Cancer is caused when the cells in a certain area of your body divide and multiply too rapidly. It is not fully understood why breast cancer occurs, but research into the causes of breast cancer is continuing.

So far, several likely causes have been identified,. The factors that increase your risk of developing the condition have also been identified. The various causes and risk factors are outlined below.

Age

Your risk of developing breast cancer increases as you get older. Breast cancer is most common among women over the age of 50 who have been through the menopause.

All women between the ages of 50 and 70 are entitled to be screened for breast cancer every three years as part of the NHS Breast Screening Programme. See Prevention, above, for more information about breast cancer screening.

Family history

Most breast cancer cases are not hereditary (run in families), although having a close relative with breast cancer can increase your chances of developing it. Particular genes, known as BRCA1 and BRCA2, can increase your risk of developing both breast and ovarian cancer, and these genes can be inherited. There is also a third gene associated with an increased risk of breast cancer, called TP53.

You have a higher than average risk of developing breast cancer if you have close relatives who have had breast or ovarian cancer. However, as breast cancer is the most common form of cancer in women, it can also occur more than once in the same family by chance.

If two or more close relatives from the same side of your family, such as your mother, sister or daughter, have had breast cancer, you may be eligible to be screened for breast cancer or for the genes that may make developing it more likely. See Prevention, above, for more information about breast screening.

Previous diagnosis of breast cancer

If you have had breast cancer before, you have a higher risk of developing it in your other breast. You should be closely monitored by your treatment team, such as your oncologist (specialist in cancer) and your breast nurse, so that any recurring cancer can be detected as soon as possible.

Previous benign breast lump

While having a benign breast lump does not mean that you have breast cancer, it can slightly increase your risk of developing it. Certain changes in your breast tissue, such as atypical hyperplasia (cells growing abnormally) or lobular carcinoma in situ (benign cell changes inside your breast lobes), can also make getting breast cancer more likely.

Research shows that having atypical hyperplasia can make you two to five times more likely to develop breast cancer. If you have atypical hyperplasia or lobular carcinoma in situ, your GP should monitor the health of your breasts with regular check-ups.

Always see your GP if you notice any lumps or changes in the appearance of your breasts.

Breast density

Your breasts are made up of thousands of tiny glands, or lobules, which produce milk, as well as fat and connective tissue. The glandular tissue contains a higher concentration of breast cells than the fat or connective tissue, making it denser. Therefore, having dense breast tissue can increase your risk of developing breast cancer because there are more cells that can become cancerous.

Dense breast tissue can also make a breast scan (mammogram) harder to read because it makes any lumps or areas of abnormal tissue harder to spot.

Despite the fact that breast cancer risk increases with age, 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, and your breasts become less dense.

Exposure to oestrogen

In some cases, breast cancer cells can be stimulated by the female hormone oestrogen. Your 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 that your body is exposed to. For example, if you started your periods at a young age and entered menopause at a late age, you will have been exposed to oestrogen over a longer period of time. Similarly, 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 have been through 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, as being overweight or obese causes more oestrogen to be produced.

You can find out if you are overweight or obese by using the Healthy weight calculator.

Being tall

If you are taller than average, you are more likely to develop breast cancer than women who are shorter than average. The reason for this is not fully understood, although it may be because taller women tend to have more breast tissue than women who are of average or smaller height.

Alcohol

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

Radiation

Certain medical procedures which use radiation, such as X-rays and CT scans, may slightly increase your risk of developing breast cancer. However, the amount of radiation that is used during these procedures is always the lowest possible and they are only carried out when medically necessary.

If you had radiotherapy for Hodgkin's 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 were not contacted or you did not attend a consultation. If you currently need radiotherapy for Hodgkin's lymphoma, your specialist should discuss the risk of breast cancer before your treatment begins.

Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT) can cause 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.

The research behind this is still in its early stages, but it is estimated that there will be an extra 19 cases of breast cancer for every 1,000 women who are 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.

See your GP if you notice a lump in your breast or any change in the appearance, feel or shape of your breasts. Your GP will examine your breasts and, if they think you may have breast cancer, they will refer you to a specialist breast clinic for tests.

At the breast clinic, a specialist or breast nurse will carry out tests to determine whether or not you have breast cancer. If you have breast cancer, the tests will also show what type of breast cancer you have. Your specialist or nurse will determine the best way to treat you. They may take photographs of your breasts to keep a record of their current appearance and any further changes which may occur.

If you are diagnosed with breast cancer, the tests can also identify the stage and grade of the cancer, which your oncologist (specialist in cancer) will discuss with you thoroughly. The stage describes how far the cancer has spread at the time of diagnosis and the grade indicates how aggressively it is spreading.

Determining the stage and grade of your breast cancer will help your doctors to decide on the best treatment. However, the stage and grade alone cannot predict how your condition will progress, which also depends on factors such as the type of breast cancer and your overall health.

The tests you may have to diagnose breast cancer and those which determine specific types of treatment are outlined below.

Blood test

A sample of your blood will be taken so that your doctor can assess your overall health, as well as how well your liver and kidneys are working.

