My Doctor Online The Permanente Medical Group

Risk Factors

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There are many factors that can increase the risk of breast cancer for women: 

• Age. The average age of women diagnosed with breast cancer is approximately 60.
• Breast density. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer.
• Alcohol. Alcohol consumption of more than 1 drink a day has been associated with an increased risk. Even more moderate alcohol consumption of 3 drinks a week was recently associated with increased risk.
• Obesity. Obesity in women after menopause increases the risk. Obesity also increases the risk of endometrial cancer, because of the increased levels of the female hormone estrogen, which is made in fat tissue.
• Early menarche. If your menstrual cycles started before age 12, you have a slightly increased risk of breast cancer.
• Late menopause. Going through menopause after age 55 is associated with an increased risk as well. Like early menarche, it is thought that a prolonged duration of hormone exposure increases the risk for developing breast cancer.
• Postmenopausal hormone replacement therapy (HRT). Taking HRT, particularly the estrogen and progesterone combination, has been shown to increase the risk of breast cancer. 

Family history

Most women diagnosed with breast cancer will be the first in their family to develop this disease.  However, having a relative with breast cancer may increase your risk of developing breast cancer. 

• For women who have a first-degree relative (mother or sister) with breast or ovarian cancer, the risk of breast cancer is twice as high as for women without a family history of breast cancer. In addition, the risk is higher if the first-degree relative is diagnosed with breast or ovarian cancer at an age younger than 50, or if she has had bilateral breast cancer.
• Having a second-degree relative (grandmother, aunt, niece, or granddaughter) with a history of breast or ovarian cancer also increases the risk of breast cancer by approximately 50 percent, compared to women without a family history of breast or ovarian cancer.
• Less than 5 to 10 percent of women with breast cancer may have developed breast cancer because of an abnormal change (mutation) in their genes, called BRCA1 or BRCA2. Women with a known BRCA1 or BRCA2 gene mutation have a 70 to 80 percent risk of breast cancer during their lifetime.
• Some more rare gene mutations (for example, p53, CHEK2, PTEN) can occasionally cause breast cancer or other cancers.
• Radiation exposure to the chest increases the risk of developing breast cancer.

There are some individuals who have a significant family history but may not have clearly identifiable gene mutations.

Pregnancy history and breast cancer risk

Some factors associated with your pregnancy history can influence the risk of breast cancer. These include the following:

• Women who have never been pregnant have twice the risk of developing breast cancer compared to women who have been pregnant.
• Women who gave birth to their first child after age 30 have a 30 percent higher risk of developing breast cancer compared to women who gave birth to their first child at age 20 or younger. 

Breast cancer in men

Male breast cancer is 100 times less common than female breast cancer, affecting around 2,000 men per year in the United States, typically between the ages of 60 and 70. There are several factors that can increase the risk of breast cancer for men: 

• Family history. Genetic mutations, especially BRCA2, but also BRCA1, PTEN, p53, and CHEK2, increase a man’s risk of developing breast cancer.
• Klinefelter's syndrome. This uncommon hereditary syndrome, in which the male child is born with more than one X chromosome, can cause testicles to develop abnormally and to produce excess estrogen that can increase a man’s risk of developing breast cancer.
• Age. As with women, the risk of developing breast cancer increases as men get older.
• Radiation exposure to the chest increases a man’s risk of breast cancer.
  

Risk reduction

There are some things you can do to help reduce your risk of developing breast cancer. Healthy lifestyle choices include:

• Get regular exercise.
• Eat a healthy diet rich in fruits and vegetables.
• Avoid smoking and tobacco products.
• Limit your intake of alcohol.
• Limit the use of hormones, particularly postmenopausal hormone replacement therapy (HRT).

Regular screening and early diagnosis are the most important tools to fight this disease.

Symptoms

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In many instances, breast cancer may not have symptoms. If symptoms are present, they can include:

• A painless lump in the breast
• Change in the shape, size, or appearance of the breast
• Change in skin texture or a dimpled appearance of the breast
• Discharge from the nipple or a retracted nipple

If you experience any of these symptoms, you need to make an appointment with your personal physician or your gynecologist to discuss your concerns.

Symptoms of breast cancer in men

Symptoms of male breast cancer include lumps or thickening of the breast tissue, nipple retraction, nipple discharge, and changes on the skin such as swelling, skin redness, or scales. If you notice any of these symptoms, contact us to schedule an examination.

Diagnosis

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If breast cancer is suspected on breast exam or in imaging studies, we may recommend a procedure known as a biopsy to determine whether cancer is present. Some women with dense breasts may need extra tests or a biopsy to get a better look at their breast tissue. During the biopsy, we will remove a sample of tissue from your breast. Even when this is necessary, most biopsies do not show cancer.

The biopsy may be accompanied by ultrasound technology to locate and remove the tissue sample. If the tumor is palpable (can be felt), the biopsy can be performed through the skin (percutaneously) without ultrasound. The biopsy can be performed in a variety of ways:

• Fine-needle aspiration uses a special needle to remove a few samples of the cells from the breast lump. This method does not require surgery.
• Core biopsy uses a special thicker needle to remove a small sample of the tissue from the breast lump. This method also does not require surgery and is often done by a radiologist.
• Surgical biopsy allows us to remove part or all of the breast lump during a surgical procedure.

The sample will be sent to the pathology laboratory for full testing.

