into three categories -- none if the total score was zero, low if the score ranged from one through four, and high if it was five or higher.
Analysis found:
663 participants (or 86.8%) reported receiving adjuvant treatment for their cancer and of those, 401 (or 60.5%) reported using antioxidants during adjuvant treatment.
120 of 310 women (or 38.7%) used antioxidants during chemotherapy, 196 of 464 women (or 42.2%) used them during radiation, and 286 of 462 women (or 61.9%) used them during tamoxifen therapy.
278 women (or 69.3%) used high doses (defined as doses higher than those contained in a Centrum multivitamin).
Tamoxifen use predicted the highest relative risk for high-dose antioxidant use -- 3.66, with a 95% confidence interval from 2.32 to 5.78.
Higher fruit and vegetable intake at diagnosis was also predictive of high use, with a relative risk of 1.71 with a 95% confidence interval from 1.13 to 2.59.
Women who had ever used herbal products had a relative risk for high antioxidant use of 3.49, with a 95% confidence interval from 2.26 to 5.38.
And women who had ever engaged in mind-body practices -- such as spirituality or meditation -- had a relative risk for high antioxidant use of 1.72, with a 95% confidence interval from 1.13 to 2.64.
The researchers noted that the participants from the original study who agreed to take part in the follow-up were younger, more likely to be white, and of higher socioeconomic status than women who did not respond.
"We believe our results are generalizable to similar populations," they said, although study participants "may have been heavier users of antioxidants than breast cancer patients in the general population."
The study was also limited by a relatively low response rate of about 55.4% of the participants who agreed to be contacted again after the end of the original study, they said.
The study was supported by the Lance Armstrong Foundation, the National Cancer Institute, and the National Institutes of Environmental Health and Sciences. The researchers did not report any conflicts.
Primary source: Cancer Source reference: Greenlee H, et al "Prevalence and predictors of antioxidant supplement use during breast cancer treatment: The Long Island Breast Cancer Study Project " Cancer 2009; DOI: 10.1002/cncr.24378
To make the best possible decisions about breast cancer treatment, you and your doctor need to know all the details of your unique medical situation, including the "personality" of the cancer as described in your pathology report.
A large group of cancer experts from around the world met in Europe and created new guidelines for treating early-stage breast cancer. The guidelines recommend that:
chemotherapy
targeted therapies
radiation therapy
hormonal therapy
should be based on the characteristics of each individual cancer being treated.
Called the 2009 St. Gallen International Expert Consensus, the meeting was attended by about 5,000 breast cancer experts. A group of 43 experts wrote the guidelines based on discussions among the entire group.
Every breast cancer is different. A breast cancer's personality is based on its:
stage, which is based on:
the cancer's size
whether it's invasive or non-invasive
whether lymph nodes are involved
whether the cancer has spread beyond the breast
grade, which is based on how different the cancer cells are from normal cells
hormone-receptor status, which tells whether or not the cancer cells have receptors for estrogen and/or progesterone
HER2 status, which tells whether or not the cancer cells are making too many copies of the HER2 gene or have too many HER2 receptors
The new guidelines for treating early-stage breast cancer are based on the best scientific knowledge available right now.
The guidelines recommend:
Hormonal therapy, which can reduce the risk of early-stage breast cancer coming back, should be used to treat all early-stage breast cancers with any detectable level of estrogen receptors. Tamoxifen and the aromatase inhibitors are examples of hormonal therapy medicines.
Herceptin (chemical name: trastuzumab), a targeted therapy, which can reduce the risk of early-stage breast cancer coming back, should be used to treat only breast cancers that are HER2-positive. Chemotherapy, either before or during Herceptin treatment, also is an important treatment for HER2-positive breast cancer.
Chemotherapy, which can reduce the risk of early-stage breast cancer coming back, always should be used to treat triple-negative early-stage breast cancer. Triple-negative breast cancer is cancer that is estrogen-receptor-negative, progesterone-receptor-negative, and HER2-negative. Hormonal therapy medicines and Herceptin usually don't work on triple-negative breast cancer.
The new guidelines also point out that hormone receptor and HER2 test results must be accurate and reliable.
The panel of experts couldn't agree on whether gene assay tests, such as the Oncotype DX test, were helpful in making treatment decisions. The Oncotype DX test looks at the behavior of a specific group of genes in breast cancer cells. The genes' activity can affect how likely a cancer is to respond to treatment. The Oncotype DX test is used on estrogen-receptor-positive breast cancers and can help doctors decide if the cancer is likely to come back; if so, chemotherapy may be recommended. Even though the expert panel's new treatment guidelines for early-stage breast cancer don't recommend using the Oncotype DX test, many doctors believe results from the Oncotype DX test can help decide which hormone-receptor-positive early-stage breast cancers also need to be treated with chemotherapy.