Mammogram

A mammogram is a simple procedure that uses X-rays to create an image of the inside of your breasts. It can identify early changes in your breast tissue, when it may be difficult to feel a lump. Younger women usually have denser breasts in which changes are more difficult to identify, so a mammogram is not as effective in women under 35. In this case, your doctor may suggest that you have a breast ultrasound instead.

If you need to have a mammogram, your radiographer (X-ray specialist) will position one of your breasts on a flat X-ray plate. A second X-ray plate will press down on your breast from above, so that it is temporarily compressed and flattened between the two plates. An X-ray will then be taken, which will give the clearest possible image of the inside of your breast. The procedure will then be carried out on your other breast.

You may find it a bit uncomfortable or even a little painful, but it only takes a few minutes. Your doctor will examine the mammography for indications of cancer, such as calcification (areas of calcium within your breast tissue that show up on the X-ray). If you have calcification, it does not mean that you have cancer. You will need further tests to confirm a diagnosis.

Breast ultrasound

You may need to have a breast ultrasound if you are under 35 because your breasts may be too dense for a mammogram. Your doctor may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid or contains liquid.

Ultrasound uses high-frequency soundwaves to produce an image of the inside of your breasts (in the same way that ultrasound can show an unborn baby in the womb). An ultrasound probe, or sensor, will be placed over your breasts to create an image on a screen. The image produced will show any lumps or abnormalities that may be present in your breasts.

Biopsy

A biopsy involves taking a sample of tissue cells from your breast and testing it to see if they are cancerous. Biopsies can be taken in different ways and the type you have will depend on what your doctor knows about your condition so far. The different methods of performing a biopsy are outlined below.

• Needle aspiration. This type of biopsy may be used to test a sample of your breast cells for cancer or to drain a benign cyst (small fluid-filled lump). Your doctor will use a small needle to extract a sample of cells without removing any tissue.
• Needle biopsy. This is the most common type of biopsy. A sample of tissue is taken from a lump in your breast using a large needle. You will have a local anaesthetic, which means that you will be awake but your breast will be numb. Your doctor may suggest a needle biopsy if they need to know whether the cancer has spread, as it allows them to examine the cells in place within the piece of breast tissue that has been removed.
• Surgical or excision biopsy. This type of biopsy is carried out under general anaesthetic, which means that you will be asleep during the procedure. Your doctor will surgically remove all or part of a lump from your breast to test it for cancer.

CT scan or MRI scan

CT and MRI scans produce detailed pictures of the inside of your body. If necessary, they can be used to highlight the areas in your body where cancer has spread. They can also show in detail the exact size and shape of a lump inside your breast.

A CT scan uses a series of X-rays to form a three-dimensional image. An MRI scan uses a strong magnetic field and radiowaves, and your doctor may suggest it if your mammogram or breast ultrasound do not show a lump in your breast in enough detail.

Chest X-ray

You may need a chest X-ray if your doctor thinks your breast cancer may have spread to your lungs.

Bone scan

You may need a bone scan if your doctor thinks the cancer may have spread to your bones. Before 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 has 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.

The radioactive substance will disappear from your body after a few hours and will not make you radioactive. The amount of radiation used is very small and has no harmful effects. However, as with any form of radiation, there is a small risk of it affecting an unborn child, so avoid contact with pregnant women for the rest of the day if possible.

Tests to determine specific types of treatment

If you are diagnosed with breast cancer, you will need to have further tests which can show whether or not the cancer will respond to specific types of treatment. The results of your tests can give your doctors a more complete picture of the type of cancer that you have and how best to treat you.

Hormone receptor test

In some cases, breast cancer cells are 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 lowering their levels in your body. This is known as hormone therapy.

A sample of cancer cells will be taken from your breast and tested to see if they respond to either oestrogen or progesterone. The cancer cells are said to respond if they have areas that let either hormone attach itself to them. These are known as hormone receptors.

If you have cancer cells that respond to oestrogen, the type of breast cancer that you have is said to be oestrogen-receptor positive. If the cancer cells respond to progesterone, the cancer is progesterone-receptor positive. Hormone therapy is most effective on cancers that are oestrogen-receptor positive, but this is only one of the ways that breast cancer can be treated.

HER2 test

While some types of breast cancer are stimulated to grow by hormones, other types are stimulated by a protein called HER2. These types of cancer may be treated by blocking the effects of HER2. This is known as biological therapy.

If the test shows that the cancer cells in your breast respond to HER2, it means that they have HER2 receptors (areas that let HER2 attach itself to them). This type of cancer is said to be HER2 positive.

Biological therapy can be used on breast cancers that are HER2 positive but, as with hormone therapy, biological therapy is only one of the ways in which breast cancer can be treated.

In the UK, breast cancer is the most common type of cancer among women. More than 45,500 cases of breast cancer are diagnosed every year, usually in women over 50 who have reached menopause. However, it is possible for women of any age to get breast cancer and, in rare cases, the condition can affect men.

Anatomy of the breast

A woman's breasts are made up of fat, connective tissue and thousands of tiny glands (known as lobules), which produce milk. If a woman has a baby, the milk is delivered to the nipple through tiny tubes called ducts, which allow her to breastfeed. Breast cancer usually shows as a lump or thickening in the breast tissue, although most breast lumps are not cancerous.