Staging

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The stage of breast cancer can help you and your treatment team understand your prognosis and make decisions about treatment. You will get your staging information in your pathology report and from your doctor. Staging is based upon 4 characteristics:

• The size of the tumor
• Whether the cancer is invasive (spreading into the neighboring structures) or noninvasive (remaining within the breast duct or lobule)
• Whether the cancer is in the lymph nodes
• Whether the cancer has spread to other parts of the body beyond the breast and lymph nodes (metastasized)

The following are some of the most common stages of breast cancer:

• Stage 0. Also known as carcinoma in situ, this type of breast cancer is confined (or "localized") to the inside of a milk duct and has not moved out of its original location. Ductal carcinoma in situ (DCIS) is not an invasive cancer and has not spread outside the milk duct.
• Stage I. The tumor has not spread beyond the breast to lymph nodes or other locations. The tumor may be up to 2 centimeters (cm), or three-quarters of an inch, in size.
• Stage II. The tumor is either 2 to 5 cm (three-quarters of an inch or larger) in size or has spread to a nearby lymph node. Usually, only one of these conditions must be met for it to be classified as stage II disease.
• Stage III. This is also known as locally advanced cancer since the tumor is 5 cm (several inches) or larger, or it has spread into many neighboring lymph nodes or into the chest wall or skin.
• Stage IV. The cancer has spread beyond the breast area and beyond nearby lymph nodes into other organs or bones. This is considered a late-stage cancer.

The staging process is important to help determine the best treatment plan for you.

Screening

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Early diagnosis with regular screening is one of the most important tools we have to fight this disease. If breast cancer is found early, treatment is likely to be effective and less complex. There are a variety of screening methods to help find breast cancer. Depending upon the type and severity of your cancer, they can include imaging (mammogram, ultrasound, or MRI) and clinical breast exam.

Imaging

Depending on your specific situation, imaging can include a mammogram, ultrasound, or MRI (magnetic resonance imaging), as appropriate. A mammogram is an X-ray of the breast. While a mammogram does not prevent breast cancer from developing, it can help detect the breast cancer at an early stage, allowing for more effective treatment. The frequency of your recommended mammogram is based upon your personal medical history.

Here are the general guidelines we use for recommending a mammogram:

• We recommend that all women ages 40 to 74 have a mammogram every 1 to 2 years.
• If you are over age 74, talk with your doctor about when to get screened.
• For women younger than 40: Screening mammograms may be recommended for women younger than 40 if there is a history of radiation therapy to the chest (for example, a history of lymphoma that required radiation), genetic mutation, close family member with breast cancer diagnosed before age 50, or other factors that put them at increased risk.

It is especially important for women with dense breasts to have regular mammograms. Breast density is not a new discovery. It has always been one of the things that we consider when reading a mammogram. We will inform you if you have dense breasts so that you can discuss your screening options with us.

An MRI is occasionally used to screen women at high risk of breast cancer. If you have a family history of breast cancer, our genetics experts can assist you in figuring out whether you are at high risk of breast cancer. The MRI is very sensitive and may detect abnormalities that are noncancerous as well as cancerous.

Clinical breast exam

As part of your regular medical exam, we may also do a clinical breast exam, looking for any abnormalities or changes in your breasts. The exam can be performed by your gynecologist, personal physician, or other health care professional.

Treatment

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We will work with you to individualize your treatment of breast cancer. Depending upon the location of the tumor and the severity of the cancer, treatments may include: 

• Surgery
• Chemotherapy
• Radiation therapy
• Hormonal therapy
• Biologic therapy
• Targeted therapy

We may recommend one or more of these treatments.

Follow-up Care

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One of the most important aspects of cancer therapy is good self-care during the treatment period and beyond. There are several things that you can do to improve your overall health and well-being during treatment:

• Eat a nutritious diet.
• Stay as active as possible.
• Keep your regularly scheduled follow-up appointments.
• Join a support group where you can talk to people who may have had an experience similar to yours.
• Ask questions of your caregivers and report any symptoms.
• Follow all instructions for blood tests if ordered, obtain X-rays if ordered, and use any medications prescribed consistently and for as long as recommended by your doctor.

Clinical trials

We may also discuss with you the possibility of enrolling in a clinical trial. Clinical trials are research studies designed to improve treatment for cancer patients. Some trials investigate new cancer drugs and treatments, while others compare standard treatments to newer promising treatments. All of the standard treatments we use today achieved that status by being the most effective in a previous clinical trial.

Clinical trials are offered at nearly all the oncology clinics at our medical centers in Northern California. We have clinical trials available for many types of breast cancer. Please ask your doctor if a clinical trial may be available for you.

Breast Reconstruction

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Following mastectomy (removal of the breast by surgery) for breast cancer, you have a variety of options available to you: 

• You may choose not to wear a prosthetic breast or undergo breast reconstruction surgery.
• You might choose to wear a prosthetic breast, which is a breast form that can be inserted into specially designed undergarments or clothing. This option does not require surgery.
• Most women are candidates for surgical breast reconstruction. Candidates for surgical breast reconstruction may be offered breast reconstruction surgery that is performed at the same time as the mastectomy or at any later time. Breast reconstruction surgery involves recreating the form of a breast using implants or by transferring tissue from other parts of your body to the breast area.

The important thing to remember is that you have many options, and we will work with you to choose the best option for you. You can view our Emmi tool to learn more about the possibilities of breast reconstruction.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours per day, 7 days per week.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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