If you've been diagnosed with early-stage breast cancer and are deciding on treatment, ask your doctor to go over ALL the information about the breast cancer with you. This should include your pathology report. Then, together, you can make the best treatment decisions for your specific situation.
HOUSTON, June 17 (MedPage Today) -- In an international consensus statement described as practice-changing, new treatment guidelines for early-stage breast cancer call for use of systemic therapies on the basis of individual tumor characteristics.
Treatment decisions should focus on the scientific justification for using endocrine therapy, anti-HER2 treatment, and chemotherapy, authors of the 2009 St Gallen International Expert Consensus concluded in guidelines published online in Annals of Oncology.
Though recognizing the heterogeneous nature of breast cancer, the consensus recommendations call for development of a personalized treatment plan for each patient.
The guidelines include a new treatment algorithm based on advances in knowledge about how to match therapy with tumor characteristics to achieve the best outcomes.
"Because these decisions are based on quite separate criteria, previous attempts to produce a single-risk categorization and a separate therapy recommendation are no longer considered appropriate," the authors said.
In a prepared statement, panel member Richard Gelber, MD, of Harvard and Dana-Farber Cancer Institute in Boston, said the consensus "further refines the treatment algorithm by identifying 'thresholds for indication' of each type of systemic treatment modality based on criteria specific to each modality.
"We expect the refined algorithm to change clinical practice because it clarifies the indications for each treatment modality available today."
Knowing the specific tumor characteristics is essential for deciding which treatment or combination offers a patient the best chance for success. Consistent with that approach to decision making, the panel set forth some general principles for treatment selection:
Adjuvant endocrine therapy is recommended for most patients with any detectable level of estrogen receptor (ER).
Anti-HER2 therapy, currently limited to trastuzumab (Herceptin), is recommended for almost all patients with HER2-positive disease.
Reflecting the more complicated decision-making process surrounding adjuvant chemotherapy, the consensus panel said chemotherapy should be the mainstay of treatment for patients with triple-negative breast cancer. For HER2-positive patients, clinical trial evidence for trastuzumab is limited to its use with or after chemotherapy. Less consensus exists about its use in patients with estrogen receptor (ER)-positive, HER2-negative disease.
The corollary to recommendations about endocrine and anti-HER2 therapy is that "ER and HER2 must be reliably and accurately measured."
Any method of ER staining is acceptable. However, the panel recommended adherence to American Society of Clinical Oncology/College of American Pathologists guidelines for assessing HER2 status.
The consensus guidelines include summaries of the state of knowledge in disciplines relevant to early breast cancer, as presented and discussed at the consensus meeting.
Examples include chemoprevention with selective estrogen receptor modulators, the role of stem cells in breast cancer, implications of circulating tumor cells, angiogenesis, pharmacogenetics, novel imaging techniques, and novel systemic therapies.
Although focused on systemic therapy, the consensus panel expressed support for continued refinement of surgical and radiation techniques to ensure the best possible outcome with the least possible morbidity.
The panel was circumspect on use of genetic testing in making treatment decisions, reflecting the controversy surrounding the issue.
Panelists avoided the term "gene assay," and said genetic testing might have some value if doubt remains after reviewing all other factors and a test is readily available.
"There was clearly a division of opinion, largely on geographic grounds," panelist Alan Coates, MD, of the University of Sydney, Australia, said in an interview.
"Many of the U.S. representatives and some Europeans were keen to say these tests are now established sufficiently, and that they are not only useful for prognosis, but also helpful to decide whether it will be valuable at prediction of the additional benefit of chemotherapy.
"Others felt that because two of the principal trials investigating markers for exactly that purpose have yet to report any results, as such, it is premature to make that conclusion. I must say I tend toward the second point of view, but there was a clear division on the panel."
The 43-member panel drafted the recommendations in March at the 11th St Gallen (Switzerland) consensus meeting, which had a total attendance of almost 5,000.
The published consensus did not include disclosures of potential conflicts of interest.
Primary source: Annals of Oncology Source reference: Goldhirsch A, et al "Thresholds for therapies: highlights of the St Gallen International Expert Consensus on the primary therapy of early breast cancer 2009" Ann Oncol 2009; DOI:10.1093/annonc/mdp322.