Types of breast cancer

There are several different types of breast cancer, which can develop in different parts of the breast. The most common is known as ductal breast cancer, which develops in the cells that line the breast ducts. Ductal breast cancer accounts for about 80% of all cases of breast cancer.

Other less common types of breast cancer include lobular breast cancer, which develops in the cells that line the milk-producing lobules, inflammatory breast cancer and Paget's disease of the breast. Breast cancer can spread to other parts of the body, such as the liver, bones or lymph nodes (small glands that remove bacteria from the body).

Breast screening

The exact cause of breast cancer is not fully understood, but many factors increase the likelihood of developing it, including age and family history of breast cancer.

Women who have 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 between the ages of 50 and 70 are entitled to be screened once every three years as part of the NHS Breast Screening Programme.

Breast cancer can be treated using a combination of surgery, chemotherapy and radiotherapy. Some cases of breast cancer may also be treated using biological or hormone treatments.

One in nine women are affected by breast cancer during their lifetime. There is a good chance of recovery if it is detected in its early stages. For this reason, it is vital that women check their breasts regularly for any changes and always get any changes examined by their GP.

Online Personal Education and Risk Assessment (OPERA)

If you are concerned about your risk of developing inherited breast cancer, you can use Macmillan's online interactive assessment tool which is called OPERA.

The tool is based on the National Institute for Health and Clinical Excellence (NICE) guideline for the classification and care of women at risk of familial breast cancer. It is designed to be used by patients and health professionals to assess a person's risk of developing the condition based on their family history of both breast cancer and ovarian cancer. This is because the genes that are mainly responsible for breast cancer are also linked to ovarian cancer.

The causes of breast cancer are not fully understood. Therefore, it is not possible to know if anything can prevent it altogether. A number of factors have been identified that may make the chances of developing breast cancer less likely.

There are also methods of screening for breast cancer. All women between the ages of 50 and 70 are eligible for breast cancer screening every three years as part of the NHS Breast Screening Programme. Women who have two or more close relatives with breast cancer may be eligible to be screened for breast cancer or for the genes that may make developing it more likely.

The possible factors for preventing breast cancer and details of the screening methods are outlined below.

Diet and lifestyle

Research into breast cancer has shown that eating a healthy, balanced diet may help to prevent it. For example, the rates of breast cancer among Japanese women, who eat a low-fat diet that is high in fruit and vegetables, are far lower than those of American women, whose diet is high in fat and similar to that of women in the UK.

It has also been suggested that regular exercise can reduce your risk of breast cancer by as much as a third. If you have been through the menopause, it is particularly important not to be overweight or obese because it causes more oestrogen to be produced, which can sometimes stimulate the growth of cancer cells.

Aside from this, it is known that regular exercise and a healthy, low-fat diet are extremely beneficial to your overall health and can help prevent all forms of cancer and heart disease.

Breastfeeding

Women who breastfeed are statistically less likely to develop breast cancer than those who do not. Research has found that women who breastfeed may reduce their risk of developing breast cancer before they reach menopause by half. Younger mothers in particular can reduce their risk of breast cancer by breastfeeding. The risk is reduced further the longer you continue to breastfeed your baby.

The reasons for this are not fully understood, but it could be because you do not ovulate as regularly while you are breastfeeding and your oestrogen levels remain stable.

The NHS Breast Screening Programme

If you are a woman between the ages of 50 and 70, you are eligible to be regularly screened for breast cancer as part of the NHS Breast Screening Programme. You should receive your first invitation for screening by the time you are 54 years old. If you don't, contact your GP surgery.

Women between 50 and 70 are considered to be most at risk. However, as your risk of breast cancer increases with age, you may wish to continue being screened after the age of 70. If this is the case, see your GP. The NHS Breast Screening Programme website has further information.

The screening method for the Breast Screening Programme is a mammogram once every three years. Always attend every appointment, even if you cannot see or feel any changes in your breasts. For more information about mammograms, see Diagnosis, above.

Screening for women at high risk of breast cancer

You may be eligible for breast cancer screening before the age of 50 if breast cancer runs in your family. Your risk of developing breast cancer is considered to be higher than average if:

• Two or more close relatives (at least one of whom is your mother or sister) on the same side of your family have or have had breast cancer.
• Three of your close relatives were diagnosed with breast cancer at any age.
• One close relative has breast cancer and one has ovarian cancer (one of them being your mother, sister or daughter),
• Your mother or sister was diagnosed with breast cancer before the age of 40.
• Your father or brother was diagnosed with breast cancer at any age.
• Your mother or sister was diagnosed with breast cancer in both breasts and was diagnosed for the first time under the age of 50.

If any of the above applies to you, see your GP, who can refer you to a breast clinic for assessment based on your family history. If you have a high risk of developing breast cancer and you are over 40, you should be offered screening with a mammogram once a year. If you are under 40, you are entitled to screening using MRI scans instead of mammograms because your breasts may be too dense to produce a clear mammogram.

Genetic screening for breast cancer

If, following an assessment at your breast clinic, it is found that you have a family history of breast cancer, it may be because one of the genes that makes breast cancer more likely runs in your family. You may be able to have screening for these genes, which are known as BRCA1, BRCA2 and TP53.

