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Breast cancers are potentially life-threatening malignancies that develop in one or both breasts. The structure of the female breast is important in understanding this cancer:
Noninvasive breast cancers include:
A diagnosis of these early cancers (DCIS and LCIS) is made when there is no evidence of invasion.
Invasive cancer occurs when cancer cells spread beyond the basement membrane, which covers the underlying connective tissue in the breast. This tissue is rich in blood vessels and lymphatic channels that are capable of carrying cancer cells beyond the breast. Invasive breast cancers include:
There are other less common breast cancers that are not discussed in this report.
About 12% of women develop breast cancer in their lifetime. Each year in the United States, about 192,000 women are diagnosed with invasive breast cancer and about 68,000 women are diagnosed with pre-invasive breast cancer. (Although breast cancer in men is rare, about 2,000 American men are diagnosed each year with invasive breast cancer.)
About 40,000 American women die from breast cancer each year. Breast cancer death rates have declined significantly since the 1990s, especially for women younger than age 50. The earlier breast cancer is diagnosed, the earlier the opportunity for treatment. In the United States, there are currently more than 2.5 million breast cancer survivors.
Risk factors for breast cancer include:
Most cases of breast cancer occur in women older than age 60. According to the American Cancer Society, about 1 in 8 cases of invasive breast cancer are found in women younger than age 45, while 2 in 3 cases of invasive breast cancer occur in women age 55 and older.
Breast cancer is slightly more common among white woman than African-American, Asian, Latina, or Native American women. However, African-American women tend to have more aggressive types of breast cancer tumors and are more likely to die from breast cancer than women of other races. It is unclear whether this is mainly due to biologic or socioeconomic reasons. Social and economic factors make it less likely that African-American women will be screened, so they are more likely to be diagnosed at a later stage. They are also less likely to have access to effective treatments.
Breast cancer is also more prevalent among Jewish women of Eastern European (Ashkenazi) descent (see Genetic Factors, below).
Women who have a family history of breast cancer are at increased risk for developing breast cancer themselves. Having a first-degree relative (mother, sister, or daughter) who has been diagnosed with breast cancer doubles the risk for developing breast cancer.
Women who have had ovarian cancer are at increased risk for developing breast cancer. And, a personal history of breast cancer increases the risk of developing a new cancer in the same or other breast.
About 5 - 10% of breast cancer cases are due to inherited genetic mutations.
BRCA Genes. Inherited mutations in genes known as BRCA1 or BRCA2 are responsible for most cases of hereditary breast cancers, ovarian cancers, or both in families with a history of these cancers.
BRCA gene mutations are present in only about 0.5% of the overall population. However, certain ethnic groups -- such as Jewish women of Eastern European (Ashkenazi) descent -- have a higher prevalence (2.5%) of BRCA gene mutations. BRCA gene mutations are also seen in some African-American and Hispanic women.
Screening Guidelines for BRCA Genes. The U.S. Preventive Services Task Force (USPSTF) recommends that women at high risk should be tested for BRCA genes, but does not recommend routine genetic counseling or testing in low-risk women (no family history of BRCA 1 or 2 genetic mutations). Risk assessment is based on a woman's family history of breast and ovarian cancer (on both the maternal and paternal sides).
In general, a woman is considered at high risk for BRCA genes if she has a first-degree relative (mother, daughter, or sister) or several second-degree relatives (grandmother, aunt) diagnosed with breast or ovarian cancer. Women who do not have a family history of breast cancer have a low probability of inheriting BRCA genes and do not need to be tested.
The relevance of the inherited BRCA1 or BRCA2 mutations to survival is controversial. Some studies have suggested that these mutations are linked to less lethal breast cancer. Others suggest that they do not change prognosis or may worsen it. Women with these genetic mutations do have a greater risk for a new cancer to develop. Patients with BRCA1 mutations tend to develop tumors that are hormone receptor negative, which can behave more aggressively.
Other Genetic Mutations. Other genes associated with increased hereditary breast cancer risk include p53, CHEK2, ATM, and PTEN.
Because growth of breast tissue is highly sensitive to estrogens, the more estrogen a woman is exposed to over her lifetime, the higher her risk for breast cancer.
Duration of Estrogen Exposure . Early age at menarche (first menstrual period) or later age at menopause may slightly increase a woman's risk for breast cancer.
Pregnancy . Women who have never had children or who had their first child after age 30 may have a slightly increased breast cancer risk. Having children at an early age, and having multiple pregnancies, reduces breast cancer risk. Scientific evidence shows there is no association between abortion and increased breast cancer risk.
Studies have been mixed on whether breast-feeding decreases breast cancer risk. Breast-feeding reduces a woman's total number of menstrual cycles, and thereby estrogen exposure, which may account for its possible protective effects. Some studies suggest that the longer a woman breast-feeds, the lower her risk, and that breast-feeding may be most protective for women with a family history of breast cancer.
Birth Control Pills . Although studies have been conflicting about whether estrogen in oral contraceptives increase the chances for breast cancer, the most recent research indicates that current or former oral contraceptive use does not significantly increase breast cancer risk. Women who have used oral contraceptives may have slightly more risk for breast cancer than women who have never used them, but this risk declines once a woman stops using birth control pills.
Hormone Replacement Therapy . Many studies have reported a higher risk for breast cancer in postmenopausal women who take combination hormone replacement therapy (HRT), which contains both estrogen and progesterone. Combination HRT is used by women who have a uterus, because estrogen alone can increase the risk of uterine cancer. Estrogen-only hormone replacement therapy is prescribed for women who have had a hysterectomy.