The study reviewed here found that women with higher incomes and women who live in urban areas have had larger drops in breast cancer rates compared to women with lower incomes and women who live in suburban or rural areas. It's not clear what's causing the difference.
Since 2002, there's been a large decrease in breast cancer diagnosis rates. A dramatic change in the use of hormone replacement therapy (HRT) contributed to the decline. Women take HRT to manage bothersome menopausal symptoms, such as hot flashes, night sweats, and insomnia. Research released in 2002 showed that using HRT significantly increases breast cancer risk while HRT is taken and for some time after HRT is stopped. These results led to a large drop in HRT use. Doctors are now much less likely to prescribe HRT to manage menopausal symptoms. Women already using HRT, or who are considering HRT, are now urged to use HRT for the shortest time possible and to consider using estrogen-only HRT. Other research has shown that breast cancer risk linked to HRT use can be minimized by taking HRT for a short period of time and by using estrogen-only HRT (instead of combination HRT, which contains both estrogen and progesterone).
In this study, the researchers looked at the records of more than 475,000 non-Hispanic white women, 50 to 74 years of age, diagnosed with invasive or non-invasive breast cancer between 1997 and 2004. The researchers noted the women's household income and where they lived -- rural, suburban, or urban areas.
The results:
Breast cancer was more likely to be diagnosed in urban areas compared to suburban and rural areas. More than 85% of breast cancer diagnoses were in urban areas.
Between 2001 and 2004, the drop in breast cancer rates was largest in urban areas and lowest in suburban and rural areas:
Breast cancer rates dropped 13.8% in urban women, 10.7% in suburban women, and 7.5% in rural women.
Between 2001 and 2004, the drop in breast cancer rates was largest in women with higher incomes and lowest in women with lower incomes.
The study didn't say why these differences happened. One possible reason might be that before 2002 urban women and women with higher incomes were more likely to use HRT. If so, then when HRT use started to decline in 2002 the resulting decrease in breast cancer diagnoses would be greatest in these same groups.
It's very clear, though, that HRT increases breast cancer risk, no matter where a woman lives or how much money she earns. Still, menopausal side effects can dramatically reduce quality of life for some women. These women have to weigh the benefits of HRT against the risks.
CLEVELAND, June 26 (MedPage Today) -- The nationwide drop in breast cancer rates linked to the decline of hormone replacement therapy tracks both income and locale, with more significant reductions observed in affluent, urban areas, a new study shows.
From 2001 to 2004 the overall incidence of invasive breast cancer fell by 13.8% in urban areas, versus a 7.5% decline in rural areas, according to Amelia K. Hausauer, PhD, of the Northern California Cancer Center in Fremont, and colleagues.
Likewise, invasive breast cancer rates fell by 13% in neighborhoods in high-income counties, compared to a 9.6% decline in poor counties, although the intracounty changes from baseline were significant in each case (P<0.001),>
"Breast cancer incidence trends for rural counties, which peaked in 1999 and then declined steadily, differed from those in observed in urban counties, where rates fell most dramatically after 2002," they remarked.
This distinctly different pattern of decline is "consistent with the changing pattern of [hormone therapy] prevalence and cessation or noninitiation," the authors concluded.
The use of hormone replacement increased steadily until 1999, when it peaked at 92 million prescriptions. It remained steady until the watershed moment of July 9, 2002.
On that day, the National Health Lung and Blood Institute announced that it had pulled the plug on a study investigating health claims for hormone replacement (estrogen-progestin) in 14,749 healthy women, when it discovered that the five-year incidence of breast cancer was significantly higher among women assigned to hormone therapy compared with those taking placebo.
Following that announcement, there was a significant decline in the use of hormone therapy, and in the past year a number of studies have reported a subsequent decline in breast cancer incidence.
Dr. Hausauer and colleagues analyzed data from 29 population-based cancer registries that participate in the North American Association of Central Cancer Registries.
According to the registry, there were 475,523 cases of invasive breast cancer and 111,885 cases of in situ breast cancer diagnosed between from 1997 through 2004.
The researchers limited their analysis to cases reported in non-Hispanic white women age 50 to 74, and stratified the findings by counties of residence at the time of diagnosis. The counties were further stratified by rural/urban status and by income.
Among the findings:
Breast cancer was most likely be diagnosed in urban areas, with 85.7% of invasive breast cancers and 88% of in situ breast cancer diagnosed in cities versus suburban or rural communities.
