Reproductive Factors And Steroid Hormones
Late age at first pregnancy, nulliparity, early onset of menses, and late age of menopause have all been consistently associated with an increased risk of breast cancer. Prolonged exposure to elevated levels of sex hormones has long been postulated as a risk factor for developing breast cancer, explaining the association between breast cancer and reproductive behaviors.
Clinical trials of secondary prevention in women with breast cancer have demonstrated the protective effect of selective estrogen receptor modulators and aromatase inhibitors on recurrence and the development of contralateral breast cancers. Use of SERMs in women at increased risk for breast cancer has prevented invasive ER-positive cancers. These data support estradiol and its receptor as a primary target for risk reduction but do not establish that circulating hormone levels predict increase risk.
A number of epidemiologic and pooled studies support an elevated risk of breast cancer among women with high estradiol levels. The Endogenous Hormones and Breast Cancer Collaborative Group reported a relative risk of 2.58 among women in the top quintile of estradiol levels.
A meta-analysis by the Collaborative Group on Hormonal Factors in Breast Cancer of 58 international studies that included 143,887 postmenopausal women with invasive breast cancer and 424,972 without breast cancer concluded the following about menopausal HRT and breast cancer :
How Much Do Anastrozole And Exemestane Lower The Risk Of Breast Cancer
Studies have shown that both anastrozole and exemestane can lower the risk of breast cancer in postmenopausal women who are at increased risk of the disease.
In one large study, taking anastrozole for five years lowered the risk of developing estrogen receptor-positive breast cancer by 53 percent. In another study, taking exemestane for three years lowered the risk of developing estrogen receptor-positive breast cancer by 65 percent.
The most common side effects seen with anastrazole and exemestane are joint pains, decreased bone density, and symptoms of menopause .
Last reviewed by a Cleveland Clinic medical professional on 12/31/2018.
How Is Breast Cancer Diagnosed
During your regular physical examination, your doctor will take a thorough personal and family medical history. He or she will also perform and/or order one or more of the following:
- Breast examination: During the breast exam, the doctor will carefully feel the lump and the tissue around it. Breast cancer usually feels different than benign lumps.
- Digital mammography: An X-ray test of the breast can give important information about a breast lump. This is an X-ray image of the breast and is digitally recorded into a computer rather than on a film. This is generally the standard of care .
- Ultrasonography: This test uses sound waves to detect the character of a breast lump whether it is a fluid-filled cyst or a solid mass . This may be performed along with the mammogram.
Based on the results of these tests, your doctor may or may not request a biopsy to get a sample of the breast mass cells or tissue. Biopsies are performed using surgery or needles.
After the sample is removed, it is sent to a lab for testing. A pathologist a doctor who specializes in diagnosing abnormal tissue changes views the sample under a microscope and looks for abnormal cell shapes or growth patterns. When cancer is present, the pathologist can tell what kind of cancer it is and whether it has spread beyond the ducts or lobules .
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Management Of Breast Cancer
Surgery and radiation therapy, along with adjuvant hormone or chemotherapy when indicated, are considered primary treatment. Surgical therapy may consist of lumpectomy or total mastectomy. Radiation therapy may follow surgery in an effort to eradicate residual disease while reducing recurrence rates. There are 2 general approaches for delivering radiation therapy:
- External-beam radiotherapy
Surgical resection with or without radiation is the standard treatment for ductal carcinoma in situ.
Pharmacologic treatment for metastatic breast cancer is typically selected according to the molecular characteristics of the tumor. Agents used include the following :
- Hormone therapy
- HER2-targeted therapy
- CDK4/6 inhibitors
- mTOR inhibitors
- PIK3CA inhibitors
In patients receiving adjuvant aromatase inhibitor therapy for breast cancer who are at high risk for fracture, the monoclonal antibody denosumab or either of the bisphosphonates zoledronic acid and pamidronate may be added to the treatment regimen to increase bone mass. These agents are given along with calcium and vitamin D supplementation.
See Treatment and Medication for more detail.
Two selective estrogen receptor modulators , tamoxifen and raloxifene, are approved for reduction of breast cancer risk in high-risk women. Prophylactic mastectomy is an option for women found to be at extremely elevated risk.
How Might Hormone Levels Affect Breast Cancer Risk
A womans risk for some types of breast cancer is related to levels of certain hormones in the body. Breast cells normally grow and divide in response to hormones like estrogen, progesterone, and prolactin. Levels of these hormones change throughout a womans life.
Breast cancer risk can be affected by a number of things that alter these hormone levels. For example, women who have more menstrual periods over their lifetime have a slightly higher risk of breast cancer. The use of some types of hormones can also increase breast cancer risk slightly . On the other hand, breastfeeding might lower breast cancer risk slightly.
