Breast Cancer (Female)

Case Study 1 - 'I've had breast cancer twice'

Breast cancer is the most common type of cancer in the UK.

In 2011, just under 50,000 women were diagnosed with invasive breast cancer. Most women who get it (8 out of 10) are over 50, but younger women, and in rare cases, men, can also get breast cancer.

If it's treated early enough, breast cancer can be prevented from spreading to other parts of the body.

The breasts

The breasts are made up of fat, connective tissue and thousands of tiny glands called lobules, which produce milk. When a woman has a baby, the milk is delivered to the nipple through tiny tubes called ducts, which allow her to breastfeed.

The body is made up of billions of tiny cells, which usually grow and multiply in an orderly way. New cells are only produced when and where they're needed. In cancer, this orderly process goes wrong and cells begin to grow and multiply uncontrollably.

Causes

The causes of breast cancer aren't fully understood, making it difficult to say why one woman may develop breast cancer and another may not.

However, there are risk factors that are known to affect your likelihood of developing breast cancer. Some of these you can't do anything about, but there are some you can change.

Age

The risk of developing breast cancer increases with age. The condition is most common among women over 50 who have been through the menopause. About 8 out of 10 cases of breast cancer occur in women over 50.

All women who are 50-70 years of age should be screened for breast cancer every three years as part of the NHS Breast Screening Programme. Women over the age of 70 are still eligible to be screened and can arrange this through their GP or local screening unit. Read more about breast screening.

Family history

If you have close relatives who have had breast cancer or ovarian cancer, you may have a higher risk of developing breast cancer. However, because breast cancer is the most common cancer in women, it's possible for it to occur in more than one family member by chance.

Most cases of breast cancer aren't hereditary (they don't run in families), but particular genes, known as BRCA1 and BRCA2, can increase your risk of developing both breast and ovarian cancer. It's possible for these genes to be passed on from a parent to their child. A third gene (TP53) is also associated with increased risk of breast cancer.

If you have, for example, two or more close relatives from the same side of your family, such as your mother, sister or daughter, who have had breast cancer under the age of 50, you may be eligible for surveillance for breast cancer or for genetic screening to look for the genes that make developing breast cancer more likely. If you're worried about your family history of breast cancer, discuss it with your GP.

Read about predictive genetic tests for cancer risk genes.

Previous diagnosis of breast cancer

If you've previously had breast cancer or early non-invasive cancer cell changes in breast ducts, you have a higher risk of developing it again, either in your other breast or in the same breast again.

Previous benign breast lump

A benign breast lump doesn't mean you have breast cancer, but certain types of lump may slightly increase your risk of developing it. Certain benign changes in your breast tissue, such as atypical ductal hyperplasia (cells growing abnormally in ducts), or lobular carcinoma in situ (abnormal cells inside your breast lobes), can make getting breast cancer more likely.

Breast density

Your breasts are made up of thousands of tiny glands (lobules), which produce milk. This glandular tissue contains a higher concentration of breast cells than other breast tissue, making it denser. Women with dense breast tissue may have a higher risk of developing breast cancer because there are more cells that can become cancerous.

Dense breast tissue can also make a breast scan (mammogram) difficult to read, because it makes any lumps or areas of abnormal tissue harder to spot. Younger women tend to have denser breasts. As you get older, the amount of glandular tissue in your breasts decreases and is replaced by fat, so your breasts become less dense.

Exposure to oestrogen

The female hormone, oestrogen, can sometimes stimulate breast cancer cells and cause them to grow. The ovaries, where your eggs are stored, begin to produce oestrogen when you start puberty, to regulate your periods.

Your risk of developing breast cancer may rise slightly with the amount of oestrogen your body is exposed to. For example, if you started your periods at a young age and experienced the menopause at a late age, you'll have been exposed to oestrogen over a longer period of time. In the same way, not having children, or having children later in life, may slightly increase your risk of developing breast cancer because your exposure to oestrogen is uninterrupted by pregnancy.

Being overweight or obese

If you've experienced the menopause and are overweight or obese, you may be more at risk of developing breast cancer. This is thought to be linked to the amount of oestrogen in your body, because being overweight or obese after the menopause causes more oestrogen to be produced.

Being tall

If you're taller than average, you're more likely to develop breast cancer than someone who's shorter than average. The reason for this isn't fully understood, but it may be due to interactions between genes, nutrition and hormones.

Alcohol

Your risk of developing breast cancer can increase with the amount of alcohol you drink. Research shows that for every 200 women who regularly have two alcoholic drinks a day, there are three more women with breast cancer, compared with women who don't drink at all.

Radiation

Certain medical procedures that use radiation, such as X-rays and computerised tomography (CT) scans, may slightly increase your risk of developing breast cancer.