According to the most recent studies, long-term use (about 5 years or more) of combination HRT increases the risk of developing and dying from breast cancer. This risk then decreases within 5 years of stopping combination HRT.
The North American Menopause Society recommends that women who are at risk for breast cancer should avoid hormone therapy and try other options to manage menopausal symptoms such as hot flashes. Most doctors recommend that women use HRT only for short-term relief of menopausal symptoms. In recent years, rates of breast cancer have decreased as fewer women have opted for HRT.
Women who take HRT should be aware that they need regular mammogram screenings, because HRT increases breast cancer density, making mammograms more difficult to read.
Infertility and Infertility Treatments . Despite some concerns that infertility treatments using the drug clomiphene may increase the risk for breast cancer, most studies do not show an association. Some studies indicate that ovulation induction with clomiphene may actually decrease breast cancer risk. (Clomphine is related to tamoxifen, a drug that is used for breast cancer prevention in high-risk women.)
Certain breast conditions may increase the risk for breast cancer:
Some common benign breast abnormalities that pose very little or no risks for breast cancer include:
The following physical characteristics have been associated with increased risk:
Exposure to Estrogen-like Industrial Chemicals. Chemicals with estrogen-like effects, called xenoestrogens, have been under suspicion for years. There has been particular concern with pesticides containing organochlorines (DDT and its metabolites, such as dieldrin) and pyrethroids (permethrin), but at this time evidence of any causal association is very weak.
Exposure to Diethylstilbestrol. Women who took diethylstilbestrol (DES) to prevent miscarriage have a slightly increased risk for breast cancer. There may also be a slightly increased risk for their daughters (commonly called "DES daughters"), who were exposed to the drug when their mothers took it during pregnancy .
Radiation Exposure. Heavy exposure to radiation is a significant risk factor for breast cancer. Girls who receive high-dose radiation therapy for cancer face an increased risk for breast cancer in adulthood. Low-dose radiation exposure before age 20 may increase the risk for women with BRCA genetic mutations.
Antiperspirants or use of deodorants after shaving have not been linked with any higher risk for breast cancer. There is also no evidence that bras increase breast risk. Abortion does not increase risk.
Regular exercise, particularly vigorous exercise, appears to offer protection against breast cancer. Exercise can help reduce body fat, which in turn lowers levels of cancer-promoting hormones such as estrogen. The American Cancer Society recommends engaging in 45 - 60 minutes of physical activity at least 5 days a week.
Exercise can also help women who have been diagnosed with breast cancer and may help reduce the risk of breast cancer recurrence. Studies indicate that both aerobic and weight training exercises benefit the body and the mind, and improve quality of life for breast cancer survivors.
Despite much research on the association between diet and breast cancer, there is still little consensus. The best advice is to eat a well-balanced diet and avoid focusing on one "cancer-fighting" food. The American Cancer Society's dietary guidelines for cancer prevention recommend that people:
For breast cancer survivors, the American Cancer Society recommends diets that include lots of fruits and vegetables, low amounts of saturated fat (from meat and high-fat dairy products), moderation in soy foods, and moderate or no alcohol consumption.
Here are results from recent studies evaluating diet and breast cancer, for preventing both the development of cancer and its recurrence:
Fats . Research is still mixed on the role that fats, and which specific types of fats, play in breast cancer risk and prevention. According to results from the Women's Health Initiative study of dietary fat and breast cancer, there is no definite evidence that a low-fat diet will help prevent breast cancer. However, the study suggested that women who normally eat a very high-fat diet may benefit by reducing their fat intake.
Fruits and Vegetables . Fruits and vegetables are important sources of antioxidants, which may help protect against the tissue damage linked to increased cancer risk. Antioxidants include vitamin C, vitamin E, and carotenoids such as beta-carotene and lycopene. Richly colored fruits and vegetables -- not supplements -- are the best sources for these nutrients. These fiber-rich foods are an essential part of a healthy diet. However, it is not clear whether fruits and vegetables can specifically prevent breast cancer development or recurrence.
Calcium and Vitamin D . Eating lots of foods rich in calcium and vitamin D (such as yogurt and milk) may modestly reduce the risk of breast cancer for premenopausal women. Low-fat or non-fat dairy products are a healthier choice than high-fat ones.
Soy . The American Cancer Society recommends that women with breast cancer eat only moderate amounts of soy foods and avoid taking dietary supplements that contain high amounts of isoflavones. Isoflavones are a type of phytoestrogen (estrogen-like plant chemical). There have been concerns that high intakes of soy may increase the risk of estrogen-responsive cancers such as breast cancer.
Lifestyle Factors. Premenopausal women at higher risk, usually because of family history, should take as many preventive measures as possible, starting at an early age. The following lifestyle choices may be beneficial:
Tamoxifen and Raloxifene. Drugs known as selective estrogen-receptor modulators (SERMs) act like estrogen in some tissues but behave like estrogen blockers (anti-estrogens) in others. Two SERMs -- tamoxifen (Nolvadex) and raloxifene (Evista) -- are approved for breast cancer prevention for high-risk women. Tamoxifen and raloxifene are not recommended as prevention for women at low risk for breast cancer or its recurrence. Women at high risk for breast cancer should discuss with their doctors the risks and benefits of SERMs.
