Today, breast cancer is the most common cancer in American women, except for skin cancer. Yet breast cancer is not one disease. There are many different types based on where the tumor starts in the breast tissue and whether the cancer has spread or not. In situ breast cancer (where abnormal cells remain in the place where they first formed) starts in a milk duct and has not spread throughout the breast. Invasive breast cancer has spread into surrounding breast tissue. The most common forms of breast cancer are:
- Ductal Carcinoma in Situ (DCIS)
According to the American Cancer Society (ACS), one in five new breast cancers are "ductal carcinoma in situ" (DCIS), meaning the cells are cancerous but have not spread to surrounding tissue. DCIS is an early stage cancer that starts in a milk duct and is non-invasive. Nearly all women with DCIS can be cured with either breast-conserving surgery (removing the tumor and treating the breast with radiation) or a simple mastectomy (which involves removing the breast tissue with or without the nipple and areolar skin but not removing all the lymph nodes).
- Invasive Ductal Carcinoma (IDC)
In 2020, ACS estimates that more than 276,000 women will be diagnosed with breast cancer that has spread into the surrounding breast tissue (invasive) and possibly other parts of the body. Of these cancers, about eight in 10 are "invasive ductal carcinomas" (IDC). This type starts in the cells that line a milk duct in the breast. Over time, IDC can spread to the lymph nodes and possibly to other parts of the body.
- Invasive Lobular Carcinoma (ILC)
Accounting for 10 to 15 percent of breast cancer cases, "invasive lobular carcinoma" (ILC) is the second most common form of invasive breast cancer. ILC starts in the milk-producing glands (lobules) and can spread to other parts of the body.
Other types of breast cancer that are rare include inflammatory breast cancer (1- 5 percent of all breast cancers), Paget disease of the breast (1-3 percent of all breast cancers) and angiosarcomas (less than 1 percent of all breast cancers).
About 5 to 10 percent of breast cancer cases are considered "hereditary," meaning the cancer is the result of gene changes passed to the woman from a parent. Of these genes, two of the best known are the BRCA1 and BRCA2 genes. In normal circumstances, these genes help make proteins that repair damaged DNA. However, when a woman inherits a mutated copy of either gene, she has a higher risk of breast cancer and the risk goes up if more family members are affected. Another gene linked to the BRCA2 gene called PALB2 also increases breast cancer risk when a woman inherits a mutation of this gene.
While BRCA1, BRCA2 and PALB2 have received the most attention, other gene mutations also have been identified as leading to inherited breast cancers. This is why genetic testing is now available for almost 100 different genes through expanded panel testing, also called multi-gene testing.
According to guidelines from the
National Comprehensive Cancer Network (NCCN), genetic testing is recommended for women who have "an increased risk of inherited gene mutation related to breast cancer." This is defined as:
- Having a family member with a BRCA1/2 gene mutation or other high-risk gene mutation linked to breast cancer.
- Having a strong family history of breast cancer, especially if the family history also includes certain other cancers, such as ovarian and pancreatic cancer.
- Being of Ashkenazi Jewish heritage
The risk of inherited breast cancer is also increased if a family member has had breast cancer. Risk is affected by:
- The closeness of the family relationship (a mother or sister with breast cancer is more of a concern than a distant relative).
- The number of family members who were diagnosed with breast cancer.
- The age when the family members were diagnosed.
Genetic testing can help women with breast cancer make important decisions, such as whether to get a lumpectomy with radiation or bilateral mastectomy, and to guide those with metastatic breast cancer about treatment with targeted therapies. However, not every woman needs to be tested, and the pros and cons need to be considered carefully. For this reason, it is helpful to seek the advice of a genetic counselor or breast health specialist who can describe genetic testing to you and explain what the tests may be able to tell you. If you decide to get tested, the genetic counselor (or other health professional) can also help explain what the results mean, both for you and possibly other family members.