If you had radiotherapy to your chest area for Hodgkin lymphoma when you were a child, you should have already received a written invitation from the Department of Health for a consultation with a specialist to discuss your increased risk of developing breast cancer. See your GP if you weren't contacted, or if you didn't attend a consultation.

If you currently need radiotherapy for Hodgkin lymphoma, your specialist should discuss the risk of breast cancer before your treatment begins.

Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT) is associated with a slightly increased risk of developing breast cancer. Both combined HRT and oestrogen-only HRT can increase your risk of developing breast cancer, although the risk is slightly higher if you take combined HRT.

It's estimated that there will be an extra 19 cases of breast cancer for every 1,000 women taking combined HRT for 10 years. The risk continues to increase slightly the longer you take HRT, but returns to normal once you stop taking it.

Want to know more?

Breakthrough Breast Cancer: Breast cancer risk factors
Breast Cancer Care: Am I at Risk of Developing Breast Cancer?
Cancer Research UK: Breast cancer risks and causes
Live Well: Breast cancer genes
Macmillan: Breast cancer causes and risk factors

Symptoms of breast cancer

The first symptom of breast cancer most women notice is a lump or an area of thickened tissue in their breast.

Most breast lumps (90%) aren't cancerous, but it's always best to have them checked by your doctor.

You should see your GP if you notice any of the following:

a lump or area of thickened tissue in either breast
a change in the size or shape of one or both breasts
discharge from either of your nipples (which may be streaked with blood)
a lump or swelling in either of your armpits
dimpling on the skin of your breasts
a rash on or around your nipple
a change in the appearance of your nipple, such as becoming sunken into your breast

Breast pain isn't usually a symptom of breast cancer.

Want to know more?

Breast Cancer Care: Changes to look and feel for.
Cancer Research UK: Breast cancer symptoms.
Macmillan: What are the symptoms of breast cancer in women?

Breast awareness

It's important to be breast aware, so you can pick up any changes as soon as possible. Get to know what is normal for you. For instance, your breasts may look or feel different at different times of your life. This will make it much easier to spot potential problems.

Want to know more?

Breast Cancer Care: Your breasts, your health: throughout your life (PDF, 1.9Mb)
Breast Cancer Care: Your breasts, your health: a quick guide to being breast aware (PDF, 3.12Mb)
Breakthrough Breast Cancer: Signs and symptoms of breast cancer

Types of breast cancer

There are several different types of breast cancer, which can develop in different parts of the breast. Breast cancer is often divided into non-invasive and invasive types.

Non-invasive breast cancer

Non-invasive breast cancer is also known as cancer or carcinoma in situ. This cancer is found in the ducts of the breast and hasn't developed the ability to spread outside the breast.

This form of cancer rarely shows as a lump in the breast that can be felt, and is usually found on a mammogram (see below). The most common type of non-invasive cancer is ductal carcinoma in situ (DCIS).

Invasive breast cancer

Invasive cancer has the ability to spread outside the breast, although this doesn't necessarily mean it has spread.

The most common form of breast cancer is invasive ductal breast cancer, which develops in the cells that line the breast ducts. Invasive ductal breast cancer accounts for about 80% of all breast cancer cases and is sometimes called "no special type".

Other types of breast cancer

Other less common types of breast cancer include invasive lobular breast cancer, which develops in the cells that line the milk-producing lobules, inflammatory breast cancer and Paget's disease of the breast.

It's possible for breast cancer to spread to other parts of the body, usually through the lymph nodes (small glands that filter bacteria from the body) or the bloodstream. If this happens, it's known as "secondary" or "metastatic" breast cancer.

Breast cancer screening

About one in eight women are diagnosed with breast cancer during their lifetime. There's a good chance of recovery if it's detected in its early stages. For this reason, it's vital that women check their breasts regularly for any changes and always get any changes examined by their GP.

Mammographic screening (where X-ray images of the breast are taken) is the best available method of detecting an early breast lesion. However, you should be aware that a mammogram might fail to detect some breast cancers. It might also increase your chances of having extra tests and interventions, including surgery.

Women with a higher-than-average risk of developing breast cancer may be offered screening and genetic testing for the condition.

As the risk of breast cancer increases with age, all women who are 50-70 years old are invited for breast cancer screening every three years.

Women over 70 are also entitled to screening and can arrange an appointment through their GP or local screening unit.

The NHS is in the process of extending the programme as a trial, offering screening to some women aged 47-73.

Diagnosis

Tests at the breast cancer clinic

If you have suspected breast cancer, either because of your symptoms or because your mammogram has shown an abnormality, you'll be referred to a specialist breast cancer clinic for further tests.

Mammogram and breast ultrasound

If you have symptoms and have been referred by your GP, you'll have a mammogram to produce an X-ray of your breasts. You may also need an ultrasound scan.

If your cancer was detected through the NHS Breast Screening Programme, you may need another mammogram or ultrasound scan.