Tamoxifen (Nolvadex) is the most studied of these drugs. It is currently used to treat breast cancer and was the first drug approved for prevention. There is strong evidence that it halves the risk for estrogen receptor-positive cancers in high-risk women, including those with BRCA2 mutations (although possibly not BRCA1). It also helps prevent recurrence in women who have been treated for breast cancers. However, it has no protective effects against estrogen receptor-negative (hormone-insensitive) cancers.
Tamoxifen can increase the risk for uterine (endometrial) cancers. It can also increase the risk for blood clots, strokes, and endometriosis. Less serious side effects include hot flashes and vaginal discharge.
Raloxifene (Evista) is approved for prevention of breast cancer in postmenopausal women with osteoporosis and postmenopausal women at high risk for invasive breast cancer. (It is also approved for prevention and treatment of osteoporosis in postmenopausal women.) Studies indicate that it works as well as tamoxifen in reducing the risk of invasive breast cancer
One of raloxifene's main benefits is that it has a lower risk than tamoxifen of causing uterine cancer and blood clots. However, women with a history of blood clots in the legs, lungs, or eyes should not take raloxifene. Although studies indicate raloxifene does not increase the risk of stroke, it can increase the risk of dying from a stroke. Women with a history of or current risk factors for stroke or heart disease should discuss with their doctors whether raloxifene is an appropriate choice.
Less serious side effects of raloxifene include hot flashes, leg cramps, swelling of the legs and feet, flu-like symptoms, joint pain, and sweating. Raloxifene can cause birth defects and is approved only for postmenopausal women. It should not be taken with the cholesterol-lowering drug cholestyramine (Questran) or with estrogens.
Breast cancers in their early stages are usually painless. Often the first symptom is the discovery of a hard lump. Fifty percent of such masses are found in the upper outer quarter of the breast. The lump may make the affected breast appear elevated or asymmetric. The nipple may be retracted or scaly. Sometimes the skin of the breast is dimpled like the skin of an orange. In some cases there is a bloody or clear discharge from the nipple.
Many cancers, however, produce no symptoms and cannot be felt on examination. With an increase in the use of mammogram screening programs during the last several decades, more breast cancers are being discovered before there are any symptoms.
Breast Examination by a Health Professional. Women ages 20 - 49 should have a physical examination by a health professional every 1 - 2 years. Those over age 50 should be examined annually.
Self-Examinations. Women have been encouraged to perform a self-examination each month, but some studies have reported no difference in mortality rates between women who do self-examination and those who do not. This does not mean women should stop attempting self-examinations, but they should not replace the annual examination done by a health professional.
1. Pick a time of the month that is easy to remember and perform self-examination at that time each month. The breast has normal patterns of thickness and lumpiness that change within a monthly period, and a consistently scheduled examination will help differentiate between what is normal from abnormal. Many doctors recommend "breast awareness" rather than formal monthly self-examinations.
2. Stand in front of a mirror. Breasts should be basically the same size (one may be slightly larger than the other). Check for changes or redness in the nipple area. Look for changes in the appearance of the skin. With hands on the hips, push the pelvis forward and pull the shoulders back and observe the breasts for irregularities. Repeat the observation with hands behind the head. Move each arm and shoulder forward.
3. Lie down on the back with a rolled towel under one shoulder. Apply lotion or bath oil over the breast area. Using the 2nd, 3rd, and 4th finger pads (not tips) held together, make dime-sized circles. Press lightly first to feel the breast area, then press harder using a circular motion.
Using this motion, start from the collarbone and move downward to underneath the breast. Shift the fingers slightly over, slightly overlapping the previously checked region, and work upward back to the collarbone. Repeat this up-and-down examination until the entire breast area has been examined. Be sure to cover the entire area from the collarbone to the bottom of the breast area and from the middle of the chest to the armpits. Move the towel under the other shoulder and repeat the procedure.
Examine the nipple area, by gently lifting and squeezing it and checking for discharge.
4. Repeat step 3 in an upright position. (The shower is the best place for this, using plenty of soap.)
Note: A lump can be any size or shape and can move around or remain fixed. Of special concern are specific or unusual lumps that appear to be different from the normal varying thicknesses in the breast.
Current Recommendations for Screening. Mammograms are very effective low-radiation screening methods for breast cancer. There is, however, debate on when women should begin to have mammograms and how frequently they should have them.
Most major professional groups, including The American Cancer Society and The American College of Obstetrics and Gynecology recommend that women have a mammogram every 1 – 2 years starting at age 40.
The U.S. Preventive Services Task Force made the following recommendations in November 2009:
Given the confusion and recommendations, women, (particularly those in their 40s), should discuss the risks and benefits of mammography with their doctors, and then base their decisions on family history, general health, and personal values.
Since mammographies in younger women produce a relatively high rate of false-positive results (when the test falsely indicates breast cancer), there is a risk of radiation exposure and potentially unnecessary biopsies or surgeries. However, mammograms can help catch tumors while they are in their earliest and most treatable stages. The most deadly types of breast cancer tend to occur in women in their 40s.
After a woman reaches age 50, her risk for developing breast cancer increases. (Women over age 65 account for most new cases of breast cancer.) Women with risk factors for breast cancer, including a close family member with the disease, should consider having annual mammograms starting 10 years earlier than the age at which the relative was diagnosed.
Magnetic Resonance Imaging and Ultrasound. Magnetic resonance imaging (MRI) and ultrasound techniques can detect very small tumors (less than half an inch). However, they are expensive and time-consuming procedures, and ultrasound may yield more false-positive results. Nevertheless, some doctors believe they are important in identifying small tumors missed on mammography in women who are receiving lumpectomy or breast-conserving surgeries. Such findings allow surgeons to remove the optimal amount of abnormal tissue. Ultrasound may be particularly helpful for women with dense breast tissue who show signs of breast cancer.