To be genetically screened for breast cancer, you must have a living relative with breast cancer. You and your relative both have a blood test to see if you both carry any of the breast cancer genes.

If a breast cancer gene is found and you are under 49, you may be offered yearly MRI scans. If you are 50 or over, you may also be offered yearly mammograms.

The NHS Breast Screening Programme screens around 1.6 million women every year and saves an estimated 1,400 lives a year in England. Screening enables breast cancer to be found at an early stage, when there is a good chance of successful treatment and full recovery.

Women aged between 50 and 70 who are registered with a GP are automatically invited for screening every three years. Women aged over 70 don’t receive invitations, but are encouraged to make their own screening appointments every three years. Women should receive their first invitation for screening some time between their 50th and 53rd birthdays.

Mammography takes place at breast screening units in hospitals or clinics, or in mobile breast screening vans. Screening is carried out by female staff, who take X-rays of the breasts (mammography) to detect abnormalities. The breasts are X-rayed one at a time. The breast is placed on the X-ray machine and gently but firmly compressed with a clear plate. Two X-rays are taken of each breast at different angles. Most women find this uncomfortable and it may be painful for some. But the compression is necessary to ensure a clear mammogram.

Results

• Results from screening are sent to you and your GP in writing.
• Around 19 out of every 20 women screened have a normal result and will be recalled for screening in three years (or encouraged to make their own appointment if aged over 70 by that time).
• Around one in 20 women may be called back for further assessment. This could be because the first mammogram was unclear or because a potential abnormality was detected. For most women, further tests show that there is no problem.
• Only around one in six women who are recalled for assessment are diagnosed with breast cancer, and around half of the cancers found at screening are still small enough to be removed from the breast. This means that the whole breast does not have to be removed (mastectomy).

Not all cancers are found at breast screening, and breast cancer can develop in the time between screening appointments. Because of this, women are encouraged to be ‘breast aware’, so that they can spot any unusual changes early on and report them to their GP.

Further information
For more information on breast screening, go to the NHS Breast Screening Programme website and download the information leaflets.

The main symptom of breast cancer is usually a lump or thickened area of tissue in your breast. Most breast lumps are found by the women who have them and it is very important to be aware of any lumps or changes in the appearance, feel or shape of your breasts. The sooner a cancerous lump is detected, the better the chances of treating it successfully.

Changes to look out for

See your GP if you notice any of the following:

• a lump or thickened area of tissue in either breast,
• discharge from either of your nipples (which may be streaked with blood),
• a lump or swelling in either of your armpits,
• a change in the size or shape of one or both of your breasts,
• 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, or
• pain in either of your breasts or armpits which is not related to your period.

A lump in your breast may not be the result of breast cancer. The majority (90%) of breast lumps are benign (non-cancerous). A breast lump may be caused by a harmless cyst (a small fluid-filled lump) or fibroadenoma (benign growths that are very common). Your breasts may also feel lumpy just before your period.

However, if you notice any changes to one or both of your breasts as listed above, get them checked by your GP.

Breast awareness

Be aware of how your breasts look and feel and report any lumps to your GP as soon as possible.

If you get to know the way your breasts normally look and feel, it will make it easier to spot any changes.

Check your breasts in the shower or bath or before dressing. Do this after your monthly period because your breasts can feel lumpy before your period is due.

Treatment for breast cancer usually involves a combination of surgery, chemotherapy, radiotherapy and, in some cases, hormone or biological therapies. The amount and type of treatment you receive will depend on the type of breast cancer you have, its stage and grade, and your overall health.

You will receive treatment from a team of healthcare professionals led by an oncologist (a specialist in cancer). Discuss any fears and concerns that you have with your oncologist as they will be able to explain each phase of your treatment.

Surgery

Most women who have breast cancer will need surgery. This is often the first form of treatment you will receive. There are two types of surgery for breast cancer. These are surgery to remove just the cancerous lump (tumour), which is known as breast-conserving surgery, and surgery to remove the whole breast, which is called a mastectomy. In many cases, a mastectomy can be followed by reconstructive surgery to recreate the removed breast.

In some cases, particularly if the cancer is detected in its early stages, you may be able to choose which type of surgery you would prefer. This is a big decision, so discuss your options fully with your surgeon and oncologist (specialist in cancer). Some women decide that they want to keep their breast if possible while others feel more comfortable having their breast removed.

The two different types of surgery are described in more detail below.

Breast-conserving surgery

The aim of breast-conserving surgery is to save as much of your breast as possible while removing as much of the cancer as possible to prevent it from recurring. You may be able to have breast-conserving surgery if the cancer is in its early stages or has not spread beyond your breast.

Breast-conserving surgery ranges from a lumpectomy or wide local excision, in which just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, in which up to a quarter of your 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 which needs to be removed, and
• 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 is no cancer present in the healthy tissue, there is less chance that the cancer will recur. If cancer cells are found in the surrounding tissue, you may need to have more tissue surgically removed from your breast.

After breast-conserving surgery, you will need to have radiotherapy to destroy any remaining cancer cells.

Mastectomy

A mastectomy removes all your breast tissue, including your nipple. You may need to have a mastectomy if the tumour is large or very central in your breast, or if the cancer has spread beyond your breast to other parts of your body.