If you're under 35 years of age, your doctor may suggest that you only have a breast ultrasound scan. This is because younger women have denser breasts, which means a mammogram isn't as effective as ultrasound in detecting cancer.

Ultrasound uses high-frequency sound waves to produce an image of the inside of your breasts, showing any lumps or abnormalities. Your doctor may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid or contains liquid.

Biopsy

A biopsy is where a sample of tissue cells is taken from your breast and tested to see if it's cancerous. You may also need a scan and a needle test on lymph nodes in your armpit (axilla) to see whether these are also affected.

Biopsies can be taken in different ways, and the type you have will depend on what your doctor knows about your condition. Different methods of carrying out a biopsy are discussed below.

Needle aspiration may be used to test a sample of your breast cells for cancer or to drain a benign cyst (a small fluid-filled lump). Your doctor will use a small needle to extract a sample of cells, without removing any tissue.

Needle biopsy is the most common type of biopsy. A sample of tissue is taken from a lump in your breast using a large needle. You'll have a local anaesthetic, which means you'll be awake during the procedure, but your breast will be numb.

Your doctor may suggest that you have a guided needle biopsy (usually guided by ultrasound or X-ray, but sometimes MRI is used) to obtain a more precise and reliable diagnosis of cancer and to distinguish it from any non-invasive change, particularly ductal carcinoma in situ (DCIS).

Vacuum-assisted biopsy, also known as mammotome biopsy, is another type of biopsy. During the procedure, a needle is attached to a gentle suction tube, which helps to obtain the sample and clear any bleeding from the area.

Want to know more?

Breakthrough Breast Cancer: Diagnosing breast cancer.
Breast Cancer Care: Referral to a breast clinic.
Breast Cancer Care: Your pathology report.
Macmillan: How breast cancer in women is diagnosed.
Cancer Research UK: Diagnosing breast cancer.

Further tests for breast cancer

If a diagnosis of breast cancer is confirmed, more tests will be needed to determine the stage and grade of the cancer, and to work out the best method of treatment.

Scans and X-rays

Computerised tomography (CT) scans, or chest X-ray and liver ultrasound scans, may be needed to check whether the cancer has spread to your lungs or liver. An MRI scan of the breast may be needed to clarify or to assess the extent of the condition within the breast.

If your doctor thinks that the cancer could have spread to your bones, you may need a bone scan. Before having a bone scan, a substance containing a small amount of radiation, known as an isotope, will be injected into a vein in your arm. This will be absorbed into your bone if it's been affected by cancer. The affected areas of bone will show up as highlighted areas on the bone scan, which is carried out using a special camera.

Tests to determine specific types of treatment

You'll also need tests that show whether the cancer will respond to specific types of treatment. The results of these tests can give your doctors a more complete picture of the type of cancer you have and how best to treat it. The types of test you could be offered are discussed below.

In some cases, breast cancer cells can be stimulated to grow by hormones that occur naturally in your body, such as oestrogen and progesterone.

If this is the case, the cancer may be treated by stopping the effects of the hormones, or by lowering the level of these hormones in your body. This is known as "hormone therapy".

During a hormone receptor test, a sample of cancer cells will be taken from your breast and tested to see if they respond to either oestrogen or progesterone. If the hormone is able to attach to the cancer cells (using a hormone receptor), they're known as "hormone receptor positive".

While hormones can encourage the growth of some types of breast cancer, other types are stimulated by a protein called human epidermal growth factor receptor 2 (HER2).

These types of cancer can be diagnosed using a HER2 test, and treated with medication to block the effects of HER2. This is known as "biological" or "targeted" therapy.

Want to know more?

Breast Cancer Care: Diagnosis.

Stage and grade of breast cancer

Stage of breast cancer

When your breast cancer is diagnosed, the doctors will give it a stage. The stage describes the size of the cancer and how far it has spread.

Ductal carcinoma in situ (DCIS) is sometimes described as Stage 0. Other stages of breast cancer describe invasive breast cancer (see below).

Stage 1 – the tumour measures less than 2cm and the lymph nodes in the armpit aren't affected. There are no signs that the cancer has spread elsewhere in the body.
Stage 2 – the tumour measures 2-5cm or the lymph nodes in the armpit are affected, or both. There are no signs that the cancer has spread elsewhere in the body.
Stage 3 – the tumour measures 2-5cm and may be attached to structures in the breast, such as skin or surrounding tissues. The lymph nodes in the armpit are affected. However, there are no signs that the cancer has spread elsewhere in the body.
Stage 4 – the tumour is of any size and the cancer has spread to other parts of the body (metastasis).

This is a simplified guide. Each stage is divided into further categories: A, B and C. If you're not sure what stage you have, ask your doctor.

TNM staging system

The TNM staging system may also be used to describe breast cancer, as it can provide accurate information about the diagnosis. T describes the size of the tumour, N describes whether cancer has spread to the lymph nodes, and M gives an indication of whether the cancer has spread to other parts of the body.