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Cohort And Other Prospective Studies
The largest, and probably the most reliable, study on this topic was done during the 1990s in Denmark, a country with very detailed medical records on all its citizens. In this study, all Danish women born between 1935 and 1978 were linked with the National Registry of Induced Abortions and with the Danish Cancer Registry. All of the information about their abortions and their breast cancer came from registries it was very complete and was not influenced by recall bias.
After adjusting for known breast cancer risk factors, the researchers found that induced abortion had no overall effect on the risk of breast cancer. The size of this study and the manner in which it was done provide good evidence that induced abortion does not affect a womans risk of developing breast cancer.
Another large cohort study was reported on by Harvard researchers in 2007. This study included more than 100,000 women who were between the ages of 29 and 46 at the start of the study in 1993. These women were followed until 2003. Because they were asked about childbirths and abortions at the start of the study, recall bias was unlikely to be a problem. After adjusting for known breast cancer risk factors, the researchers found no link between either spontaneous or induced abortions and breast cancer.
A French cohort study of more than 100,000 women, published in 2003, also found no link between induced abortion and breast cancer risk.
Integrating Geriatric Principles Into Oncology Treatment Decisions
An integral part of the cancer treatment decision is to determine whether the patient will die of cancer, or simply with cancer. Furthermore, one needs to weigh whether the cancer is likely to cause significant disability for the patient in his/her lifetime. While younger patients with breast cancer can usually anticipate that having a diagnosis of cancer will shorten their life expectancy without treatment, the same may not be true for older adults. The prevalence of comorbid conditions increases with age. Competing comorbidities increase the risk that the older adult with cancer may die of another cause., In this setting an indolent cancer may not influence the lifespan or quality of life of the patient.
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What Are The Symptoms Of Breast Cancer
Breast pain can be a symptom of cancer. If you have any symptoms that worry you, be sure to see your doctor right away.
Different people have different symptoms of breast cancer. Some people do not have any signs or symptoms at all.
Some warning signs of breast cancer are
- New lump in the breast or underarm .
- Thickening or swelling of part of the breast.
- Irritation or dimpling of breast skin.
- Redness or flaky skin in the nipple area or the breast.
- Pulling in of the nipple or pain in the nipple area.
- Nipple discharge other than breast milk, including blood.
- Any change in the size or the shape of the breast.
- Pain in any area of the breast.
Keep in mind that these symptoms can happen with other conditions that are not cancer.
If you have any signs or symptoms that worry you, be sure to see your doctor right away.
Your Personal History Of Breast Cancer
If youve been diagnosed with breast cancer in the past, you are more likely to develop a new cancer in the other breast or in another part of the same breast. This is not considered a recurrence but a new breast cancer.
What to do: Follow your cancer teams instructions on monitoring to stay on top of this risk. Ask your doctor whether you should see a genetic counselor.
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Family History Of Breast Cancer
A positive family history of breast cancer is the most widely recognized risk factor for breast cancer. The lifetime risk is up to 4 times higher if a mother and sister are affected, and it is about 5 times greater in women who have two or more first-degree relatives with breast cancer. The risk is also greater among women with breast cancer in a single first-degree relative, particularly if the relative was diagnosed at an early age .
Despite a history indicating increased risk, many of these families have normal results on genetic testing. However, identification of additional genetic variants associated with increased risk may prove valuable. Michailidou et al conducted a controlled genome-wide association study of breast cancer that included 122,977 cases of European ancestry and 14,068 cases of East Asian ancestry, and identified 65 new loci associated with overall breast cancer risk. A GWAS by Milne et al identified 10 variants at 9 new loci that are associated with risk of estrogen receptornegative breast cancer.
A family history of ovarian cancer in a first-degree relative, especially if the disease occurred at an early age , has been associated with a doubling of breast cancer risk. This often reflects inheritance of a pathogenic mutation in the BRCA1 or BRCA2 gene.
The family history characteristics that suggest increased risk of cancer are summarized as follows:
- Ontario Family History Assessment Tool
Direct-to-consumer genetic testing
What Causes Breast Cancer
While there is no specific cause for breast cancer, some lifestyle factors are associated with a higher risk of developing the condition:
- Drinking alcohol may raise oestrogen levels in the body and is associated with a 30 to 50% increased risk of breast cancer.
- Unhealthy weight Being obese is associated with a 20 to 40% increased risk of breast cancer in post-menopausal women.
- Smoking, particularly if you started as a teenager, increases your breast cancer risk.
Other factors that cant be changed also impact your likelihood of getting breast cancer:
- Your age The older you get, the more likely it is your cells become damaged and progress to cancer. Nearly 4 in 5 new breast cancers are diagnosed in women over 50 years.
- Your family history Women with a first-degree relative with breast cancer are twice as likely to get it themselves than women without one.
