Understanding Breast Cancer, 1st Edition

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Library of Congress Cataloging-in-Publication Data

Ogden, Joy
Understanding breast cancer / Joy Ogden.
p. cm.
Includes bibliographical references and index.
ISBN 0-470-85435-9 (pbk . : alk. paper) – ISBN 0-470-85435-9
1. Breast – Cancer – Popular works. I. Title.
RC280 .B80355 2004
616.99’44906–dc22
2003027617

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 0-470-85435-9
Illustrations by Jason Broadbent

Typeset in 9.5/13pt Photina by Laserwords Private Limited, Chennai, India

Printed and bound in Great Britain by TJ International, Padstow, Cornwall
This book is printed on acid-free paper responsibly manufactured from sustainable forestry
in which at least two trees are planted for each one used for paper production.
Contents

About the author vii

Acknowledgements ix

1 Introduction 1
2 What is breast cancer? 3
3 Who gets it? What are the risk factors? 9
4 Symptoms and diagnosis 19
5 Psychological impact – coming to terms with breast cancer 29
6 The role of family, friends and health professionals 41
7 What are the treatment options? 49
8 Surgery 59
9 Breast reconstruction or prosthesis? 71
10 Radiotherapy 77
11 Chemotherapy 85
12 Hormonal therapies and immunotherapy 97
13 Breast cancer, pregnancy and fertility 103
14 How does it feel to live with breast cancer? 109
15 Complementary therapies, holistic practice and diet 115
16 Frequently asked questions 125

Glossary 129
Useful addresses and contacts 133
References 139
Index 141

v
About the author

JOY OGDEN is an award-winning health journalist of nearly 20 years’ standing,

who has written for a range of professional health titles such as Nursing Times,
Nursing Standard, Health Service Journal and Therapy Weekly. She has contributed
to national newspapers such as The Guardian, The Observer, The Independent and
magazines such as Yours Health Plus. She is managing editor of Acupuncture in
Medicine. Joy has recently had treatment for breast cancer and draws on her own
experiences of living with its effects and her re-acquaintance with the NHS as
a patient.

vii
Acknowledgements

I would like to thank all the people who talked to me about their experiences of
living with breast cancer. Their comments and contributions were generous, full of
insight and extremely valuable – both for this book and for my own understanding,
as someone who also lives with breast cancer.
I would like to thank my family and friends – and especially my two wonderful
daughters, Louise Jones and Jane Ogden – for their unstinting and invaluable
support and encouragement when I was coming to terms with my own diagnosis.
Thanks to Jane also, as editor of this series, for her support in writing this book, and
to Dr Polly James for her useful advice.

ix
Introduction
1

As a health journalist I thought I knew a lot about cancer and my own chances
of getting it. Looking around my long-lived, relatively cancer-free family I blithely
assumed I was safe. It’s true that my father died of lung cancer at the age of 59,
but that was after a lifetime – starting at 13 – of chain-smoking. Oh, and his sister
died of cancer, but she was also a very heavy smoker, so I never felt that counted
either. I concentrated, instead, on the fact that all four of my grandparents lived
well into their 80s or 90s, and that my mother is a miracle of fitness who survived
a major car crash on a bridge holiday in France a couple of years ago at the age of
87 without a broken bone.
Well, I was wrong. I was sitting in the bath one Saturday night in March 2002
when I felt a shooting pain in my right breast. It felt – in retrospect at least – as
though I was following a neon arrow pointing to The Lump. At first I thought I
must be mistaken. But no, it did seem like a definite lump. That night I slept fitfully
and every time I woke I reached again to feel for it, hoping that perhaps I had been
mistaken. It was an agonising wait until Monday morning, when I went to the GP
as an emergency appointment.
He was very kind. A bad sign, I thought. ‘It doesn’t feel like a bad lump,’ he
said. But nevertheless he said he would fax the consultant at the local hospital and I
should get an appointment within two weeks. Two weeks. Two weeks sipping cold
white wine by a pool in the south of France is no time at all. This was two weeks
sitting in the dentist’s chair with the drill whirring in my mouth. At the end of the
first week I was an emotional wreck and rang the hospital to see when I could see
the consultant. A pleasant-sounding receptionist assured me they had the letter
and if it was considered urgent I would be seen as soon as possible. I just started
quietly weeping, unable to control myself and unable to answer. I put the phone
down. Half an hour later she rang and said they realised how distressed I was and

