HMC's Pink October is not about Barbie
October is Breast Cancer Awareness Month
Cathy, 40, went in for a screening mammogram. She had no symptoms, performed monthly breast checks, and no family history. The results of her routine mammography showed a suspicious but not large calcification, so it was recommended she come back in six months for a follow-up. At the follow-up screening, another calcification was detected. Cathy’s doctor told her a biopsy would be needed.
It’s the season for pink. Not for Barbie, but to mark the advent of October, which is Breast Cancer Awareness Month. Joan Lunden, Olivia Newton-John, Jane Fonda, Robin Roberts, and Angelina Jolie are just a few celebrities who have had breast cancer. But what is breast cancer? How does it become cancer and how is it detected? What happens if you are diagnosed with breast cancer? Let’s answer these questions so we can understand how important breast cancer awareness is.
The breast is made up three main parts: lobules, ducts, and connective tissue. What is breast cancer?There are different kinds of breast cancer depending on which cells turn into cancer. The most common kinds of breast cancer are invasive ductal carcinoma and invasive lobular carcinoma. When breast cancer spreads to other parts of the body (via blood vessels and lymph nodes), it has metastasized. This is how breast cancer is staged.
Cathy had a mammography-guided biopsy, which revealed ductal carcinoma in situ, or DCIS. DCIS is considered stage 0 pre-invasive breast cancer and is a precursor to invasive ductal carcinoma.
Ductal carcinoma in situ (DCIS) is when the cancer cells are only in the lining of the ducts and have not spread to other tissues. The primary concern with DCIS is that it may lead to invasive breast cancer. Any type of cancer is essentially uncontrolled cell growth. The development of breast cancer is characterized by genetic mutations that can occur spontaneously or be inherited, as in the case of BRCA genes. Breast cancer progression is divided into stages, with Stage 0 being non-invasive to Stage IV considered an advanced stage and spread to other organs. Breast cancer is also classified by the presence or absence of certain hormones, which include hormone receptor-positive (HR+), HER2-positive, and triple-negative. Knowing what hormones are involved and what stage the cancer is can guide treatment.
Breast cancer is the most common cancer among women worldwide. While it can also affect men, the incidence is much lower in males. The exact cause of breast cancer remains complex and multifactorial, but several risk factors have been identified:
Gender: Being female is the most significant risk factor for breast cancer. Women are nearly 100 times more likely to develop breast cancer than men.
Age: Most breast cancer cases are diagnosed in women over the age of 50, with the average age of diagnosis at 62. As a woman ages, the risk of breast cancer increases.
Family history/genetics: A family history of breast cancer, particularly in first-degree relatives such as mother, daughter, or sister, increases the risk. Inherited mutations in genes such as BRCA1 and BRCA2 are associated with a higher risk of breast cancer.
Hormonal factors: Exposure to the hormones estrogen and progesterone over an extended time as in during menopause, early menstruation, or hormone replacement therapy can increase risk. Certain birth control pills have also been found to raise breast cancer risk.
Reproductive factors: Women who have never had children, had their first child after the age of 30, did not breastfeed, started their period before the age of 12 or experienced menopause after the age of 55, or never had a full-term pregnancy have a slightly higher risk.
Exposure to certain carcinogens: High doses of ionizing radiation, such as radiation therapy for other cancers, as well as exposure to the drug diethylstilbestrol (DES) can increase the risk of breast cancer.
Breast density: Women with denser breast tissue may have an increased risk. Having dense breast tissue also makes it more difficult to see abnormalities on a mammogram.
Lifestyle factors: Obesity, excessive alcohol consumption, smoking, lack of physical activity, and diet (although this is still under investigation) are associated with an increase of breast cancer.
Personal history: Women who’ve had breast cancer before are more likely to get breast cancer a second time; similarly, being diagnosed with certain non-cancerous breast diseases such as atypical ductal hyperplasia or lobular carcinoma in situ are associated with a higher risk of getting breast cancer.
Cathy didn’t have any obvious risk factors. In fact, she was a young, physically fit non-smoker with two small children. She also did not have a family history of breast cancer. Cathy’s doctor ordered additional testing for the high-risk BRCA genes and an MRI to look for other tumors in both breasts and to determine the exact size and location of her cancer.