ER, PR, HER2 and TRIPLE NEGATIVE
Because breast cancer is not a one-size-fits-all disease, treatment depends on whether the tumor cells are fueled by estrogen and/or progesterone. Some breast cancer cells have proteins in or on cells called "hormone receptors" (HR) that attach to estrogen or progesterone, causing the cells to depend on these hormones for growth. HR-positive breast cancer cells need estrogen and/or progesterone to grow and can be treated with drugs that lower hormone levels or block the hormone receptors. HR-negative breast cancers do not have estrogen or progesterone receptors and will not benefit from hormone drug therapy. Therefore, HR-negative cancers typically grow faster than HR-positive tumors.
Breast cancers can be identified as:
- Estrogen Receptor Positive (ER+)
An estimated 80 percent of all breast cancers are estrogen-receptor positive (ER+) and need estrogen to grow.
- Progesterone Receptor Positive (PR+)
Of the breast cancers that are estrogen-receptor positive, about 65 percent are also PR-positive and grow in response to progesterone.
- Hormone Receptor Negative
Being "hormone-receptor negative" means the cancer cells do not have hormone receptors and will not be affected by treatments aimed at blocking estrogen or progesterone.
- HER2 Positive or Negative
In about 20 percent of breast cancers, the cells make too much of a protein known as HER2 (human epidermal growth factor receptor 2). These HER2-positive cancers tend to be fast-growing and aggressive and are treated with therapies that target the HER2 protein. Cancer cells that are HER2-negative have little or no HER2 protein and are less likely to spread to other parts of the body.
- Triple Negative Breast Cancer (TNBC)
Accounting for roughly 10 to 15 percent of all breast cancers, "triple negative breast cancer" refers to cancer cells that do not have estrogen or progesterone receptors and also do not make too much of the HER2 protein (the cells test negative in all three areas). More common in women younger than 40, African American women and women with a BRCA1 mutation, TNBC grows and spreads faster than other types of invasive breast cancer and has worse treatment outcomes.
Receptor type as
Human Epidermal Growth
Hormone receptor positive cancers
HER2 positive cancers
|+ or -||+ or -||+|
|Triple Negative cancers (TNBC)||-||-||-|
A treatment plan for breast cancer is determined by the surgeon or oncologist in partnership with a woman and her loved ones. Because surgery remains the primary treatment for breast cancer, one of the first decisions most women will make after a breast cancer diagnosis is the type of surgery to remove the cancer.
Here is a summary of the factors that go into a treatment decision and the different types of breast cancer surgery.
- The type of cancer
- The location of the tumor in the breast
- The size of the tumor
- Whether the cancer has spread
- How abnormal the cells look under a microscope (the grade)
- Whether the cancer has hormone receptors for targeted cancer drugs
- Whether you have gone through menopause
- Whether you have been previously treated for breast cancer
Based on these factors, your doctor will make recommendations about surgical options so you can make a decision that is best for you.
Surgical Options to Remove Breast Cancer
There are two main types of surgery to treat (remove) breast cancer:
Also known as "breast-conserving surgery," a lumpectomy involves the surgeon removing the part of the breast where the tumor is located and a border of healthy tissue around the cancer in order to get clean margins. The surgeon may also remove part of the chest wall lining if the cancer is near it or remove some lymph nodes under the arm for biopsy. If the biopsy indicates the margins also have cancer, a re-operation or mastectomy may be necessary. Lumpectomy may be a good choice if you have a non-invasive breast cancer or a less advanced stage of cancer. However, in most cases, women opting for a lumpectomy also have radiation therapy to the breast, and sometimes the underarm area.
- Oncoplastic Reduction Lumpectomy is a procedure where a larger amount of breast is removed during the lumpectomy, but the breast is re-shaped smaller. This procedure allows the woman to get a breast reduction and the benefit of a larger lumpectomy. After this surgery, women still need radiation therapy.
Mastectomy is an operation to remove the entire breast and is typically done if the woman has more advanced breast cancer, has small breasts but a big tumor in one of the breasts, or has a genetic mutation for inherited breast cancer. There are different types of mastectomy, including:
removal of the entire breast with the nipple and surrounding skin.
Some of the lymph nodes under the arm may also be removed. This can
be done with or without reconstruction at the time of surgery.
removal of the entire breast with the nipple and surround skin and
the lymph nodes under the arm. A reconstruction can be done at the
time of surgery.
is the removal of
the entire breast, the overlying skin, chest wall muscle, and the
lymph nodes under the arm. This procedure is rarely done any more.
removing the breast tissue and preserving the nipple and areola.