1
2 j UNDERSTANDING BREAST CANCER

the consultant would see me the following day. So that’s how the long journey
began. My cancer was malignant, but thankfully very small and there was no
trace of it in the lymph nodes. I had a lumpectomy, followed by radiotherapy. The
receptionist’s kindness and understanding was typical of the treatment I received
from everyone in the following weeks. I’m a seasoned complainer about poor
service, but you won’t hear me knock the NHS or the people who work in it.
I coped with my own diagnosis by reading everything I could find, trawling
through the internet for information, and by talking to my family and friends.
This book contains both facts and figures and the perspective of people who have
experienced the different diagnoses and forms of treatment. This book aims to
provide the sort of information and support that I was looking for. I hope that it
will be a useful resource for others who have been diagnosed with breast cancer,
as well as for their family and friends and for health professionals who come into
contact with them.
What is breast cancer?
2

Overview

This chapter will look first at cancers in general and then in more detail at breast
cancer. To give a clearer understanding of the different types of breast cancer,
there is a brief description of the structure of the breast. There are explanations
of the different types of tumours – non-invasive and invasive – and of secondary
breast cancer.

What is cancer?

There is no one disease called ‘cancer’ which will one day be curable with a single
remedy. It is a group of many different diseases that have some important things
in common.
Cancers all develop as the result of cells which have run out of control and
they all begin in the same way in the body’s basic building block of life – the cell.
The body has billions of cells of many different types which are grouped together to
form tissues and organs. Normal cells grow in a controlled way and are constantly
dividing to repair damaged tissues, to replace old cells and for tissues to grow. This
helps to keep our body healthy. But normal cells only divide or reproduce when
there is a need. Cells in tissues such as the skin or blood, for instance, are constantly
wearing out and being replaced. When we cut ourselves, the cells around the injury
will reproduce in order to repair and replace the damaged tissue, but once they have
repaired it and the wound is healed they stop dividing. Sometimes, however, the
control system goes wrong: the ‘switch-off’ mechanism fails and the cells become
abnormal. Instead of stopping, the abnormal cells just keep on multiplying and

3
4 j UNDERSTANDING BREAST CANCER

dividing until a lump forms. This lump of extra tissue is called a tumour. It is
thought that most invasive breast cancers have been present from 6 to 10 years
before they are picked up by a mammogram or felt as a lump.

Are all tumours cancerous?

Not all tumours are cancerous, some are non-malignant or benign; that is, as it
sounds, harmless – except when they grow in places where the pressure they exert
causes a problem (for example large benign brain tumours). They are made up of
cells that are quite like normal ones – and don’t usually need to be treated. Benign
tumours tend to grow very slowly, if at all, and don’t spread beyond the tissue
where they first started and into the rest of the body.
Malignant tumours, though, are made up of cancer cells that look abnormal
and are not like the cells from which they developed. As a rule, the more abnormal
(or anaplastic) the cells look, the more aggressively the cancer grows. Malignant
tumours continue growing into surrounding areas and can spread to other parts of
the body. It’s this ability to damage and destroy surrounding tissues and to travel
to other organs, where they grow as secondary (or metastatic) tumours, which
makes cancerous cells so dangerous.
A malignant tumour which can invade and damage nearby tissues and organs
is cancer. A benign tumour which will not spread to other parts of the body is
not cancer.

What is meant by ‘primary cancer’?

The place where a cancer starts is called the ‘primary cancer’. Tumours from cancers
that have spread are called ‘secondary cancers’ (doctors call these ‘metastases’ and
they say a cancer that has migrated from its original site has ‘metastasised’).

So what is breast cancer?