The type of mastectomy that you have will depend on whether or not the cancer has spread to your lymph nodes (small glands under your breast and in your armpit that filter bacteria from the body), or to your chest wall muscles.

If the cancer has not spread to your lymph nodes, you may have a simple mastectomy in which only your breast is removed. If the cancer has spread to your lymph nodes, you may need a modified or radical mastectomy, in which your breast will be removed along with lymph nodes under your arm or your chest wall muscles.

If you have lymph nodes removed from your armpit during a mastectomy, the scarring can sometimes block the filtering action of the lymph nodes. This is known as lymphoedema and can cause excess fluid to build up in your arm. Lymphoedema can also be caused by radiotherapy.

Lymphoedema can be treated through exercise, massage and using compression sleeves (tightly fitting bandages that push excess fluid out of your arm), but it is a long-term (chronic) condition. Lymphoedema can develop months or sometimes years after surgery. See your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your operation.

Breast reconstruction and prostheses

If you have a mastectomy, you may be able to have reconstructive surgery at the same time or later to recreate your breast. This can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast.

You decide whether to have reconstructive surgery following a mastectomy and when to have it, as long as there is no medical reason for delaying the surgery. Discuss your options fully with your surgeon and breast nurse before making a decision.

Women who decide against breast reconstruction can wear a false breast or breast prosthesis, which are available free on the NHS. After having a mastectomy, you may have a temporary fibre-filled prosthesis and a permanent prosthesis made from silicone, which can be replaced every two years.

Chemotherapy

Chemotherapy is a specialist treatment for cancer which uses medicines to stop the growth of cancer cells. These medicines are known as cytotoxic, which means that they target rapidly growing cancer cells, stopping them from dividing and multiplying.

Chemotherapy is usually used before radiotherapy to destroy any cancer cells that cannot be removed by surgery, although you may have it before surgery to shrink a large tumour. It can also be used to treat breast cancer that has recurred (come back).

If you need to have chemotherapy, you will probably be given the medicine intravenously (by injection through a vein, directly into your bloodstream). In some cases, you may need to take tablets. There are many different cytotoxic medicines for breast cancer and you will probably be given a combination of three at the same time. As it circulates through your blood, the medicine targets cancer cells in your breast, as well as any that may have spread elsewhere in your body.

If you have not yet been through the menopause, chemotherapy can stop the production of oestrogen in your body (which can encourage the growth of some breast cancers). Your ovaries should start producing oestrogen again once your chemotherapy is over. In a small number of cases, this does not happen and chemotherapy can cause you to enter early menopause.

It is not possible to predict whether or not this will happen, but it is more likely to occur in women over the age of 40 as they are closer to menopausal age. If you do enter menopause as a result of chemotherapy, you will no longer be able to conceive.

You may receive chemotherapy sessions three or four times a week, over a period of four to eight months. Your sessions will be three to four weeks apart to give your body a rest between treatments. The medicine is usually injected over a period of three hours, although in some cases this may be extended to 24 hours. If this is the case, you will need to stay in hospital overnight.

Side effects of chemotherapy

Chemotherapy works by preventing cells, such as those that are cancerous, from growing rapidly. However, there are other cells in your body that divide and multiply rapidly, including hair follicles and red and white blood cells. Chemotherapy also destroys these non-cancerous cells, which can cause many side effects, including:

• hair loss,
• nausea and vomiting,
• diarrhoea or constipation,
• rashes on the skin of your hands and feet,
• loss of appetite,
• sores around your mouth,
• anaemia (tiredness and breathlessness brought on by a lack of red blood cells), and
• leukopenia (infection brought on by a lack of white blood cells).

If you need chemotherapy, the side effects you experience will depend on the type of cytotoxic medicine that you take, the number of treatment sessions you have and your individual reaction to treatment.

If you experience nausea and vomiting as a result of chemotherapy, you may be able to take anti-sickness medication to help it. This may be given intravenously (by injection directly into your bloodstream) at the same time as your chemotherapy.

The side effects of chemotherapy only last as long as your course of treatment. Once your treatment is over, the rapidly growing cells that occur naturally in your body will repair themselves. This means that your hair will grow back, although it may look or feel different to how it did before. For example, it may be a slightly different colour, or softer or curlier than before.

Radiotherapy

Radiotherapy uses high-energy X-rays. Like chemotherapy, it targets rapidly growing cancer cells. Radiotherapy is usually given after chemotherapy to minimise the risk of the cancer recurring following breast-conserving surgery, or to destroy any remaining cancer cells in your lymph nodes under your arm after a mastectomy. It may also be given without chemotherapy if the cancer is detected in its early stages.

If you have radiotherapy, your treatment will begin about a month after your surgery or chemotherapy to give your body a chance to recover. It is a painless procedure in which you lie under a radiotherapy machine while it directs radiation at your affected breast. You will be positioned by your radiographer (a specialist in radiotherapy) so that the machine targets only the cancer cells and avoids as much of your healthy tissue as possible.

You will probably have radiotherapy sessions five days a week for three to six weeks. Each session will only last a few minutes. The radiation does not stay in your system afterwards and it is perfectly safe to be around others between treatments.

