Breast cancer remains the disease most feared by women, no matter their race, ethnicity, or age. Hardly a week goes by without someone learning that a friend, neighbor, or colleague has been diagnosed with breast cancer.
And yet, all women who are diagnosed don't get the same treatment. Why not?
One reason for this is that treatment depends a lot on what type of breast cancer it is. Treatment also depends on the stage of the breast cancer in question--how far along it is, how it has spread, and how large it is in the breast. Finally, treatment will depend on the way that a particular kind of breast cancer is known to behave over time--that is, its predictive or prognostic factors.
Let's first look at the different types of breast cancer and their nuances.
Invasive-ductal carcinoma or infiltrating-ductal carcinoma
The most common form of breast cancer is called invasive-ductal or infiltrating-ductal carcinoma, which on average makes up 80 percent of all invasive forms of breast cancer. This form of breast cancer begins inside a single duct of the breast (ducts carry the milk from the lobule--where the milk is actually made--to the nipple) but in time it manages to bore a hole through the wall of the duct; from there, it finds its way into the fatty tissue of the breast. Think of the duct as a water pipe that has rusted through and sprung a leak--although, thank heavens, breast cancer doesn't pour out of the duct like water would!
Invasive-lobular breast carcinoma, or infiltrating-lobular carcinoma
The second most common type of breast cancer, a type that accounts for about 15 percent of them, is known as invasive-lobular or infiltrating-lobular carcinoma. Invasive-lobular disease begins in the lobules, where the milk is made. Invasive-lobular disease, although it can be less aggressive than some forms of the invasive-ductal type, can deceive. Its untrustworthiness stems from the fact that the image of an invasive-lobular carcinoma seen in a mammogram often looks smaller than the tumor really is. This is because the invasive-lobular type grows into a star shape, a star with points that are of different lengths--and these points do not always show up clearly on breast-imaging studies. Ductal carcinoma, on the other hand, usually grows more evenly, so that its true size can be assessed pretty accurately by a mammogram or other breast-imaging technology.
A few other kinds of breast cancer
So, let's see: If invasive-ductal carcinomas account for 80 percent of invasive breast cancers, and invasive-lobular carcinomas for 15 percent, that only equals 95 percent. What makes up the other 5 percent of invasive tumors? There are some rarer ones, such as the phyllodes tumors and metaplastic tumors, which I won't discuss in detail here. But then there's one more that you should be particularly aware of, one with a misleadingly innocent-sounding name: inflammatory breast cancer.
Inflammatory breast cancer
Inflammatory breast cancer is extremely sneaky. First of all, it doesn't present as a lump and it usually doesn't even show up on breast-imaging studies. It in fact begins inside the tiny lymphatic vessels within the skin of the breast, and so it presents as a rash on the breast, a rash that's commonly accompanied by swelling and a sensation of heat.
This characteristic "skin trouble," however, means that inflammatory breast cancer is commonly misdiagnosed as mastitis or dermatitis. A round of antibiotic therapy is usually tried first, but if there's no response after 5 days, then mastitis is unlikely. (In fact, mastitis is unlikely in any woman who is not breastfeeding.) A definite diagnosis is done by taking a biopsy of the skin of the breast. The pathology report will describe "the presence of breast-cancer cells in the dermal lymphatic channels."
Why am I emphasizing inflammatory breast cancer so much? First, because it is the most commonly misdiagnosed type of breast cancer, and second, it is the most aggressive type of all.
At its onset, inflammatory breast cancer is from the very first classified as stage-III breast cancer, despite there being no large mass inside the breast. Treatment always starts with chemo, then goes on to mastectomy (never lumpectomy). And when the mastectomy is done, none of the skin of the breast is ever saved. Reconstruction also must be done later, well after chest-wall radiation is completed.
Ductal carcinoma in situ
One other type of breast cancer is worth mentioning, and it's one that is being diagnosed more and more: ductal carcinoma in situ (DCIS). DCIS is becoming more common now because, as more women become aware of the value of mammography, more of them are going for their annual screening studies--and ductal carcinoma in situ can only be found by using mammography.
DCIS is the earliest form of breast cancer; that is, it is noninvasive and is also known as stage-0 breast cancer. This type is very difficult to detect because it is inside the duct and cannot get out to travel to a node or anywhere else. Usually, lumpectomy with radiation is enough to vanquish DCIS, but in some cases there may be a lot of it, which might require that the surgeon do a mastectomy with reconstruction. No matter how much DCIS is present, however, it remains as a stage-0 breast cancer, which is good news.
So now you see how different breast cancers can be from each other. In a future blog, I'll talk about the stages of breast cancer and how a tumor is matched with its treatment.
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