The breast cancer guide every woman should read

One in seven women will develop breast cancer in their lifetime, but the earlier it’s caught the more likely it can be treated

The figures for breast cancer in the UK make for sober reading. There are around 55,900 new cases diagnosed in the UK every year – that’s more than 150 every day. One in seven women will develop breast cancer in their lifetime and, according to Cancer Research UK, breast cancer is the most common cancer in Britain, accounting for 15 per cent of all new cases.
But there is hope, as the earlier the signs are detected, the more likely the cancer can be caught and treated.
“It’s vital to be aware of unusual signs and symptoms, because around two thirds of breast cancers are found by women noticing breast changes and getting these checked out by their GP,” says Dr Stephen John Sammut, a clinician scientist at the Institute of Cancer Research in London. “Being breast aware means getting to know what your breasts look and feel like normally for you. The earlier breast cancer is detected, the higher the chances that the treatment will be successful.”
And although lumps are the dominant symptom of breast cancer, “we can get completely focussed on them,” says Zoe Winters, a consultant oncoplastic breast surgeon and professor of breast surgery at University College London. “They are far from the only sign.”
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Simply put, breast cancer is “where you get abnormal breast cells growing out of control, which form tumours that we call cancer,” says Dany Bell, a strategic adviser on treatment, medicines and genomics for Macmillan’s Centre of Clinical Expertise.
“That usually manifests as a lump,” she says, “but there are other signs and symptoms that you might see – such as skin puckering, nipple inversion or a rash.” 
Where lumps occur, “some people have lumps that can’t be felt because they’re deep inside the breast tissue, and are found for the first time in routine mammograms.” 
The major signs of breast cancer can include the following: 
See our expert guide for more detail on how to spot the signs and symptoms
There is no one cause of breast cancer, but scientists have identified factors that may put women at greater risk of developing it. These include:
“Around 80 per cent of breast cancers occur in women over the age of 50 and one in four cases are diagnosed in women aged 75 and over,” says Dr Samut. Only 5 per cent of breast cancers occur in women under 40. 
Some women may also be at an increased risk because of their genetics, “While most breast cancers aren’t inherited, a small number of people have an increased risk of developing breast cancer because they have a significant family history,” says Louise Grimsdell, clinical nurse specialist at Breast Cancer Now.  
“Someone may be more likely to have a significant family history if one first degree relative, for example their mother or father, has had breast cancer before the age of 40, or if one relative has had breast cancer in both breasts.”
One well-known genetic factor in breast cancer is the BRCA gene, which can be passed down by either parent “and may be given to 50 per cent of any children that they have”, says Bell. 
Lifestyle factors also play a large role in the chances that someone may develop breast cancer. Being overweight, drinking alcohol and smoking are all habits that increase your risk of developing breast cancer. 
According to Breast Cancer Now, obesity causes an extra two or three women in every hundred to develop breast cancer after turning 50, and compared with women who don’t drink at all, those who have just three alcoholic drinks per week have a 15 per cent higher chance of developing breast cancer. 
There are other risk factors linked to breast cancer development that are less clear. “Taking the contraceptive pill or hormone replacement therapy (HRT) during the menopause are thought to increase risk,” says Bell, “as can going through the menopause early or having your first period before you turn 12”.
One 2017 study found that women who have taken contraceptive pills containing oestrogen have a 20 per cent higher risk of developing breast cancer than those who have never taken it, with the risk tied to how long they have been taking it for. 
The same study suggested that progesterone-only pills (or “mini-pills”) do not pose the same risk, however, and studies from Cancer Research UK have shown that any increased risk disappears after 10 years from when a woman has last taken the pill.
Nearly half of women – 40 per cent – have dense breasts that double their breast cancer risk, while 10 per cent have extremely dense breasts that raise the risk between four and sixfold. 
Density refers to the amount of glands and fibrous breast duct tissue a woman has, compared to the fat in her breasts. They are usually an inherited trait. 
Prof Winter says that having “dense breasts” can raise the risk of developing breast cancer significantly. This is because they have more cells that can become cancerous. 
Dense breasts can only be seen on a mammogram, says Prof Winter. They cannot be felt and have nothing to do with breast size. Women are not told their density score after NHS mammograms, which Prof Winter says is wrong. “Every woman should understand their density score.” 
As you get older, the amount of glandular tissue in your breasts decreases and is replaced by fat, so your breasts become less dense.
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Most breast cancers are diagnosed either following a woman’s self-check (followed up by a visit to a GP) or a routine mammogram. In both cases, you will be referred to a specialist breast clinic.
Lumps might also be found accidentally, as you are putting on clothes or looking in the mirror. “A person or their partner might feel a lump,” says Bell, “after which your first port of call should be to see your GP.”
If cancer is suspected, your GP will fast track you for an appointment with a breast clinic, where a small sample of the lump (known as a biopsy) is removed for testing. You will then be able to return to the clinic in a week’s time for the results. 
If a potential cancer is identified in a mammogram rather than through a self-check, you will likely also be referred on for a biopsy.
Mammograms take place every three years after a woman turns 50, until she turns 71, though “people who have a genetic risk might be screened earlier,” Bell says. 
If you are eligible for mammograms you will receive a letter inviting you as long as you are registered with a GP. Around one in four women are asked to come back after a mammogram for more tests, and of those, one will be found to have cancer. 