Grade of breast cancer

The grade describes the appearance of the cancer cells.

Low grade (G1) – the cells, although abnormal, appear to be growing slowly.
Medium grade (G2) – the cells look more abnormal than low-grade cells.
High grade (G3) – the cells look even more abnormal and are more likely to grow quickly.

Treating breast cancer

If cancer is detected at an early stage, it can be treated before it spreads to nearby parts of the body.

Breast cancer is treated using a combination of surgery, chemotherapy and radiotherapy. Surgery is usually the first type of treatment you'll have, followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments.

The type of surgery and the treatment you have afterwards will depend on the type of breast cancer you have. Your doctor will discuss the best treatment plan with you.

In a small proportion of women, breast cancer is discovered after it's spread to other parts of the body (metastasis). Secondary cancer, also called advanced or metastatic cancer, isn't curable, so the aim of treatment is to achieve remission (symptom relief).

Treatment overview

Surgery is usually the first type of treatment for breast cancer. The type of surgery you undergo will depend on the type of breast cancer you have.

Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments. Again, the treatment you'll have will depend on your type of breast cancer.

Your doctor will discuss the most suitable treatment plan with you. Chemotherapy or hormone therapy will sometimes be the first treatment.

Secondary breast cancer

Most breast cancers are discovered in the condition's early stages. However, a small proportion of women discover that they have breast cancer after it's spread to other parts of the body (known as metastasis).

If this is the case, the type of treatment you have may be different. Secondary cancer, also called "advanced" or "metastatic" cancer, isn't curable and treatment aims to achieve remission (where the cancer shrinks or disappears, and you feel normal and able to enjoy life to the full).

Want to know more?

Breakthrough Breast Cancer: Controlling secondary breast cancer.
Breast Cancer Care: Secondary breast cancer.

Surgery

There are two main types of breast cancer surgery. They are:

surgery to remove the cancerous lump (tumour), known as breast-conserving surgery
surgery to remove the whole breast, which is called a mastectomy

In many cases, a mastectomy can be followed by reconstructive surgery to try to recreate a bulge to replace the breast that was removed.

Studies have shown that breast-conserving surgery followed by radiotherapy is as successful as total mastectomy at treating early-stage breast cancer.

Breast-conserving surgery

Breast-conserving surgery ranges from a lumpectomy or wide local excision, where just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, where up to a quarter of the breast is removed.

If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:

the type of cancer you have
the size of the tumour and where it is in your breast
the amount of surrounding tissue that needs to be removed
the size of your breasts

Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer. If there's no cancer present in the healthy tissue, there's less chance that the cancer will reoccur. If cancer cells are found in the surrounding tissue, more tissue may need to be removed from your breast.

After having breast-conserving surgery, you will usually be offered radiotherapy to destroy any remaining cancer cells.

Mastectomy

A mastectomy is the removal of all the breast tissue, including the nipple. If there are no obvious signs that the cancer has spread to your lymph nodes, you may have a mastectomy, where your breast is removed, along with a sentinel lymph node biopsy (see below).

If the cancer has spread to your lymph nodes, you will probably need more extensive removal (clearance) of lymph nodes from the axilla (under your arm).

Reconstruction

Breast reconstruction is surgery to make a new breast shape that looks as much as possible like your other breast. Reconstruction can be carried out at the same time as a mastectomy (immediate reconstruction), or it can be carried out later (delayed reconstruction). It can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.

Lymph node surgery

To find out if the cancer has spread, a procedure called a sentinel lymph node biopsy may be carried out.

The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. They're part of the lymph nodes under the arm (axillary lymph nodes). The position of the sentinel lymph nodes varies, so they're identified using a combination of a radioisotope and a blue dye.

The sentinel lymph nodes are examined in the laboratory to see if there are any cancer cells present. This provides a good indicator of whether the cancer has spread.

If there are cancer cells in the sentinel nodes, you may need further surgery to remove more lymph nodes from under the arm.

Want to know more?

Predict: Decide on the ideal course of treatment following breast cancer surgery.
Cancer Research UK: Types of breast cancer surgery.
Breakthrough Breast Cancer: Treating early breast cancer.
Breast Cancer Care: Breast reconstruction: an animated guide.

Radiotherapy

Radiotherapy uses controlled doses of radiation to kill cancer cells. It's usually given after surgery and chemotherapy to kill any remaining cancer cells.

If you need radiotherapy, your treatment will begin about a month after your surgery or chemotherapy, to give your body a chance to recover. You'll probably have radiotherapy sessions three to five days a week, for three to six weeks. Each session will only last a few minutes.