Breast cancer, too, is not just one disease, but several. It can be found in a pre-
cancerous state (which might go on to develop into invasive cancer if it is not
treated), as a cancer which has not yet spread, or after it has spread to other
organs. It can grow very fast or very slowly or somewhere in between. Breast lumps
are common in women of all ages, but in younger women, particularly, they are
usually non-malignant. Though it is rare, men can and do also get breast cancer.
Breasts are composed mainly of fat and breast tissue, together with nerves,
veins, arteries and the connective tissue that helps to keep it all in place. The main
 WHAT IS BREAST CANCER? j 5

Figure 1. Diagram of the breast. From Breast cancer: spot the symptoms early.
Leaflet by Cancer Research UK (2002). Reproduced by permission.

chest muscle is behind the breast and in front of the ribs in the chest wall. The
breast (see Figure 1) is divided into around 20 lobes which look something like
bunches of grapes. The ‘grapes’ are called lobules and the ‘stems’ are called ducts.
The lobules produce milk and the ducts, which are thin tubes, transport the milk
from the lobules to the nipple openings during breastfeeding.
Strands of fibrous tissue and globules of fat develop around the lobules and ducts
in the breast during puberty. The breast also contains vessels carrying blood and
lymph. Lymph is a yellow fluid that bathes cells. It is derived from blood as it passes
through the blood vessels within a tissue, and is returned to the blood after passing
through lymph glands. It flows through the lymphatic system throughout the body
to help fight disease. The lymph vessels lead to lymph nodes, small bean-shaped
organs which can trap bacteria or cancer cells travelling through the body in the
lymph. There are clusters of lymph nodes near the breast in the axilla (under the
arm), above the collarbone and in the chest. Benign or malignant tumours can
develop in any of the breast’s tissues – skin, gland, duct, fat, nerves, muscles, blood
vessels or fibrous tissue.
Male breast tissue normally remains undeveloped, with rudimentary ducts
ending in tiny lobular buds, like that of females before puberty.
After the menopause, when the ovaries stop producing hormones, the number
of lobules decreases, and those that are left shrink. This means that the breasts,
which are then composed of a higher proportion of soft fat, are less dense. And this
means that interpretation of the X-rays is more reliable, so mammography is more
6 j UNDERSTANDING BREAST CANCER

likely to be effective in picking up abnormalities in post-menopausal women than

in younger women with denser, firmer breasts.

What are the different types of breast cancer?

There are two main types of breast cancer – non-invasive or ‘in situ’ (cancers
that are confined to the ducts or lobules and have not spread beyond the layer of
tissue where they developed) and invasive (cancers that have started to spread into
surrounding tissue).

Non-invasive (‘in situ’)

Ductal carcinoma (cancer) in situ (DCIS) is non-invasive and is becoming
more common because it is picked up at an early stage on mammograms. If there
is DCIS it means there are cells in the milk ducts of the breast that have started
to grow and divide abnormally and turn into cancer cells. But they have not yet
broken out of the ducts and developed the ability to spread either to the rest of the
breast or the rest of the body. There is a very high chance that the cancer will be
cured and will not recur if it is removed at this stage.
Some doctors call this a very early form of breast cancer, but others describe it
as a pre-cancerous condition because it might develop into a more serious invasive
cancer if it isn’t treated.
Lobular carcinoma in situ (LCIS) means there are abnormal cells in the
lining of the milk lobule. This is not considered to be breast cancer at this stage, but
it does mean there is more risk of getting invasive breast cancer in either breast in
the future. It is more common in women who are pre-menopausal and should be
closely monitored.