In 2007, the American Cancer Society recommended that high-risk women have an MRI of their breast with their annual mammogram, including those who have:
For women who have had cancer diagnosed in one breast, MRIs can also be very helpful for detecting hidden tumors in the other breast. An important study reported that MRI scans of women who were diagnosed with cancer in one breast detected over 90% of cancers in the other breast that had been previously missed by mammography or clinical breast exam. Currently, few women who are diagnosed with cancer in one breast are offered an MRI of the other breast. Some doctors advocate MRIs for all women newly diagnosed with breast cancer; others oppose this view. MRI scans may be most useful for younger women with breast cancer who have dense breast tissue that may obscure tumors from mammography readings. MRIs are less likely to be helpful for older women with early tumors in one breast and clear mammography readings in the other.
It is very important that women have MRIs at qualified centers that perform many of these procedures each year. MRI is a complicated procedure and requires special equipment and experienced radiologists. MRI facilities should also be able to offer biopsies when suspicious findings are detected.
Scintimammography. In scintimammography, a radioactive chemical is injected into the circulatory system, which is then selectively taken up by the tumor and revealed on mammograms. This method is used for women who have had abnormal mammograms or for women who have dense breast tissue. It is not used for regular screening or as an alternative to mammography.
A definitive diagnosis of breast cancer can be made only by a biopsy (a microscopic examination of a tissue sample of the suspicious area).
Final analysis of the breast tissue may take several days.
The sentinel lymph node is the first lymph node that cancer cells are likely to spread to from the primary tumor (the original site of the cancer). Sentinel node biopsy is a procedure that examines the sentinel node to determine if cancer has spread.
Sentinel node biopsy involves:
Patients who have a sentinel node biopsy tend to have better arm function and a shorter hospital stay than those who have an axillary node biopsy. The American Society of Clinical Oncology's guidelines recommend sentinel node biopsy instead of axillary lymph node dissection for women with early stage breast cancer who do not have nodes that can be felt during a physical exam.
If the sentinel node biopsy finds evidence that cancer has spread, the next diagnostic step is to find out how far it has spread. To do this, the doctor performs a procedure called an axillary lymphadenectomy , which partially or completely removes the lymph nodes in the armpit beside the affected breast (called axillary lymph nodes). It may require a hospital stay of 1 - 2 days.
Once the lymph nodes are removed, they are analyzed to determine whether subsequent treatment needs to be more or less aggressive:
Side effects of the procedure may include increased risk for infection and pain, swelling in the arm from fluid build-up, and impaired sensation and restricted movement in the affected arm.
Breast cancer is the second most lethal cancer in women. (Lung cancer is the leading cancer killer in women.) The good news is that early detection and new treatments have improved survival rates. The 5-year survival rate for women diagnosed with cancer is 80%. About Unfortunately, women in lower social and economic groups still have significantly lower survival rates than women in higher groups.
Several factors are used to determine the risk for recurrence and the likelihood of successful treatment. They include:
The good news is that women are living longer with breast cancer. Due to better treatment options, breast cancer mortality rates declined by about 25% since 1990. However, survivors must live with the uncertainties of possible recurrent cancer and some risk for complications from the treatment itself.
Recurrences of cancer usually develop within 5 years of treatment. About 25% of recurrences and half of new cancers in the opposite breast occur after 5 years.
The location of the tumor is a major factor in outlook:
The location of the tumor within the breast is an important predictor. Tumors that develop toward the outside of the breast tend to be less serious than those that occur more toward the middle of the breast.
Breast cancer cells may contain receptors, or binding sites, for the hormones estrogen and progesterone. Cells containing these binding sites are known as hormone receptor-positive cells. If cells lack these connectors, they are called hormone receptor-negative cells. About 75% of breast cancers are estrogen receptor-positive (ER-positive, or ER+). About 65% of ER-positive breast cancers are also progesterone receptor-positive (PR-positive, or PR+). Cells that have receptors for one of these hormones, or both of them, are considered hormone receptor-positive.
Hormone receptor-positive cancer is also called "hormone sensitive" because it responds to hormone therapy such as tamoxifen or aromatase inhibitors. Hormone receptor-negative tumors are referred to as "hormone insensitive" or "hormone resistant."
Women have a better prognosis if their tumors are hormone receptor-positive because these cells grow more slowly than receptor-negative cells. In addition, women with hormone receptor-positive cancer have more treatment options. (Hormone receptor-negative tumors can be treated only with chemotherapy.) Recent declines in breast cancer mortality rates have been most significant among women with estrogen receptor-positive tumors, due in part to the widespread use of post-surgical hormone drug therapy.
Tumor markers are proteins found in blood or urine when cancer is present. Although they are not used to diagnose cancer, the presence of certain markers can help predict how aggressive a patient's cancer may be and how well the cancer may respond to certain types of drugs.
Tumor markers relevant for breast cancer prognosis include:
HER2 . The American Cancer Society recommends that all women newly diagnosed with breast cancer get a biopsy test for a growth-promoting protein called HER2/neu. HER2-positive cancer usually occurs in younger women and is more quickly-growing and aggressive than other types of breast cancer. The HER2 marker is present in about 20% of cases of invasive breast cancer. Two types of tests are used to detect HER2:
Either test may be used as long as it is performed by an accredited laboratory. Tests that are not clearly positive or negative should be repeated.