From 2001 to 2004 the breast cancer rate declined by 13.8% in urban areas (P<0.001 p="0.02).
Although hormone therapy seems a likely explanation for the declines seen in this analysis, the authors cautioned that some of the change -- especially the slow but steady decline observed in rural communities -- could be explained by "saturation of or decreases in mammographic screening."
The authors said their report was limited by the lack of individual socioeconomic information, and a lack of adjustment for possible delays in reporting. Moreover, the authors could not stratify the results by gene-expression subtype or by hormone receptor status.
Dr. Hausauer declared that she had no competing interests.
The registries used in the study were supported by individual states with additional funding from the CDC, and, in some cases, the National Cancer Institute's SEER Program.
Primary source: BMC Medicine Source reference: Hausauer AK, et al "Recent trends in breast cancer incidence in US white women by county-level urban/rural and poverty status" BMC Med 2009.
"My mother died of breast cancer when I was five. Whenever I saw friends or relatives diagnosed, it was always like, 'Oh, God. That could be me.' It was always in the back of my mind. I worried about it all the time. It was almost to the point where I was afraid of talking about it at all." —Eileen
So 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.
Initially, 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.
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. 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.
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 control
Weight. 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 control
Gender. 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.
The term “risk” is used to refer to a number or percentage that describes how likely a certain event is to occur. When we talk about factors that can increase or decrease the risk of developing breast cancer, either for the first time or as a recurrence, we often talk about two different types of risk: absolute risk and relative risk.
Absolute risk
Absolute risk is used to describe an individual’s likelihood of developing breast cancer. It is based on the number of people who will develop breast cancer within a certain time period. Absolute risk also can be stated as a percentage.
When we say that 1 in 8 women in the United States, or 13%, will develop breast cancer over the course of a lifetime, we are talking about absolute risk. On average, an individual woman has a 1-in-8 chance of developing breast cancer over an 80-year lifespan.
The absolute risk of developing breast cancer during a particular decade of life is lower than 1 in 8. The younger you are, the lower the risk. For example:
From age 30 to 39, absolute risk is 1 in 233, or 0.43%. This means that 1 in 233 women in this age group can expect to develop breast cancer. Put another way, your odds of developing breast cancer if you are in this age range are 1 in 233.
From age 40 to 49, absolute risk is 1 in 69, or 1.4%.
From age 50 to 59, absolute risk is 1 in 38, or 2.6%.
From age 60 to 69, absolute risk is 1 in 27, or 3.7%.
As you can see, the older you are, the higher your absolute risk of breast cancer. Keep in mind that these numbers and percentages are averages for the whole population. Your individual breast cancer risk may be higher or lower, depending on a number of factors, including family history, reproductive history (such as menstrual and childbearing history), race/ethnicity, and other factors.
Take family history, for example. The absolute risk of breast cancer is much higher for women who have inherited mutations in the genes known as BRCA1 or BRCA2. Their absolute risk over the course of a lifetime ranges from 40-85%. This means that out of every 100 women who have these mutations, anywhere from 40 to 85 of them can expect to develop breast cancer should they live to age 80.
If you have breast cancer, absolute risk also can be used to describe the likelihood of a certain treatment outcome or the course of the disease. For example, suppose that, based on the characteristics of the breast cancer (stage, grade, other test results), your age and medical history, and the treatments you have, your doctor tells you that your likelihood of disease-free survival at 5 years — being alive with no evidence of breast cancer — is 90%. This means that your absolute risk of having the breast cancer come back within 5 years is 10%, or 1 in 10. In other words, 1 out of 10 women with similar characteristics and the same treatment plan can expect to have a recurrence within that time frame. Nine out of 10, or 90%, would not.
Relative risk
Relative risk is a number or percentage that compares one group’s risk of developing breast cancer to another’s. This is the type of risk frequently reported by research studies, which often compare groups of women with different characteristics or behaviors to determine whether one group has a higher or lower risk of breast cancer than the other (either as a first-time diagnosis or recurrence).
Understanding relative risk can help you answer an important question: If I make certain lifestyle choices or have certain treatments, how much will I increase or decrease my risk of developing breast cancer or having a recurrence?