Side effects of radiotherapy

As radiotherapy targets rapidly growing cancer cells, like chemotherapy it can have several side effects. Other rapidly growing cells, such as skin cells and the cells that line your digestive system, are also damaged by radiotherapy. The side effects of radiotherapy include:

• irritation and darkening of the skin on your breast,
• fatigue (extreme tiredness), and
• lymphoedema (excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm).

Lymphoedema can develop months or years after radiotherapy. See your breast care nurse or GP if you notice any swelling in your arm or hand on the side of your treatment.

Hormone therapy

If your breast cancer was found to be hormone-receptor positive when it was diagnosed, you may be able to have hormone therapy to further minimise the risk of your breast cancer recurring. For more information about hormone receptor testing, see Diagnosis, above.

Breast cancers that are hormone-receptor positive are stimulated to grow by the hormones oestrogen or progesterone, which are found naturally in your body. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects. It may be used as the only treatment for breast cancer if your general health prevents you from having surgery, chemotherapy or radiotherapy.

If hormone therapy is suitable for you, your treatment will probably be given after surgery or chemotherapy. In some cases, it may be given before surgery to shrink a large tumour. There are several different hormone therapy medicines, including tamoxifen, aromatase inhibitors and pituitary downregulators. In most cases, you will need to take hormone therapy for up to five years after your breast cancer surgery.

Tamoxifen

Tamoxifen is the most common type of hormone therapy. It is most effective for treating cancers that are oestrogen-receptor positive, although you may be prescribed tamoxifen if your cancer is progesterone-receptor positive. If you are prescribed taxmoxifen, you will need to take it every day by mouth (orally) as either a tablet or a liquid. Tamoxifen can cause several side effects, including:

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

Aromatase inhibitors

Aromatase inhibitors come in brands called Arimidex, Aromasin and Femara. They are only suitable for women who have been through the menopause because they block the oestrogen that is made after the menopause by the adrenal glands. Aromatase inhibitors are taken as a tablet once a day. Aromatase inhibitors can cause side effects, including:

• hot flushes and sweats,
• loss of interest in sex,
• nausea and vomiting,
• tiredness,
• aching joints,
• headaches, and
• skin rashes.

Pituitary downregulators

The most commonly used pituitary downregulator in the treatment of breast cancer is goserelin (Zoladex). It is prescribed to women who are still having periods as it stops the ovaries from producing hormones.

If you are prescribed a pituitary downregulator, your periods will stop while you are taking it. They should start again once your treatment is complete. However, if you are approaching menopause (around the age of 50), you may find that your periods do not start again once you stop taking the pituitary downregulator.

This type of hormone therapy is taken as an injection once a month and can cause menopausal side effects, including:

• hot flushes and sweats,
• mood swings, and
• trouble sleeping.

Biological therapy

If your breast cancer was found to be HER2 positive at the time of diagnosis, you may be able to have biological therapy to further minimise the risk of your breast cancer recurring. Biological therapy can also increase the effects of chemotherapy on breast cancer cells. For more information about HER2 testing, see Diagnosis, above.

Breast cancers that are HER2 positive are stimulated to grow by the protein HER2. Biological therapy works by stopping the effects of HER2 and by helping your immune system to fight off cancer cells.

Trastuzumab (Herceptin)

If you are able to have biological therapy, you will probably be prescribed a medicine called trastuzumab (Herceptin). Trastuzumab is usually used after chemotherapy.

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. Trastuzumab targets and destroys cancer cells that are HER2 positive.

If you are prescribed trastuzumab, you will need to have your treatment in hospital as it is given intravenously (an injection directly into your vein). Each treatment session takes up to one hour and the number of sessions you need will depend on whether you have early breast cancer or cancer that is more advanced. On average, you will need one session 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 is not suitable if you have existing heart problems, such as angina, uncontrolled high blood pressure (hypertension) or heart valve disease. If you need to take trastuzumab, you will have regular tests on your heart to make sure the medication is not causing any problems. Other side effects of trastuzumab include:

• an initial allergic reaction that can cause nausea, wheezing, chills and fever,
• diarrhoea,
• tiredness, and
• aches and pains.

Will the NHS fund an unlicensed drug if my doctor wants to prescribe it for me?

It is possible for your doctor to prescribe a drug outside the uses it is licensed for if they are willing to take personal responsibility for this ‘off-licence’ use of treatment.

Your local primary care trust (PCT) may need to be involved, as it would have to decide whether to support your doctor’s decision and pay for the drug from NHS budgets.

Find out about access to new treatment.

Breast awareness is an important issue for all women, and being aware of how your breasts look and feel at different times of the month can help you detect any problems early on.

Breast cancer is rare in women under 40, but the likelihood of developing breast cancer increases with age. 80% of breast cancers occur in woman aged over 50. If you are aged 50 or over, you should take advantage of the NHS Breast Screening Programme, which offers three-yearly mammography (a special x-ray of the breast). If you are registered with a GP, you will automatically be invited for screening every three years. Your first invitation will arrive some time between your 50th and 53rd birthday.

As part of being breast aware, it is important to know what is normal for you. For instance, your breasts may look or feel different at different times of the month and at different times during your life.

Before the menopause normal breasts feel different at different times of the month. The milk-producing tissue in the breast becomes active in the days before a period starts. In some women, the breast at this time feel tender and lumpy, especially near the armpits.