Treatment with trastuzumab (Herceptin) or lapatinib (Tykerb) may help women who test positive for HER2. In 2008, the FDA approved a new genetic test (Spot-Light) that can help determine which patients with HER2-positive breast cancer may be good candidates for trastuzumab treatment.
Other Markers . Other markers that may be evaluated include CA 15-3, CA 27.29, CEA, ER, PgR, uPA, and PAI-1.
Gene expression profiling tests (Oncotype DX, MammaPrint) examine a set of genes in tumor tissue to determine the likelihood of breast cancer recurrence. These tests are also used to help determine whether adjuvant (following surgery) drug treatments should be given. The American Society of Clinical Oncology and the National Comprehensive Cancer Network now recommend that gene expression profiling tests be administered to newly diagnosed patients with node-negative, estrogen-receptor-positive breast cancer. Based on the results, a doctor can decide whether a patient who has had surgery may benefit from chemotherapy.
Tumor Size and Shape . Large tumors pose a higher risk than small tumors. Undifferentiated tumors, which have indistinct margins, are more dangerous than those with well-defined margins.
Rate of Cell Division . The more rapidly a tumor grows, the more dangerous it is. Several tests measure aspects of cancer cell division and may eventually prove to predict the disease. For example, the mitotic index (MI) is a measurement of the rate at which cells divide. The higher the MI, the more aggressive the cancer. Other tests measure cells at a certain phase of their division.
Recent evidence has not supported early reports of survival benefits for women with metastatic breast cancer who engage in support groups. However, some studies have suggested that psychotherapy, group support, or both may relieve pain and reduce stress, particularly in women who are suffering emotionally.
Stress has been ruled out as a risk factor either for breast cancer itself or for its recurrence.
The three major treatments of breast cancer are surgery, radiation, and drug therapy. No one treatment fits every patient, and combination therapy is usually required. The choice is determined by many factors, including the age of the patient, menopausal status, the kind of cancer (ductal verses lobular), its stage, and whether or not the tumor contains hormone-receptors.
Breast cancer treatments are defined as local or systemic:
Any or all of these therapies may be used separately or, most often, in different combinations. For example, radiation alone or with chemotherapy or hormone therapy may be beneficial before surgery, if the tumor is large. Surgery followed by radiation and hormone therapy is usually recommended for women with early-stage, hormone-sensitive cancer. There are numerous clinical trials investigating new treatments and treatment combinations. Patients, especially those with advanced stages of cancer, may wish to consider enrolling in a clinical trial.
Treatment strategies depend in part on the stage of the cancer.
Stage 0 (Carcinoma in Situ). Stage 0 breast cancer is considered non-invasive ('in situ"), meaning that the cancer is still confined within breast ducts or lobules and has not yet spread to surrounding tissues. Stage 0 cancer is classified as either:
Treatment options for DCIS include:
Treatment options for LCIS include:
Stage I and II (Early-Stage Invasive). In stage I cancer, cancer cells have not spread beyond the breast, and the tumor is no more than 2 cm (about 3/4 of an inch) across.
Stage II cancer is classified as either stage IIA or stage IIb.
In stage IIA cancer the tumor is either:
In stage IIB cancer the tumor is either:
Treatment options for stage I and stage II breast cancer may include:
Stage III (Locally Advanced). Stage III breast cancer is classified into several sub-categories: Stage IIIA, stage IIIB, and stage IIIC (operable or inoperable).
In stage IIIA breast cancer, the tumor is either of the following:
Treatment options for stage IIIA breast cancer are the same as those for stages I and II.
In stage IIIB breast cancer, the tumor has spread to either of the following:
Stage IIIB treatment options may include:
Stage IIIC breast cancer is classified as either operable or inoperable.
In operable stage IIIC, the cancer may be found in:
Treatment options for operable stage III breast cancer are the same as those for stage I and II breast cancers.
In inoperable stage III breast cancer, the cancer has spread to lymph nodes above the collarbone and near the neck on the same side of the body as the affected breast. Treatment options are the same as those for stage IIIB.
Stage IV (Advanced Cancer). In stage IV, the cancer has spread (metastasized) from the breast to other parts of the body. In about 75% of cases, the cancer has spread to the bone. The cancer at this stage is considered to be chronic and incurable, and the usefulness of treatments is limited. The goals of treatment for stage IV cancer are to stabilize the disease and slow its progression, as well as to reduce pain and discomfort.
Treatment options for stage IV cancer include:
The American Society of Clinical Oncology (ASCO) recommends follow-up care for patients who have been treated for breast cancer:
ASCO does not recommend the use of laboratory blood tests (complete blood counts, carcinoembryonic antigen) or imaging tests (bone scans, chest x-rays, liver ultrasound, FDG-PET scan, CT scan) for routine breast cancer follow-up.
Genetic counseling may be helpful if you have:
Pregnancy after Breast Cancer Treatment . There are no definite recommendations on how long a woman should wait to become pregnant after breast cancer treatment. Because of the connection between estrogen levels and breast cancer cell growth, some doctors recommend delaying pregnancy until 2 years after treatment in order to reduce the risk of cancer recurrence and improve odds for survival. However, other studies indicate that conceiving 6 months after treatment does not negatively affect survival. Discuss with your doctor your risk for recurrence, and when it may be safe to attempt pregnancy.