The type of radiotherapy you have will depend on your cancer and surgery type. Some women may not need to have radiotherapy at all. The types available are:

breast radiotherapy – after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue
chest wall radiotherapy – after a mastectomy, radiotherapy is applied to the chest wall
breast boost – some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed; however, the boost may affect the appearance of the breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of the breast tissue (fibrosis)
radiotherapy to the lymph nodes – where radiotherapy is aimed at the armpit (axilla) and the surrounding area to kill any cancer that may be present in the lymph nodes

The side effects of radiotherapy include:

irritation and darkening of the skin on your breast, which may lead to sore, red, weepy skin
fatigue (extreme tiredness)
lymphoedema (excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm)

Want to know more?

Cancer Research UK: Radiotherapy for breast cancer.
Macmillan: Radiotherapy for breast cancer in women.
Breast Cancer Care: Radiotherapy for primary breast cancer.
Breakthrough Breast Cancer: Radiotherapy.

Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) medication to kill the cancer cells. It's usually used after surgery to destroy any cancer cells that haven't been removed. This is called adjuvant chemotherapy.

In some cases, you may have chemotherapy before surgery, which is often used to shrink a large tumour. This is called neo-adjuvant chemotherapy.

Several different medications are used for chemotherapy and three are often given at once. The choice of medication and the combination will depend on the type of breast cancer you have and how much it's spread.

Chemotherapy is usually given as an outpatient treatment, which means you won't have to stay in hospital overnight. The medications are usually given through a drip straight into the blood through a vein.

In some cases, you may be given tablets that you can take at home. You may have chemotherapy sessions once every two to three weeks, over a period of four to eight months, to give your body a rest in between treatments.

The main side effects of chemotherapy are caused by their influence on normal, healthy cells, such as immune cells. Side effects include:

infections
loss of appetite
nausea and vomiting
tiredness
hair loss
sore mouth

Many side effects can be prevented or controlled with medicines that your doctor can prescribe.

Chemotherapy medication can also stop the production of oestrogen in your body, which is known to encourage the growth of some breast cancers.

If you haven't experienced the menopause, your periods may stop while you're undergoing chemotherapy treatment. After you've finished the course of chemotherapy, your ovaries should start producing oestrogen again.

However, this doesn't always happen and you may enter an early menopause. This is more likely in women over 40 years old, because they're closer to menopausal age. Your doctor will discuss with you the impact that any treatment will have on your fertility.

Chemotherapy for secondary breast cancer

If your breast cancer has spread beyond the breast and lymph nodes to other parts of your body, chemotherapy won't cure the cancer, but it may shrink the tumour, relieve your symptoms and help lengthen your life.

Want to know more?

Breakthrough Breast Cancer: Chemotherapy.
Breast Cancer Care: Chemotherapy.
Cancer Research UK: Chemotherapy for breast cancer.
Macmillan: Chemotherapy for breast cancer in women.
NICE guidance: Advanced breast cancer (PDF, 156kb).

Hormone treatment

Some breast cancers are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body.

These types of cancer are known as hormone-receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects.

The type of hormone therapy you'll have will depend on the stage and grade of your cancer, which hormone it's sensitive to, your age, whether you've experienced the menopause and what other type of treatment you're having.

You'll probably have hormone therapy after surgery and chemotherapy, but it's sometimes given before surgery to shrink a tumour, making it easier to remove.

Hormone therapy may be used as the only treatment for breast cancer if your general health prevents you from having surgery, chemotherapy or radiotherapy.

In most cases, you'll need to take hormone therapy for up to five years after having surgery. If your breast cancer isn't sensitive to hormones, hormone therapy will have no effect.

Tamoxifen

Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. It's taken every day as a tablet or liquid. It can cause several side effects, including:

tiredness
changes to your periods
nausea and vomiting
hot flushes
aching joints
headaches
weight gain

Aromatase inhibitors

If you've experienced the menopause, you may be offered an aromatase inhibitor. This type of medication works by blocking aromatase, a substance that helps produce oestrogen in the body after the menopause. Before the menopause, oestrogen is made by the ovaries.

Three aromatase inhibitors may be offered. These are anastrozole, exemestane and letrozole. These are taken as a tablet once a day. Side effects include:

hot flushes and sweats
lack of interest in sex (loss of libido)
nausea and vomiting
tiredness
aching joints and bone pain
headaches
skin rashes

Ovarian ablation or suppression

In women who haven't experienced the menopause, oestrogen is produced by the ovaries. Ovarian ablation or suppression stops the ovaries working and producing oestrogen.

Ablation can be carried out using surgery or radiotherapy. It stops the ovaries working permanently and means you'll experience the menopause early.

Ovarian suppression involves using a medication called goserelin, which is a luteinising hormone-releasing hormone agonist (LHRHa). Your periods will stop while you're taking it, although they should start again once your treatment is complete.

If you're approaching the menopause (around the age of 50), your periods may not start again after you stop taking goserelin.