After a hysterectomy the breasts usually show the same monthly differences until the time when your periods would have stopped.

After the menopause activity in the milk-producing tissue stops. Normal breasts feel soft, less firm and not lumpy.

If you notice any changes to what is normal for you, tell your doctor without delay because it could be the first sign of cancer.

All women should follow the breast awareness five-point code:

• Know what is normal for you.
• Know what changes to look for.
• Look and feel.
• Report any changes without delay.
• Attend for breast screening if aged 50 or over.

Changes to look out for include:

• any change in the outline or shape of the breast or any puckering or dimpling of the skin,
• any discomfort or pain in one breast that is different from normal,
• any lumps, thickening or bumps in one breast or armpit that is different to normal,
• any discharge or bleeding or moist reddish areas that will not heal easily,
• any change in nipple position or a nipple rash.

For more information about breast awareness, please go to www.cancerscreening.nhs.uk (links to external site).

Risk of breast cancer in over 70s

About one third of all breast cancers occur in women over the age of 70, making them more at risk than younger women.

If you're a 70+ woman, you're still eligible to be screened every three years even though you won’t receive invitations. You can make your own screening appointments by contacting your local screening unit direct. Your GP will have contact details for the unit, or you can phone NHS Direct on 0845 4647. Screening can detect small changes in the breast before there are any outward signs or symptoms. The earlier any changes are found the better chance there is of successful treatment and recovery.

For more information about screening if you're aged over 70, please go to www.cancerscreening.nhs.uk (links to external site).

If you have been diagnosed with cancer, your treatment and medical care will probably be the first thing on your mind. But there are other aspects of your life to think about and it’s important to know exactly what kind of assistance is available and where you can get it.

If you are finding it hard to cope with day-to-day life, you should at first talk about your needs with your doctor or nurse, who will refer you to a social worker.  Your social worker will be responsible for assessing exactly the kind of help you should get. There are so many sources of help that it’s essential to have a social worker to guide you towards the correct course.

Social services can provide assistance with meals, laundry, or even a sitting service, who can come to your home. For more advanced care, an occupational therapist will be able to provide a more detailed assessment of your needs at home, making life easier by arranging equipment and fitting adaptations to your home.

A care attendant may also be organised to come and help with housework, dressing and washing, or even just to keep you company and give your carer a break. It’s advised that you look into this as soon as you can, since many care attendants have waiting lists.

Social care options include:

Care attendants

Meals on Wheels

Benefits

Home Adaptations

For more on support for patients and carers:

Macmillan

Cancer Backup

Being a carer isn’t an easy role.  When you’re busy responding to the needs of others, it can deplete your reserves of emotional and physical energy and make it easy to forget your own health and mental well-being (research on carers’ health shows that high numbers of carers suffer health effects through caring).  And if you are trying to combine caring with a paid job or looking after a family, this can bring about even more stress.

But putting yourself last on the list doesn’t work in the long term.  If you are caring for someone else, it’s important to look after yourself and get as much help as possible.   Not only is it in your best interests – but also those of the person you are caring for.

Look after your physical and emotional health 
Eat regularly and healthily.  If you don’t have time to sit down with every meal, try to make time to sit down once a day.  Instead of relying on fast food snacks, try to go for healthier options.

You can find more about looking after yourself on Carers Direct, including advice on how to get time off.

Look for support 
Friends and family may not always understand what you’re going through and it can be helpful to talk to people in the same situation.

• Carers UK have a lot of useful information on their website and run a helpline: www.carersuk.org CarersLine 0808 808 7777
  They also have a help and information booklet ‘New To Caring’ which can be downloaded. 
• The Princess Royal Trust for Carers have a chatroom on their website and also run 129 Carers Centres nationwide which provide information and advice and emotional support.  For more information visit: www.carers.org.

Find out what benefits you're entitled to
You can find benefits available to you on the Carers Direct website or by calling Carers Direct on 0808 802 0202.

Other people to contact: 

• Your GP and primary care team
• Social services.
• For details of government services and information for carers, go to Carers Direct.   

For more on support for people with breast cancer and their carers:

• Macmillan  (links to external site)

In this video, people who have been through cancer treatment talk about what kept them going and the practicalities of treatment.

Emma Duncan, 33, has been diagnosed with breast cancer twice in the past 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 that 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, they 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 did have 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. Anybody who had 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 hit my five-year point.

"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."

Learn about the medicines used to treat or manage this condition - preparations, benefits and side-effects are all covered.

The information is provided through a collaboration between NHS Choices, the medicines information provider Datapharm, and other health organisations. It's based on the best available clinical evidence, and is continually updated.

To take advantage of this unique resource go to:

The main complication of breast cancer is the spread of cancer to other parts of the body. Cancerous growths (tumours) that develop in other parts of the body from an original growth in the breast are called metastases or secondaries. These often occur in the following places:

• lymph nodes in the armpits,
• lungs,
• bones,
• liver,
• brain, and
• eye.

Treatment for cancer is always more effective when it is diagnosed early and before it has spread to other areas of the body. So it is important to get any lumps or other symptoms checked out by your GP as soon as possible.