Recurrent breast cancer is considered to be an advanced cancer. In such cases, the disease has come back in spite of the initial treatment. Most recurrences appear within the first 2 - 3 years after treatment, but breast cancer can recur many years later. Treatment options are based on the stage at which the cancer reappears, whether or not the tumor is hormone responsive, and the age of the patient. Between 10 - 20% of recurring cancers are local. Most recurrent cancers are metastatic. All patients with recurring cancer are candidates for clinical trials.
Because most breast cancer recurrences are discovered by patients in between doctor visits, it is important to notify your doctor if you experience any of the following symptoms. These symptoms may be signs of breast cancer recurrence:
Surgery forms a part of nearly every patient's treatment for breast cancer. The initial surgical intervention is often a lumpectomy, the removal of the tumor itself. In the past, mastectomy (the removal of the breast) was the standard treatment for nearly all breast cancers. Now, many patients with early-stage cancers can choose breast-conserving treatment, or lumpectomy followed by radiation, with or without chemotherapy.
For invasive breast cancer, studies indicate that lumpectomy or partial mastectomy combined with radiation therapy works as well as a modified radical mastectomy.
Breast-conserving procedures are now appropriate and as successful as mastectomy in most women with early stage breast cancer. All women should discuss these options fully with their doctor. Recurrence rates with conservative surgery are highest in women under age 45. Some women choose mastectomy over breast-conserving treatment even if the latter is appropriate because it gives them a greater sense of security and allows them to avoid radiation therapy.
Lumpectomy. Lumpectomy is the removal of the tumor, often along with lymph nodes in the armpit. It serves as an opportunity for biopsy, a diagnostic tool, and a primary treatment for small local breast tumors. If invasive cancer is found, the doctor will decide to proceed with breast radiation therapy, to remove additional tissue (should the margins of the specimen show signs of cancer), or to perform a mastectomy. Lumpectomy followed by radiation therapy is appropriate and as effective as mastectomy for most women with Stage I or II breast cancers.
Breast-Conserving Surgery (Quadrantectomy). Breast-conserving surgery (sometimes referred to as quadrantectomy) removes the cancer and a large area of breast tissue, occasionally including some of the lining over the chest muscles. It is less invasive than a full mastectomy, but the cosmetic results are less satisfactory than with a lumpectomy. Studies have found that breast-conserving surgeries plus postoperative radiotherapy offer the same survival rates as radical mastectomy in most women with early breast cancer.
Surgery to remove the breast (mastectomy) is important for women with operable breast cancer who are not candidates for breast conserving surgeries. There are different variations on the procedure:
Complications and Side Effects of Surgery. Short-term pain and tenderness occur in the area of the procedure, and pain relievers may be necessary.
The most frequent complication of extensive lymph node removal is lymphedema, or swelling, of the arm. The likelihood of edema can be lessened by removing only some of the lymph nodes instead of all of them.
Infrequent complications include poor wound healing, bleeding, or a reaction to the anesthesia.
After mastectomy and lymph node removal, women may experience numbness, tingling, and difficulty in extending the arm fully. These effects can last for months or years afterward.
After a mastectomy, some women choose a breast prosthesis or opt for breast reconstruction, which can be performed during the mastectomy itself, if desired. Several studies have indicated that women who take advantage of cosmetic surgery after breast cancer have a better sense of well-being and a higher quality of life than women who do not choose reconstructive surgery. The breast is reshaped using a saline implant or, for a more cosmetic result, a muscle flap is taken from elsewhere in the body. Muscle flap procedures are more complicated, however, and blood transfusions may be required. (It should be noted that implants, including silicone implants, do not appear to put a woman at risk for breast cancer recurrence.) If the nipple is removed, it is rebuilt from other body tissues and color is applied using tattoo techniques. It is nearly impossible to rebuild a breast that is identical to its partner, and additional operations may be necessary to achieve a desirable effect.
Radiation therapy uses high-energy x-rays to kill cancer cells or to shrink the size of a tumor in the breast or surrounding tissue. It is used for several weeks following lumpectomy or partial mastectomy, and sometimes after full mastectomy. Radiation therapy can help reduce the chance of breast cancer recurrence in the breast and chest wall. Radiation is also important in advanced stages of cancer for relief of symptoms and to slow progression. Research shows that radiation therapy is helpful for women of all ages, including those over age 65.
Radiation is generally administered in the following ways:
External Beam Radiation. This type of radiation is administered 4 - 6 weeks after surgery and delivered externally by an x-ray machine that targets radiation to the whole breast. It may be delivered to the chest wall in high-risk patients (large tumors, close surgical margins, or lymph node involvement). The treatment is generally given daily (except for weekends) for about 6 weeks. Some hospitals offer a shortened course of 3 weeks of radiation for patients with early-stage breast cancer.
Brachytherapy. Less commonly, radiation is delivered in implants (called brachytherapy). Implants are most often used as a radiation boost after whole breast radiation.
Side effects of radiation include:
Future complications include:
Current advanced imaging techniques use precise radiation that reduces exposure. These newer techniques are likely to reduce the risks for heart disease and other serious complications.
Chemotherapy drugs are "cytotoxic" (cell-killing) drugs. They are given orally or by injection. They work systemically by killing cancer cells throughout the body. (Unfortunately, they also kill normal cells, which accounts for many of their side effects.) Chemotherapy is always used for advanced breast cancer, but may also be used to treat types of early-stage breast cancer.