In 2023 in the U.S., the American Cancer Society estimates there will be nearly 298,000 new cases of invasive breast cancer diagnosed in women and about 2,100 in men. And although mortality from breast cancer has declined over time, it is still the leading cause of cancer death among women overall with about 43,700 women dying each year in the United States (and about 500 men). The fact is that screening and treatments for breast cancer have improved dramatically – to the point where the overall survival rate for any stage of breast cancer is 91%.
The treatment of breast cancer depends on various factors, including the type and stage of the cancer, as well as the patient’s overall health. Common treatment options include surgery, radiation therapy, chemotherapy, hormone and targeted hormone therapy, immunotherapy, and clinical trials using experimental treatments.
Cathy talked to two different breast surgeons about her treatment options: a lumpectomy with tamoxifen (a common hormone blocker therapy that can lower the risk of another DCIS) for five years, a lumpectomy with radiation, or a bilateral mastectomy with reconstruction. Although a lumpectomy is breast sparing, there is still the possibility of the cancer returning. She learned that tamoxifen causes changes in the menstrual cycle, essentially leading to menopause, and as for radiation therapy, a person can only have so much radiation to their body in a lifetime so if she ever contracted any other cancer, radiation might not be an option for that cancer if it’s been exhausted earlier.
Cathy decided she wasn’t ready for menopause at 40 years old. She chose bilateral mastectomy with reconstruction. A mastectomy is the removal of the entire breast. “Radiation and chemo change your body. I figured all my breast tissue had been exposed to the same things for 40 years, so I didn’t want to be looking over my shoulder forever wondering if it would come back and be harder to treat. Surgery is not a whole lot of fun, but at least it’s over when it’s over.”
Cathy was lucky in that her cancer was detected early when it was a noninvasive type and before it could metastasize anywhere else. She’s also a perfect example of how any woman at any age can develop breast cancer. Early detection is crucial for improving the prognosis of breast cancer. Women are encouraged to perform regular breast self-exams to check for any lumps, changes in size or shape, unusual tenderness or leakage, or other abnormalities. Another prevention strategy for early detection is to get screened regularly – by a healthcare professional doing a clinical breast exam and an annual mammogram. Mammography is a low-dose x-ray screening recommended for women to detect breast cancer at an early stage. The American Cancer Society recommends women with an average risk of breast cancer between the ages of 45 and 54 get mammograms every year. Prior to age 45, a woman has the option to begin annual mammograms, and many healthcare providers recommend getting a baseline mammogram by age 40. Check with your medical insurance provider to see what is covered. Women older than 55 can opt for a mammogram every other year, as long as they are in good health and expected to live more than 10 years.
Cathy does not require any future mammograms since her breast tissue was removed. She will follow-up with her breast surgeon for the next 10 years. Cathy’s sisters are strongly urged to get annual mammograms and a breast ultrasound every year. And Cathy’s daughter will need to begin getting mammograms 10 years prior to Cathy’s age of diagnosis (so at 30 years old). Her daughter’s doctor may recommend a breast MRI, but she will not need genetic testing because of Cathy’s negative hormone status.
While breast cancer cannot always be prevented, advances in early detection, personalized treatment, and prevention strategies offer hope for improved outcomes. Significant progress has been made in recent decades, but continued research, education, and awareness are vital in the fight against breast cancer. Breast Cancer Awareness Month and the pink ribbon is a great reminder for women to get an annual mammogram and continue their monthly breast self-exams.
Cathy’s final thoughts on her experience? “Catch it early so treatment can be initiated. Talk to women who have been through breast cancer treatment before your treatment, as they will have tips and tricks you would have never thought of. And finally, in the time you have between diagnosis and treatment, find support and prepare for what to expect.”
For more information about breast cancer and its treatment, here are some helpful resources:
 American Cancer Society. “What Is Breast Cancer?” Available at: https://www.cancer.org/cancer/types/breast-cancer/about/what-is-breast-cancer.html.  Centers for Disease Control and Prevention, Division of Cancer Prevention and Control. “Basic Information about Breast Cancer”, available at https://www.cdc.gov/cancer/breast/basic_info/index.htm. Reviewed July 25, 2023.  American Cancer Society. Survival Rates for Breast Cancer. Cancer Facts & Figures 2023. Atlanta, Ga; 2023. Available at: https://www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-survival-rates.html.  Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from The American Cancer Society. JAMA. 2015; 314 (15): 1599-1614. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831582/.