Goserelin is taken as an injection once a month and can cause menopausal side effects, including:

hot flushes and sweats
mood swings
trouble sleeping

Want to know more?

Breakthrough Breast Cancer: Hormone treatment.
Breast Cancer Care: Hormone therapy.
NICE: Hormonal therapies for the adjuvant treatment of early oestrogen-receptor-positive breast cancer (PDF, 64kb).

Biological therapy (targeted therapy)

Some breast cancers are stimulated to grow by a protein called human epidermal growth factor receptor 2 (HER2). These cancers are called HER2-positive. Biological therapy works by stopping the effects of HER2 and by helping your immune system to fight off cancer cells.

If you have high levels of the HER2 protein and are able to have biological therapy, you'll probably be prescribed a medicine called trastuzumab. Trastuzumab, also known by the brand name Herceptin, is usually used after chemotherapy.

Trastuzumab

Trastuzumab is a type of biological therapy known as a monoclonal antibody. Antibodies occur naturally in your body and are made by your immune system to destroy harmful cells, such as viruses and bacteria. The trastuzumab antibody targets and destroys cancer cells that are HER2-positive.

Trastuzumab is usually given intravenously, through a drip. It's also sometimes available as an injection under the skin (a subcutaneous injection).

You will have the treatment in hospital. Each treatment session takes up to one hour and the number of sessions you need will depend on whether you have early or more advanced breast cancer. On average, you'll need a session once every three weeks for early breast cancer, and weekly sessions if your cancer is more advanced.

Trastuzumab can cause side effects, including heart problems. This means that it's not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension) or heart valve disease. If you need to take trastuzumab, you'll have regular tests on your heart to make sure it's not causing any problems.

Other side effects of trastuzumab may include:

an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever
diarrhoea
tiredness
aches and pains

Want to know more?

Breakthrough Breast Cancer: Targeted biological) treatment.
Breast Cancer Care: Targeted therapy.

Clinical trials

A great deal of progress has been made in breast cancer treatment, and more women now live longer and have fewer side effects from treatment.

These advances were discovered in clinical trials, where new treatments and treatment combinations are compared with standard ones.

All cancer trials in the UK are carefully overseen to ensure they're worthwhile and safely conducted. In fact, participants in clinical trials can do better overall than those in routine care.

If you're asked to take part in a trial, you'll be given an information sheet and, if you want to take part, you'll be asked to sign a consent form. You can refuse or withdraw from a clinical trial without it affecting your care.

Want to know more?

Clinical trials and medical research.
Breast Cancer Care: Clinical trials.
Cancer Research UK: Breast cancer research.
Against Breast Cancer: Our research.

Psychological help

Dealing with cancer can be a huge challenge, for both patients and their families. It can cause emotional and practical difficulties. Many women have to cope with the removal of part or all of a breast, which can be very upsetting.

It often helps to talk about your feelings or other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness.

There are various ways to find help and support. Your hospital doctor, specialist nurse or GP can refer you to a counsellor. If you're feeling depressed, talk to your GP. A course of antidepressant drugs may help, or your GP can arrange for you to see a counsellor or psychotherapist.

It can help to talk to someone who's been through the same thing as you. Many organisations have helplines and online forums. They can also put you in touch with other people who've had cancer treatment.

Want to know more?

Breast Cancer Care: Someone to talk to.
Macmillan Cancer Support: Online community.

Complementary therapies

Complementary therapies are holistic therapies that can promote physical and emotional wellbeing. They're given alongside conventional treatments and include relaxation techniques, massage, aromatherapy and acupuncture.

Complementary therapy can help some women cope with diagnosis and treatment, and provide a break from the treatment plan.

Your hospital or breast unit may be able to provide access to complementary therapies or suggest where you can get them. It's important to speak to your breast cancer specialist nurse about any complementary therapy you wish to use, to make sure it doesn't interfere with your conventional treatment.

Want to know more?

Breakthrough Breast Cancer: Complementary therapies (PDF).
Breast Cancer Care: Complementary therapies.
Paul's Cancer Support Centre.

Preventing breast cancer

As the causes of breast cancer aren't fully understood, it's not possible to know if it can be prevented altogether.

If you're at increased risk of developing the condition, some treatments are available to reduce the risk.

Studies have looked at the link between breast cancer and diet and, although there are no definite conclusions, there are benefits for women who maintain a healthy weight, exercise regularly and who have a low intake of saturated fat and alcohol.

It's been suggested that regular exercise can reduce your risk of breast cancer by as much as a third. If you've been through the menopause, it's particularly important that you're not overweight or obese. This is because being overweight or obese causes more oestrogen to be produced, which can increase the risk of breast cancer.

Living with breast cancer

Being diagnosed with breast cancer can affect daily life in many ways, depending on what stage it's at and what treatment you're having.