Example of breast cancer risk going up
Many studies have shown that women who have two or more alcoholic drinks each day have a higher risk of developing breast cancer. (A drink is defined as 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor.) You may hear this relative risk described as a percentage or a number:
Compared to women who do not drink, women who have two or more drinks per day have a 25% higher risk of breast cancer. Put another way, they are 25% more likely to develop breast cancer over the course of a lifetime than nondrinkers are. This doesn’t mean that their lifetime risk of getting breast cancer is 25% — it means that their risk of getting breast cancer is 25% higher relative to people who don’t drink. This percentage is how you are likely to see relative risk reported by television, the Internet, and newspapers.
Compared to women who do not drink, women who have two or more drinks per day have a relative risk of 1.25. This number is how researchers and scientific papers would usually talk about relative risk. The number “1” is assigned to the baseline group (women who do not drink), since their risk remains the same. The .25 describes the relative increase in risk for the other group; it is another way of expressing the 25% higher lifetime risk (25% = .25).
Another way of saying this is that women who drink two or more alcoholic drinks per day have 1.25 (1 + .25 = 1.25) times the risk of developing breast cancer than women who do not drink.
Relative risk can be a tricky concept, because most people tend to focus on the reported percentage — e.g., 25% higher risk — which sounds alarming. Yes, a 25% higher risk of developing breast cancer (relative to people who don’t drink) is significant, but it doesn’t tell a woman what her lifetime risk is if she drinks two or more alcoholic drinks per day for the rest of her life. Since women in this group have 1.25 times the risk of developing breast cancer, it’s necessary to multiply the absolute risk of breast cancer for women in the general population (13%, or .13) by relative risk (1.25):
.13 x 1.25 = .1625, or 16.25%. This means that a woman’s absolute lifetime risk of developing breast cancer if she drinks two or more alcoholic drinks per day is just over 16%, or roughly 1 in 6, versus 13%, or 1 in 8, for women who do not drink.
Suppose you have had breast cancer and undergone lumpectomy (removal of the tumor itself and a margin of healthy surrounding tissue). The absolute risk of the breast cancer coming back in the same breast is about 25%. But if you have radiation therapy to the remaining breast tissue, you can reduce that risk by about 60%. To describe this relative risk decrease, your doctor might say:
Compared to women who have lumpectomy alone, you have a 60% lower risk of developing breast cancer again in the same breast if you have radiation therapy after lumpectomy.
Medical researchers might express it this way:
Compared to women who do not have radiation therapy, your relative risk of developing breast cancer is .40 (1 – .60 = .40). Again, the number “1” is assigned to the baseline group, which is not taking the extra action to decrease the risk. The .60 is subtracted from 1 because it represents a decrease in risk. In other words, you have about 40% of the risk of developing breast cancer again in the same breast as they do.
So in this scenario, what difference does radiation therapy really make for you in terms of reducing the absolute risk of cancer recurrence in the same breast? To know that, you have to multiply the risk of recurrence without radiation (25%, or .25) by the relative risk of .40:
.25 X .40 =.10. In this hypothetical situation, your absolute risk of the cancer returning in the same breast is 10%, or 1 in 10, if you have radiation therapy, versus about 25%, or 1 in 4, if you don’t. Put another way, 1 in 10 women who have radiation therapy can expect to experience recurrence in the same breast, versus 1 in 4 women who do not have the treatment.
So, relative risk is the number that tells you how much something you do, such as a certain behavior or treatment, can change your risk for breast cancer compared to those who don’t do it. A relative risk of:
.5 means that your risk decreases by half, or 50%
1.88 means that your risk increases by 88%
3.0 means that your risk triples, or goes up by 300% (you have three times the risk)
As the examples above show, knowing how much your breast cancer risk goes up or down with certain lifestyle factors and treatment options can help you and your doctor make the best decisions for you. These are hypothetical examples; you can find out more about breast cancer risk in the Lower Your Risk section.
By now you may be familiar with the statistic that says 1 in 8 women will develop 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 — or 13%, or 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 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 13% 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.
Breast cancer incidence in women in the United States is 1 in 8 (about 13%).
In 2008, an estimated 182,460 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 67,770 new cases of non-invasive (in situ) breast cancer.
About 1,990 new cases of invasive breast cancer will be diagnosed in men in 2008. Less than 1% of all new breast cancer cases occur in men.
From 2001 to 2004, breast cancer incidence rates in the U.S. decreased by 3.5% per year. One theory is that this decrease was 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 40,480 women in the U.S. are expected to die in 2008 from breast cancer, though death rates have been decreasing since 1990. 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 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.
As of 2008, there are about 2.5 million women in the U.S. who have survived breast cancer.