Invasive
Ductal carcinoma is invasive and the most common type of breast cancer. It
begins in the milk ducts of the breast but – unlike DCIS (see above) – it has developed
the potential to spread to other parts of the body. The cancerous cells could do
this by invading either the lymph or blood vessels in the breast and then being
carried through them to other parts of the body, where they form other tumours.
Because they have the potential to spread doesn’t necessarily mean they have
done, but doctors will want to assess the likely risk of it having happened, and if so
how extensively, before deciding what treatment to recommend. This assessment
is called ‘staging’. (See Chapter 7 for definitions of cancer stages.)
Lobular carcinoma is an invasive cancer that begins in the lobules where
milk is produced. It does not always show up as a definite lump and so it can be
 WHAT IS BREAST CANCER? j 7

difficult to diagnose, which means it might be larger than other types of breast
cancer when it’s diagnosed. It is also more common for it to be diagnosed in both
breasts at the same time.
Inflammatory breast cancer is a rare type of advanced breast cancer. It
happens when the cancer cells block the lymph channels in the breast, and these
then become inflamed. Inflammatory breast cancer can be confused with a breast
infection or an allergic reaction because the symptoms can come on quite suddenly
and are very similar, making diagnosis difficult. The first symptoms are usually
a redness and warmth in the skin of the breast, often without a distinct lump.
Other possible symptoms include sudden swelling – as much as a cup size in a
couple of days – dark spots that look like bruises and a change in the colour of the
areola (the dark area around the nipple). It can also show itself through ridges,
welts, pitting and a change in colour – which can be difficult to see in women with
darker skin tones. There might also be stabbing pains or persistent aches in the
breast, discharge from the nipple and swollen lymph nodes under the arm or near
the collarbone. If the breast is treated with antibiotics and fails to get better – or
worse – it is important to have it investigated by a biopsy of the breast tissue and the
skin itself. Inflammatory breast cancer grows and metastasises rapidly and must
be taken very seriously.
Paget’s disease is a rare invasive cancer which begins in the milk ducts of
the nipple. One form of the disease is associated with an invasive cancer in the
breast and another involves only the nipple. It often goes untreated until it is more
advanced because its symptoms (including redness, oozing, crusting, itching of the
nipple) are often thought to be due to an infection or inflammation. It is rarely
found in both breasts, so if both nipples are itchy and scaling it is probably eczema,
a far more common condition. If it doesn’t clear up, however, it should be checked
out. Paget’s disease that involves the breast is treated as any other breast cancer,
but when it involves only the nipple the cancer tends to grow slowly and can be
treated by removing the nipple and areola.

Secondary breast cancer

The original cancer is the ‘primary’ cancer, so a secondary breast cancer is one
that has developed from cancerous breast cells.
Tumours are made from millions of cancerous cells. Sometimes malignant cells
that have grown into blood or lymph vessels break off and are carried round the
body in the bloodstream or the lymph fluid. Once they have escaped they can
become trapped in different organs, tissues, or lymph nodes, where they form a
new tumour. Sometimes breast cancer cells that have migrated die and sometimes
they lie dormant for many years. No one knows why some remain inactive or why
some are reactivated years later.
8 j UNDERSTANDING BREAST CANCER

Cancer can reappear either locally (close to the primary cancer site) or
somewhere else in the body. If it recurs locally – in the skin over where the lump
used to be, the scar from a mastectomy or in the remaining breast tissue after
a lumpectomy – it is often because a few cancer cells were left there and have
grown into a new tumour, and not because they have spread through the blood or
lymphatic system.
Secondary breast cancer is more likely to occur in some parts of the body than
others, commonly in: the lymph nodes near the breast (especially in the armpit, or
the lower neck or chest); one or more bones; the lungs; the liver; and, sometimes,
the brain. It is possible for it to affect more than one area at a time, but often it only
affects one part of the body.
The earlier any recurrence is found and treated, the better is the outlook for
the patient.

Summary

l Cancer cells lose the mechanism for dividing and self-destructing in

an orderly way, become abnormal and continue to divide when new
cells are not needed, thus producing a tumour.

l The place where a cancer starts is called the ‘primary cancer’.

l A malignant tumour is one that can invade and damage nearby

tissues and organs.

l A benign tumour will not spread to other parts of the body and is
not cancer.

l There are two main types of breast cancer: non-invasive, that has not
yet developed the ability to spread either to the rest of the breast or
to the rest of the body; and invasive, that has the potential to spread
to other parts of the body.

l Tumours that have spread to other parts of the body are called
‘secondary cancers’ or ‘metastases’.