This is usually done with a reconstruction at the time of the
- Double mastectomy , also known as bilateral mastectomy, is the removal of both breasts. Typically, doctors only recommend a double mastectomy if there is cancer in both breasts or the woman carries the BRCA1 or BRCA2 gene or is at higher risk of developing breast cancer for any reason.
- Total (simple) mastectomy is the removal of the entire breast with the nipple and surrounding skin. Some of the lymph nodes under the arm may also be removed. This can be done with or without reconstruction at the time of surgery.
Making the Decision About Mastectomy
Of the estimated one in eight American women who will develop invasive breast cancer during her lifetime, more than 100,000 will undergo a mastectomy (surgery that removes the entire breast to treat or prevent breast cancer). Women who get a mastectomy have the option to restore one or both breasts to near normal shape, size and appearance through breast reconstruction surgery. Women undergoing a lumpectomy (the removal of the breast section that contains the tumor) also have the option of breast reconstruction.
For women who have a choice between a lumpectomy or mastectomy, there are no right or wrong answers. The chance of survival with lumpectomy plus radiation therapy is the same as with mastectomy and both procedures lower the risk of dying from breast cancer by the same amount. However, many women want to keep their breast if possible and opt for a lumpectomy with radiation.
At the same time, more than 100,000 women in the U.S. choose some form of mastectomy each year, especially younger women (less than 40 years) and those with larger and/or more aggressive tumors. One major reason women choose a mastectomy is to reduce their risk of the cancer coming back (recurrence) if the entire breast is removed. Other reasons for a mastectomy include not wanting to undergo radiation therapy or the opportunity to rebuild the shape and size of their breast through reconstruction, often at the time of mastectomy.
Because the decision is very personal, experts recommend discussing the options for mastectomy with your breast specialist based on your type of cancer, and getting a second opinion before making a final decision. It is also a good idea to discuss reconstructive surgery options with a breast surgeon and a plastic surgeon before undergoing a mastectomy so there is time to plan the timing of reconstruction and the steps involved in advance.
Paying for Screening and Testing
INSURANCE COVERAGE FOR BREAST CANCER SCREENINGS, PREVENTION SERVICES AND DIAGNOSTIC TESTS
Breast cancer screenings and diagnostic tests are expensive but there is good news: under the Affordable Care Act (ACA) and many state laws, private insurance plans as well as Medicare and Medicaid must cover the cost for breast cancer screenings, including genetic testing and preventive drug therapy. However, this is not the case for diagnostic tests, where insurers may require a co-pay and other fees. Here is an update.
No Cost Coverage for Screening and Prevention
Private health insurance companies base their coverage policies for breast cancer screenings and prevention services on guidelines from two authoritative bodies: the United States Prevention Services Task Force (USPSTF) – an independent panel of national experts in disease prevention – and the Health Resources and Services Administration (HRSA), a federal government agency that is part of the Department of Health and Human Services (HHS).
Under these guidelines, private insurance plans and state Medicaid programs must cover these breast cancer screenings and prevention services at no cost to women:
- Screening mammogram at least every two years and as often as every year for women ages 40 to 74 with average risk for breast cancer
- Genetic counseling and testing for mutation of the BRCA1 and BRCA2 genes in some women with a personal or family history breast, ovarian, fallopian tube, or peritoneal cancer
- Preventive drug therapy for women ages 35 and above with elevated risk of breast cancer
Coverage for Diagnostic Tests
When it comes to diagnostic tests for breast cancer, insurers can require a co-pay and other fees for diagnostic tests, depending on the health plan. This is why it is important to know the terms of your health insurance and to talk to your healthcare team. They usually know who can help you find answers to your questions about coverage for your diagnostic tests.
Additionally, the American Cancer Society recommends these outside resources if you need help managing the costs of your diagnostic tests and breast cancer treatment.
- Patient Access Network Foundation (PANF)
Toll-free number: 1-866-316-7263; www.panfoundation.org
Helps under-insured patients cover out-of-pocket costs
- Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274; www.patientadvocate.org
Works with the patient and their insurer to resolve insurance problems
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