The treatment options for breast cancer depend on the stage the cancer has developed to. The treatment options include:
Primary breast cancer, where the cancer is contained to one or both breasts and has not spread to other parts of the body, “is treated with a combination of surgery and other options,” says Grimsdell.  
The full range of treatments could include “a lumpectomy, mastectomy, chemotherapy, radiotherapy, hormone therapy and targeted therapies, depending on the type of breast cancer you have and a number of other factors,” she explains. 
A lumpectomy removes the tumour and any abnormal tissue from the breast, while a mastectomy removes the breast itself. 
Stage one, two or three breast cancer – which spans cancers that are very small, as well as cancers that have spread into the lymph nodes or chest muscles – “will be treated with a combination of surgery and then chemotherapy and radiotherapy, or one of the two,” Bell says. 
This is often followed up with hormone therapy, to stop or slow the growth of the cancer, which involves lowering the amount of hormones including oestrogen and progesterone in the body or blocking them from getting to the cancer cells. 
Chemotherapy and radiotherapy are then used to kill any remaining cancer cells. However, not all women will need to have either.
“We now have tests where we can look at a woman’s risk of recurrence,” says Bell. 
“If someone has, say, a 10 per cent chance that their cancer comes back after surgery, and they really don’t want to go through chemotherapy, we can give them this information and let them make an informed decision,” she explains. 
Another newer option is targeted immunotherapy, which supports the body’s immune system to attack cancer cells. This is another treatment that is offered after surgery to prevent the cancer from coming back.
“Breast cancer results from a combination of the way we live our lives, our genes and our environment,” says Dr Sammut. “Unfortunately, we cannot predict who will get breast cancer. However, there are some lifestyle factors that may affect your risk.” 
These measures include:
Dr Sammut  says: “There is growing evidence that smoking slightly increases the risk of breast cancer and the younger a woman is when she begins smoking, the higher her risk. The increased risk remains for at least 20 years after stopping smoking.” 
Compared to women who don’t drink at all, women who have three alcoholic drinks per week have a 15 per cent higher risk of breast cancer.
Studies show that women who take regular exercise are up to 20 per cent less likely to develop breast cancer. 
This benefit is seen most clearly in postmenopausal women. Even brisk walking can cut breast cancer risk, but former breast cancer surgeon Liz O’Riordan, who is now a cancer patient advocate and educator, says: “Aim to get at least 30 minutes of aerobic exercise, three times a week, and two 30-minute sessions of strength or resistance training a week.” 
This can be done at the gym using weights machines or at home, or by doing Pilates or any training that involves body-weight exercises such as planks and push-ups. 
Prof Winters says that the breast cancer risk from “old style combination synthetic” HRT for menopausal women equates to “an extra nine to 34 cancers per 10,000 women”. 
But, she says, “with modern lower-dose HRT, the risks are probably lower now.” She says the safest way to take HRT is oestrogen alone via patches and gels, “as this doesn’t increase breast cancer risk”, but that’s only for women who have had a hysterectomy. 
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If you have a uterus, you need to take progesterone, “which does increase risk”, to protect against womb cancer. For these women, Prof Winters suggests taking transdermal HRT via patches or gels, plus micronised progesterone in a tablet (Utrogestan) or a Mirena coil. 
Some women with a very high genetic risk might opt for preventative surgery, to lower their risk as they age. “But this is quite a big life-changing decision,” Bell says. “There are drugs that can lower breast cancer risk for women with a family history of breast cancer, particularly after menopause, which they are now eligible to take on the NHS from when they turn 60. The process is sometimes called chemo prevention.” 
What should I do if there is breast cancer in my family?
“If you have breast cancer in your family, talk to your GP so you can discuss testing to see if you are carrying the BRCA gene,” Bell says. A GP may then refer you to a genetic counsellor. 
This may be a good course of action “if you have a first relative, like a mother or sister, with breast cancer, and especially if you have more than one.” 
When should you see a doctor? 
It’s important to see a doctor after noticing any changes in your breast tissue, so that you can be referred for further scans and tests.
“If you have a lump, then see your doctor as soon as possible,” Bell says. “Don’t think on it.”
In the UK, the Faster Diagnosis Standard ensures that people who may have cancer are either diagnosed or told that they are in the clear within 28 days of a GP referral. 
What is secondary breast cancer?
“Secondary breast cancer, also called metastatic or stage 4 breast cancer, occurs when breast cancer cells spread from the breast to other parts of the body,” says Grimsdell. “It is treatable but not currently curable.”
Secondary breast cancer is often seen in the chest bones or lungs. The main treatments for secondary breast cancer include surgery and chemotherapy. 
Between 6-7 per cent of people with secondary breast cancer find out that they have it at their first breast cancer diagnosis, and around 30 per cent of women with breast cancer will develop it. It is the main cause of all breast cancer-related deaths.
What is inflammatory breast cancer?
Inflammatory breast cancer is a rare form of breast cancer that “resembles skin inflammation,” Bell says. It is sometimes confused with mastitis and shares many symptoms, such as hotness, swelling and rashes. 
It is rare and aggressive, accounting for one to five per cent of breast cancer diagnoses. Other symptoms include nipple inversion and pitting in the skin.
“It’s hard to diagnose, because a lot of women will put it down to their hormones,” Bell says. 
What percentage of breast biopsies are cancerous?
“Many women are referred for testing, and about 20 per cent of women who have breast biopsies are diagnosed with cancer,” Bell says.
Fast-track testing means that many women with lumps are quickly given the all-clear.
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