Newer biologic drugs target specific proteins involved in cancer. Treatment with these drugs is called targeted therapy. Because targeted therapy drugs do not work as systemically as chemotherapy or hormone therapy drugs, they tend to cause fewer widespread side effects, although they also carry risks of their own
Chemotherapy needs to be tailored to the type of cancer involved. Women require different treatments depending on whether the tumor is node-negative or -positive, hormone receptor-positive or -negative, or HER2-positive or -negative. Different treatment approaches are also used for early-stage cancer and advanced cancer.
Adjuvant chemotherapy is administered following surgery and before radiation therapy. Delaying chemotherapy until more than 12 weeks after surgery may increase the risk for breast cancer recurrence and reduce the odds for survival.
Many different types of chemotherapy drugs are used to treat breast cancer. Common types of chemotherapy drug classes include:
Some of the abbreviations used for chemotherapy drug combinations (regimens) refer to drug classes rather than drug names. For example, regimens that contain an anthracycline drug (such as doxorubicin) use the letter "A," and regimens that contain a taxane drug (such as docetaxel) use the letter "T." Cyclophosphamide (Cytoxan), fluorouracil (5-FU), and methotrexate (MTX) are standard cancer drugs used in many breast cancer chemotherapy regimens.
Chemotherapy regimens usually consist of 4 - 6 cycles of treatment given over 3 - 6 months. Common chemotherapy regimens for early-stage breast cancer include:
Trastuzumab (Herceptin). Trastuzumab is a monoclonal antibody that targets the HER2 protein on cancer cells. HER2-positive cancers account for 15 - 25% of early-stage breast cancer and are associated with more aggressive disease. Younger women tend to be most affected. In 2006, the Food and Drug Administration approved trastuzumab for treatment of HER2-positive, early-stage breast cancer (cancer confined to the breasts or lymph nodes that has been surgically removed).
Trastuzumab is given along with other chemotherapy drugs following lumpectomy or mastectomy. Research indicates that trastuzumab can help prevent cancer recurrence and death among women with early-stage breast cancer, but it increases the risk of heart problems. Trastuzumab can cause heart failure. Women who have heart failure or weak heart muscle (cardiomyopathy) should not use this drug. Women who take trastuzumab need to have regular heart monitoring, especially if they have already have heart problems.
Patients who develop metastatic disease (cancer that spreads throughout the body) are generally not curable. New advances in drug therapies, however, can help shrink tumors, prolong survival, and improve quality of life.
Chemotherapy regimens for advanced cancer may use a single drug or a combination of drugs. Many chemotherapy regimens used for early-stage breast cancer are also used for advanced breast cancer. Some specific combinations for advanced cancer include:
Numerous chemotherapy drugs and drug combinations are being tested in clinical trials. Patients with advanced breast cancer may also receive other types of drug treatments. For example, bisphosphonate drugs, such as zoledronic acid (Zometa) and pamidronate (Aredia), are important supportive drugs for preventing fractures and reducing pain in people whose cancer has spread to the bones.
Three targeted therapy drugs are approved for the treatment of HER2-positive advanced breast cancer
Promising new treatments for breast cancer include:
Side effects occur with all chemotherapeutic drugs. They are more severe with higher doses and increase over the course of treatment.
Common side effects include:
Serious short- and long-term complications can also occur and may vary depending on the specific drugs used. They may include:
High-dose chemotherapy along with peripheral-blood stem cell rescue or bone marrow transplantation procedures have been used for cancer that has metastasized and, in some cases, for earlier stages of breast cancer in high-risk patients. The objective of this treatment is to be able to give patients very high toxic doses of cell-killing drugs.
Transplantation procedures are based on stem cells , which are produced in the bone marrow. Stem cells are the early forms for all blood cells in the body (including red, white, and immune cells). Cancer treatments can harm these growing cells as well as cancer cells.
Despite the initial enthusiasm over the use of transplantation therapy for treatment of high risk breast cancer, this approach is no longer generally recommended and is rarely used outside of a clinical trial setting.
The goal of hormone therapy is to prevent estrogen from stimulating breast cancer cells. It is recommended for women whose breast cancers are hormone-receptor positive (either estrogen or progesterone), regardless of the size of the tumor and whether or not it has spread to the lymph nodes. Like chemotherapy, hormone therapy works systemically.
Hormone therapy works by blocking estrogen that causes cell proliferation. It is used only for patients with hormone receptor-positive ("hormone sensitive") tumors. Different types of hormone therapy work in different ways by:
Tamoxifen was the first widely used hormonal therapy drug, but today it is mainly used as adjuvant therapy for premenopausal women with hormone-sensitive breast cancer. Postmenopausal women are now generally prescribed aromatase inhibitors.
Tamoxifen (Nolvadex) has been the standard hormonal drug used for breast cancer. It belongs to a class of compounds called selective estrogen receptor modulators (SERMs). SERMs chemically resemble estrogen and trick the breast cancer cells into accepting it in place of estrogen. Unlike estrogen, however, they do not stimulate breast cancer cell growth. Because SERMs block estrogen's effects on cancer cells, they are sometimes referred to as "anti-estrogen" drugs.
Tamoxifen is used for all cancer stages in (mainly premenopausal) women with hormone receptor-positive cancers. In addition, it is used to prevent breast cancer in high-risk women. Another SERM drug, toremifene (Fareston), is an option for women with advanced cancer, but this drug is rarely used in the United States. A third drug, fulvestrant (Faslodex), works in a similar anti-estrogen way to tamoxifen but belongs to a different drug class. Fulvestrant is approved only for postmenopausal women with hormone-sensitive advanced breast cancer in which tamoxifen or aromatase inhibitors no longer work.