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 are caused by gene mutations 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 often are diagnosed at a younger age (before age 50). An increased ovarian cancer risk is also associated with these genetic mutations. Men with a BRCA1 mutation have a 1% risk of developing breast cancer by age 70 and a 6% risk when they have a BRCA2 mutation.
About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of the aging process and life in general.
The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).
Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.
Stage I
Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear).
Stage IIA
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 smaller and has spread to the axillary lymph nodes OR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB
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 IIIA
No tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone OR the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone.
Stage IIIB
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.
There may either be no sign of cancer in the breast or a tumor 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 either above or below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Stage IV
The cancer has spread — or metastasized — to other parts of the body.
“Just think about the many things that might cause the wear and tear that leads to abnormal cell growth—pollutants, hormones, pesticides, smoking, alcohol use, obesity, stress…. Or maybe your cells just made a mistake one day when they were making new genes to pass on to their baby cells. Perhaps there was a misprint in the genetic instruction manual that said switch growth on instead of growth off. This is a test. ”
Breast cancer is an uncontrolled growth of breast cells. To better understand breast cancer, it helps to understand how any cancer can develop.
Cancer occurs as a result of mutations, or abnormal changes, in the genes responsible for regulating the growth of cells and keeping them healthy. The genes are in each cell’s nucleus, which acts as the “control room” of each cell. Normally, the cells in our bodies replace themselves through an orderly process of cell growth: healthy new cells take over as old ones die out. But over time, mutations can “turn on” certain genes and “turn off” others in a cell. That changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumor.
A tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous). Benign tumors are not considered cancerous: their cells are close to normal in appearance, they grow slowly, and they do not invade nearby tissues or spread to other parts of the body. Malignant tumors are cancerous. Left unchecked, malignant cells eventually can spread beyond the original tumor to other parts of the body.
The term “breast cancer” refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast.
Breast Anatomy
Over time, cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body. The breast cancer’s stage refers to how far the cancer cells have spread beyond the original tumor
Breast cancer is always caused by a genetic abnormality (a “mistake” in the genetic material). However, only 5-10% of cancers are due to an abnormality inherited from your mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the “wear and tear” of life in general.
While there are steps every person can take to help the body stay as healthy as possible (such as eating a balanced diet, not smoking, limiting alcohol, and exercising regularly), breast cancer is never anyone's fault. Feeling guilty, or telling yourself that breast cancer happened because of something you or anyone else did, is not productive.
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.
Early Detection If you can't prevent cancer, the next best thing you can do to protect your health is to detect it early. Getting regular check-ups is the best way to do this. Finding Cancer Early: ACS Guidelines ACS checkup/testing guidelines for healthy people help find cancerous changes early, when doctors can cure or even prevent certain cancers. Learn the tests needed by age and try our Mammogram Reminder tool. Exam and Test Descriptions What to expect from mammograms, Pap tests, colonoscopy, biopsies, the PSA and other tumor marker blood tests, as well as other imaging tests. ACS Prevention & Detection Programs Find out about cancer prevention and detection programs sponsored by your American Cancer Society. Colon Testing Saves Lives Let us walk you through the sometimes confusing and stressful world of colorectal cancer screening. Which tests are best? What can you expect? We have the information, tools, and support you need to make a decision that might save your life.
Can you prevent cancer or reduce your cancer risk? How can you detect cancer early? What are the risk factors for different types of cancer? Concerned about cancer because it runs in your family? Frequently exposed to tobacco or environmental hazards? Just want to stay healthy? You can find answers to these questions and more using the resources in this area.
Cancer Prevention
What you eat and drink, how active you are, and other lifestyle behaviors all can affect your risk for cancer. Find out more about these risks and what you can do to reduce them. Tobacco and Cancer Smoking is the most preventable cause of death in our society. Learn about the health issues, get quitting tips, and find out about recent legislation. Sun Safety The sun's UV rays cause the vast majority of skin cancers including melanoma, which can be life-threatening. Learn who's at high risk and how to protect yourself. Food and Fitness Your diet can affect your risk for cancer. Get recommendations, recipes, and more. Environmental Carcinogens Learn about the cancer risks posed by your surroundings and what you can do about them. Healthy Schools = Healthy Youth Schools have a critical role to play in teaching young people about their personal health and the health of their community. Genetics and Cancer Mutations (changes) in certain genes can make cancer more likely to develop. Learn about the different kinds of genes that can be involved in cancer, how some can be passed from parents to children, and what genetic testing can reveal about cancer risk.
Breast Anatomy