How women cope with their diagnosis and treatment varies from person to person. You can be reassured that there are several forms of support available, if you need it. For example:

your family and friends can be a powerful support system
you can communicate with other people in the same situation
find out as much as possible about your condition
don't try to do too much or overexert yourself
make time for yourself

Recovery and follow-up

Recovery

Most women with breast cancer have an operation as part of their treatment. Getting back to normal after surgery can take some time. It's important to take things slowly and give yourself time to recover.

During this time, avoid lifting things – for example, children or heavy shopping bags – and avoid heavy housework. You may also be advised not to drive.

Read more about recovering from an operation.

Some other treatments, particularly radiotherapy and chemotherapy, can make you very tired. You may need to take a break from some of your normal activities for a while. Don't be afraid to ask for practical help from family and friends.

Follow-up

After your treatment has finished, you'll be invited for regular check-ups, usually every three months for the first year.

If you've had early breast cancer, your healthcare team will agree a care plan with you after your treatment has finished. This plan contains the details of your follow-up. You will receive a copy of the plan, which will also be sent to your GP.

During the check-up, your doctor will examine you and may carry out blood tests or X-rays to see how your cancer is responding to treatment. You should also be offered a mammogram every year for the first five years after your treatment.

Long-term complications

Although it's rare, your treatment for breast cancer may cause new problems, such as:

pain and stiffness in your arms and shoulders may occur after surgery, and the skin in these areas may be tight
lymphoedema (a build-up of excess lymph fluid which causes swelling) – this may occur if surgery or radiotherapy damages the lymphatic drainage system in the armpit

Talk to your healthcare team if you experience these or any other long-term effects of treatment.

Want to know more?

Breast Cancer Care: Your operation and recovery (PDF, 148kb).
Breast Cancer Care: Lymphoedema.
Cancer Research UK: Breast cancer follow-up.
Macmillan: Follow-up after breast cancer treatment.

Your body and breasts after treatment

Dealing with changes to your body

A diagnosis of breast cancer may change how you think about your body. All women react differently to the bodily changes that happen as a result of breast cancer treatment. Some women react positively, but others find it more difficult to cope. It's important to give yourself time to come to terms with any changes to your body.

Want to know more?

Breast Cancer Care: Coping emotionally.
Healthtalkonline: Body image.
Macmillan: Effects after breast cancer treatment.

Early menopause

Although most cases of breast cancer occur in women over 50 who gave experienced the menopause, some younger women have to cope with an early menopause brought on by cancer treatment.

Symptoms can include hot flushes, vaginal dryness and loss of sexual desire. Talk to your healthcare team about any symptoms you have and they'll be able to help.

Want to know more?

Breast Cancer Care: Early menopause and fertility.
Cancer Research UK: Breast cancer and menopausal symptoms.
Macmillan: Breast cancer treatment and menopausal symptoms.

Prosthesis

A breast prosthesis is an artificial breast, which can be worn inside your bra to replace the breast that's been removed.

Soon after a mastectomy, you'll be given a lightweight foam breast to wear until the area affected by surgery or radiotherapy has healed. After it's healed, you'll be offered a silicone prosthesis. Prostheses come in many different shapes and sizes, and you should be able to find one that suits you.

Want to know more?

Breast Cancer Care: Breast prostheses.
Cancer Research UK: After your breast cancer surgery: your false breast shape (prosthesis).

Reconstruction

If you didn't have immediate breast reconstruction (carried out at the time of a mastectomy), you can have reconstruction later. This is called a delayed reconstruction.

There are two main methods of breast reconstruction – reconstruction using your own tissue and reconstruction using an implant. The type that's most suitable for you will depend on many factors, including the treatment you've had, any ongoing treatment and the size of your breasts. Talk to your healthcare team about which reconstruction is suitable for you.

Want to know more?

Breakthrough Breast Cancer: Breast reconstruction and prosthesis.
Breast Cancer Care: Breast reconstruction.
Cancer Research UK: About breast reconstruction.
Live Well: "My mastectomy and reconstruction".
Live Well: Breast reconstruction.

Relationships and sex

Relationships with friends and family

It's not always easy to talk about cancer, either for you or your family and friends. You may sense that some people feel awkward around you or avoid you.

Being open about how you feel and what your family and friends can do to help may put them at ease. However, don't be afraid to tell them that you need some time to yourself, if that's what you need.

Want to know more?

Breast Cancer Care: Relationships.
Live Well: Talking to your kids about cancer.
Macmillan: Talking about your cancer.
Healthtalkonline: How breast cancer affects families.

Your sex life

Breast cancer and its treatment can affect your sex life. It's common for women to lose interest in sex after breast cancer treatment. Your treatment may leave you feeling very tired. You may feel shocked, confused or depressed about being diagnosed with cancer. You may be upset by the changes to your body or grieve the loss of your breasts or, in some cases, your fertility.