Women who received treatment for Hodgkin's disease at a young age have an increased chance of developing breast cancer. This is because they may have had a large dose of radiation therapy to the chest. The Department of Health has arranged for all women who have been treated since 1962, and were under 35 years of age when treated, to have a consultation with a specialist.

Early diagnosis can save lives

What you need to know about breast cancer

• Breast cancer is the most common cancer in the UK with more than 45,500 women diagnosed each year.
• Around one in nine women will develop breast cancer during their lifetime. Most women who get breast cancer are past their menopause (change of life), but around one in five women diagnosed each year are under 50 years old. 
• The good news is that survival rates for breast cancer are improving. Of those who do get the disease, eight out of 10 women will survive for five years or more after diagnosis. Two thirds are likely to survive for at least 20 years.
• Men can get breast cancer too but it is very rare.
• It is important to diagnose breast cancer early. We know that the sooner breast cancer is diagnosed, the better the outcome is likely to be.

What can increase my risk of breast cancer?

It is difficult to pinpoint definite causes of breast cancer and that’s why we talk about what might increase or decrease your risk. 

• Older women are at greater risk of breast cancer, particularly after the menopause, but it can affect younger women too.  
• You may be more at risk if several close members of your family have had breast cancer, particularly at a young age, although most people with breast cancer do not have any close relatives with the disease.
• Being overweight, drinking alcohol and taking HRT (hormone replacement therapy) can increase your risk of breast cancer.  

How can I reduce my risk of breast cancer?

• Maintain a healthy weight.
• Drink less alcohol.
• Do regular exercise.
• Breastfeeding can reduce your risk of breast cancer, although women who have breastfed their children can still develop the disease.

What are the signs and symptoms of breast cancer?

There can be many reasons for changes in the breast and often they will be harmless. Any unusual change needs to be checked as there is a chance it could be a sign of cancer.

• Size and shape: if one breast changes in size or shape.
• A new lump or thickening in one breast or armpit that is different to the rest of the breast.
• Skin changes: puckering, dimpling, inflammation or redness of the skin.
• Nipple changes: if a nipple becomes inverted (pulled in), changes shape or points differently.
• Rashes on or around the nipple.
• Discharge or fluid (not milky) from one or both nipples.
• Pain or discomfort in the breast or armpit that is not related to your periods.
• Swelling under the armpit or around the collarbone.

Be breast aware

• It is important to be aware of how your breasts normally look and feel at different times. You will then notice if something is different or if you develop any of the signs and symptoms listed above.
• You can become familiar by looking and feeling your breasts from time to time in any way that is best for you.
• You can feel your breasts in the bath or shower using a soapy hand or lying down in bed. Using body lotion can help. It is important to feel the whole breast including the armpit.
• You can look at your breasts in the mirror. Move your arms (above your head, on your hips or by your sides) so that you can see your breasts from every angle, including the underside.
• As older women are at greater risk of breast cancer, it is very important to be aware of any unusual changes after the menopause, when your periods have stopped.
• Breasts may change with age and life events, such as pregnancy, breastfeeding, at different times of the month if you still have periods and after the menopause. This is why it is important to know what is normal for you so you will recognise any changes.

What to do if you find a change

• If you notice any change in your breasts, tell your doctor without delay. Remember, you are not wasting anyone’s time. 
• Even if you are not sure if the changes in your breast are serious, if you are worried, that is a good enough reason to go to your doctor.
• If it is breast cancer, finding it early means treatment is more likely to be successful.
• On the other hand, if there is no cancer, your doctor can reassure you so that you spend less time worrying.
• Even if you have other health worries to think about or family members to look after, it is important if you notice any changes in your breasts not to put off visiting your doctor.

The NHS Breast Screening Programme

It is important to detect breast cancer as early as possible. In the early stages, breast cancer may not have symptoms. This is why the government has introduced the NHS Breast Screening Programme. Screening is free. 

Women are invited for screening between the ages of 50 and 70. You will be offered mammograms every three years. A mammogram is an X-ray of the breast. It can detect breast cancer at a very early stage.

From 2009, this age range began to be extended. Women in their late forties and up to the age of 73 are also starting to be invited. It will take a few years for this to happen everywhere in England.

NHS breast screening is not usually available for younger women as mammograms are not as effective on younger breasts. If you are below screening age and worried about breast changes, or have a family history of breast cancer, speak to your GP.

Women over 70 (73 in some parts of England) are not sent invitations for breast screening. This does not mean that older women can’t develop breast cancer. Women over 70 are still at a higher risk of breast cancer. If you are over the screening invitation age range, you can ask for free breast screening every three years. Contact your local breast screening unit to make a free appointment.

Breast awareness five-point code

1. YOU should know what is normal for you.
2. KNOW what changes to look for.
3. LOOK and feel.
4. TELL your GP about any changes straightaway.
5. GO for breast screening when invited.

Make a plan

You may find it helpful to make a plan of how you will become breast aware.

• Work out how you will get to know how your breasts normally look and feel, perhaps in the bath or shower or when getting dressed.
• Decide what you will do if you find a change in your breasts, such as seeing your doctor straightway.
• As soon as your invitation to breast screening arrives, plan how you will keep the appointment.

The above information was produced by the Department of Health.