- Having BRCA1, BRCA2 or other gene mutations Up to 1 in 10 breast cancers are due to a strong family history of these genetic mutations.
- Dense breasts Women with more dense tissue in their breasts may have a higher risk of breast cancer.
- Previous radiation exposure Women who were exposed to radiation therapy in the chest region may have 5 times the risk of breast cancer as women who were not.
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Where Does Breast Cancer Recur
Breast cancer recurrence can be categorized by where in the body it occurs when it returns. These categories include:
- Local recurrence This type of recurrence describes breast cancer that develops in or near the same area where it originally developed, such as scar tissue, the chest wall or other nearby tissue.
- Regional recurrence Breast cancer that returns in a nearby region, such as the lymph nodes in the armpit or collar bone, is known as a regional recurrence.
- Distant recurrence Also called metastatic recurrence, this type of recurrence describes breast cancer that returns in a distant area of the body, such as the bones, lungs or liver.
Can Breast Cancer Recur After A Mastectomy
A mastectomy is a surgical procedure that removes an entire breast. This procedure may be used as a treatment for breast cancer or a preventative measure for individuals at high risk of developing breast cancer. If your physician has recommended a mastectomy as part of your treatment plan, you may be wondering if this procedure will prevent breast cancer recurrence. Although a mastectomy removes all of the breast tissue, there is still a chance that breast cancer can return.
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Relative Risks In Research
You can put your knowledge of relative risks to work right away.
Our Breast Cancer Research Studies section has research summary tables on topics ranging from risk factors to treatment to social support.
These tables show research behind many recommendations and standards of care related to breast cancer discussed in this section.
If you dont know how the research process works , our How to read a research table section is a good place to start before looking at the tables.
Learn more about breast cancer research.
The Emotional Toll Of Breast Cancer
Younger women are more likely to be affected to the point of depression if they feel overwhelmed by the disease. In addition, unlike older breast cancer patients, they generally lack a strong peer support system
“I think when you’re older you expect it more… it’s not something that’s atypical for your peer group,” said Bryndza’s doctor, Dr. Dawn Hershman, co-director of the breast cancer program at the Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center. “When you’re young you feel like you’re the only one. Everybody wants to help but no one knows what it’s like.”
But younger women may not want empathy, craving normality instead. Often, the greatest source of anxiety for a young woman with breast cancer is not the disease — it’s whether their peers will treat them differently. Both Thompson and Bryndza said they felt the most anxious about heading back to school.
“Because she was so young, she did not know exactly what was, and that helped her deal with it,” Anderson said. “But she was worried about her peers — if they were going to talk about her as if she had a disease… She didn’t want a lot of young people to know. I guess because she didn’t understand herself what was going on, they might not understand either.”
Things Fall Apart
“It was hard because I was such a wreck, emotionally, sometimes,” Bryndza said. “I needed to focus on myself and my health and it was hard to be in a relationship when I had to worry about myself.”
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Why Dont All Of The Studies Agree
Induced abortion brings up many strong feelings in people, so it is often hard to study its long-term effects.
Before 1973, induced abortions were illegal in much of the United States. So when researchers asked a woman about past pregnancies, she may not have felt comfortable saying that she had an abortion. Even though abortion is now legal, it is still a very personal, private matter that many women do not like to talk about. This means that many women might not report having an abortion if asked for a study. In contrast, women with breast cancer are more likely to accurately report their reproductive histories, including a history of having an abortion. This recall bias could lead to retrospective studies finding links that arent found in prospective studies. Still, not everyone agrees that this is the reason that the different types of studies conflict.
In general, though, when prospective and retrospective studies conflict, experts generally accept the results of the prospective studies over the retrospective studies.
What Will The Doctor Do
Sometimes a doctor will discover a lump in a woman’s breast during a routine examination or a patient might come to the doctor with questions about a lump she found.
In other cases, a mammogram may find a lump in the breast that can’t be felt. A mammogram is a special kind of X-ray of the breast that helps doctors see what’s going on inside. Sometimes, other kinds of pictures, like an MRI, also can be taken.
When a lump is found, the doctor will want to test it. The best way to do this is usually with a biopsy. In a biopsy, a small amount of breast tissue is removed with a needle or during a small operation. Then, the tissue is examined under a microscope to look for cancer cells.
The biopsy may be benign , which means the lump is not cancer. If the biopsy shows cancer cells, the lump is malignant . If a breast lump does contains cancer cells, the woman, along with her doctor and family, will decide what to do next.
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What Do The Studies Show
The results of studies looking at the possible link between breast cancer and induced abortion often differ depending on how the study was done. Cohort studies and studies that used records to determine the history of abortions have not found an increased risk. Some case-control studies, however, have found an increase in risk.