It's understandable that you may not feel like having sex while coping with all this. Try to share your feelings with your partner. If you have problems with sex that aren't getting better with time, you may want to speak to a counsellor or sex therapist.

Want to know more?

Breast Cancer Care: Sex and intimacy.
Cancer Research UK: Living with breast cancer surgery: sexuality after breast surgery.
Macmillan: Cancer and sexuality.

Money and financial support

If you have to reduce or stop work because of your cancer, you may find it difficult to cope financially.

If you have cancer or you're caring for someone with cancer, you may be entitled to financial support, for example:

if you have a job but can't work because of your illness, you're entitled to Statutory Sick Pay from your employer
if you don't have a job and can't work because of your illness, you may be entitled to Employment and Support Allowance
if you're caring for someone with cancer, you may be entitled to Carer’s Allowance
you may be eligible for other benefits if you have children living at home, or if you have a low household income

Find out what help is available to you as soon as possible. The social worker at your hospital will be able to give you the information you need.

Free prescriptions

People being treated for cancer are entitled to apply for an exemption certificate, giving them free prescriptions for all medication, including medicine for unrelated conditions.

The certificate is valid for five years, and you can apply for it through your GP or cancer specialist.

Want to know more?

Breast Cancer Care: Summary of benefits.
Breast Cancer Care: Finances and practicalities.
GOV.UK: Benefits and financial support.
Care and Support: Benefits for carers and benefits for the person you care for.
Find your nearest Citizens Advice Bureau.
Q&A: free prescriptions.

Talk to other people

Your GP or nurse may be able to answer any questions you have about your cancer or treatment. You may find it helpful to talk to a trained counsellor or psychologist, or to someone at a specialist helpline. Your GP surgery will have information on these.

Some people find it helpful to talk to other people who have breast cancer, either at a local support group or in an internet chatroom.

Want to know more?

Breast Cancer Care: Someone to talk to.
Breast Cancer Care: Community.
Breakthrough Breast Cancer: Join a Breakthrough group.
Macmillan: Online community.

Case Study 1 - 'I've had breast cancer twice'

Emma Duncan was diagnosed with breast cancer twice in four years, once in each breast.

Her first treatment was a lumpectomy with chemotherapy and radiotherapy. Her second treatment included a full mastectomy, removing both breasts, followed by reconstructive plastic surgery.

"I asked my GP if there was any screening programme they could put me into when I was 25, because my mother had died from breast cancer when she was 32. They referred me to the Royal Victoria Infirmary, and I used to come once a year just for a check-up.

"A few years later I was in the bath and I noticed a lump under my left armpit. I didn’t quite know what to make of it. I was quite worried at first. I went to see my GP the next day and he suspected that it might just be a cyst, as I was only 28 at the time. But because of my family history, he referred me to a specialist.

"At the hospital, I had an ultrasound, a mammogram and a needle biopsy. When I returned a week later for the results, they confirmed that I had breast cancer and that I would need to come in for lumpectomy surgery 10 days later.

"I had chemotherapy for six months after my first diagnosis, followed by five weeks of radiotherapy. It was really hard. All my hair fell out and it made me feel so ill.

"My husband Graham was great and tried to support me as best he could throughout it. My sister-in-law was never off the phone and my best friend Claire was lovely.

"My sister handled it in a very different way. She had watched my mum become very poorly, and then her older sister was diagnosed. She found it hard to deal with and she just couldn’t handle coming to see me. She later admitted being terrified that it might be her next.

"The second time I was diagnosed, I had a bigger operation – a double mastectomy. The decision to have a mastectomy was quite easy to make. For me, it was the only decision, having had cancer twice.

"The reality after the event was very different. With the reconstructive surgery as well, I knew it would be a long recovery, but I don’t think anything prepared me for just how long. I cried every single day because I was so uncomfortable.

"I was referred to a psychologist, who told me I wasn’t going mad. Anyone who'd been through what I had would be expected to have a few tearful days. Things settled down, then it was just a case of trying to get back to normal.

"Looking back at everything, I wouldn’t have changed my decision at all. It was definitely for the best.

"I now have check-ups every six months with my oncologist, breast surgeons and at the family clinic. I see my plastic surgeon, my geneticist, and have an ultrasound once a year, plus a blood test every four months as part of the ovarian screening programme. The Macmillan breast care nurses ring me up every once in a while to keep me up to date and to check that I’m all right. I’m very well looked after.

"Now I just want to stay cancer-free. I’ve done as much as I possibly can to prevent it from coming back or getting a new cancer. I didn’t quite make it after my first diagnosis, but I’d like to get through the next five years without the cancer returning.

"My advice to other women would be to speak to your breast care nurse or go on the Cancer Research UK or Breast Cancer Care websites. There are so many recognised sources of information. The internet is full of horror stories, so make sure you get as much information as you can from reputable sources."