To prevent cancer recurrence, women should take tamoxifen for 5 years following surgery and radiation. Tamoxifen is an effective cancer treatment, but it can cause unpleasant side effects and has small (less than 1%) but serious risks for blood clots and uterine (endometrial) cancer. Immediately report any signs of vaginal bleeding to the doctor, as this may be a symptom of uterine cancer.
Less serious, but discomforting, side effects include hot flashes and mood swings. According to one study, nearly 25% of women stop taking tamoxifen within 1 year because of these symptoms. By 3.5 years, over 33% stop treatment. Taking tamoxifen for fewer than 5 years, however, increases the risk for cancer recurrence and death. Talk with your doctor about antidepressants or other therapies that may help you cope with tamoxifen's side effects.
Many doctors now recommend that postmenopausal women switch to an aromatase inhibitor after 2 - 3 years of tamoxifen therapy. Several recent studies have indicated that switching from tamoxifen to an aromatase inhibitor significantly improves survival rates and reduces the risk of death from breast cancer as well as other causes.
Aromatase inhibitors block aromatase, an enzyme that is a major source of estrogen in many major body tissues, including the breast, muscle, liver, and fat. Aromatase inhibitors work differently than tamoxifen. Tamoxifen interferes with tumors' ability to use estrogen by blocking their estrogen receptors. Aromatase inhibitors reduce the overall amount of estrogen in the body.
Because these drugs cannot stop the ovaries of premenopausal women from producing estrogen, they are recommended only for postmenopausal women.
There are currently three aromatase inhibitors approved for treating early-stage, hormone receptor-positive breast cancer in postmenopausal women:
All of these drugs are also approved for women with advanced (metastatic) hormone-sensitive breast cancer. Studies indicate that the introduction of aromatase inhibitors has helped greatly in prolonging survival for women with advanced cancer.
Compared to tamoxifen, aromatase inhibitors are less likely to cause blood clots and uterine cancer. However, these drugs are more likely to cause osteoporosis, which can lead to bone loss and fractures. In general, recent studies indicate that aromatase inhibitors are better than tamoxifen in improving survival and reducing the risk of cancer recurrence. Unfortunately, like tamoxifen, they can cause hot flashes, as well as joint pain.
Ovarian ablation is a treatment that stops estrogen production from the ovaries. Medications can accomplish ovarian ablation. Destroying the ovaries with surgery or radiation can also shut down estrogen production. (Osteoporosis is one serious side effect of this approach, but several therapies are available to help prevent bone loss.)
Chemical Ovarian Ablation . Drug treatment to block ovarian production of estrogen is called chemical ovarian ablation. It is often reversible. The primary drugs used are luteinizing hormone-releasing hormone (LHRH) agonists, such as goserelin (Zoladex). (They are also sometimes called GnRH agonists). These drugs block the release of the reproductive hormones LH-RH, therefore stopping ovulation and estrogen production.
Bilateral Oophorectomy . Bilateral oophorectomy, the surgical removal of both ovaries, is a surgical method of ovarian ablation. It may modestly improve breast cancer survival rates in some premenopausal women whose tumors are hormone receptor-positive. In these women, combining this procedure with tamoxifen may improve results beyond those of standard chemotherapies. Oophorectomy does not benefit women after menopause, and its advantages can be blunted in women who have received adjuvant chemotherapy. The procedure causes sterility.
Berg WA, Blume JD, Cormack JB, Mendelson EB, Lehrer D, Böhm-Vélez M, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA . 2008 May 14;299(18):2151-63.
Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, et al. Mammographic density and the risk and detection of breast cancer. N Engl J Med . 2007 Jan 18;356(3):227-36.
Carlson RW, Allred DC, Anderson BO, Burstein HJ, Carter WB, Edge SB, et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw . 2009 Feb;7(2):122-92.
Casey PM, Cerhan JR and Pruthi S. Oral contraceptive use and risk of breast cancer. Mayo Clin Proc. 2008;83(1): 86-90.
Chlebowski RT, Kuller LH, Prentice RL, Stefanick ML, Manson JE, Gass M, et al. Breast cancer after use of estrogen plus progestin in postmenopausal women. N Engl J Med . 2009 Feb 5;360(6):573-87.
Chia SK, Speers CH, D'Yachkova Y, Kang A, Malfair-Taylor S, Barnett J, et al. The impact of new chemotherapeutic and hormone agents on survival in a population-based cohort of women with metastatic breast cancer. Cancer . 2007 Jul 23;110(5):973-979 [Epub ahead of print]
Committee on Gynecologic Practice. ACOG Committee Opinion No. 434: induced abortion and breast cancer risk. Obstet Gynecol . 2009 Jun;113(6):1417-8
Coombes RC, Kilburn LS, Snowdon CF, Paridaens R, Coleman RE, Jones SE, et al. Survival and safety of exemestane versus tamoxifen after 2-3 years' tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial. Lancet . 2007 Feb 17;369(9561):559-70.
Ferguson T, Wilcken N, Vagg R, Ghersi D and Nowak AK. Taxanes for adjuvant treatment of early breast cancer. Cochrane Database Syst Rev . 2007;(4): CD004421.
Geiger AM, Thwin SS, Lash TL, Buist DS, Prout MN, Wei F, et al. Recurrences and second primary breast cancers in older women with initial early-stage disease. Cancer . 2007 Mar 1;109(5):966-74.
Harris L, Fritsche H, Mennel R, Norton L, Ravdin P, Taube S, et al. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. J Clin Oncol . 2007 Nov 20;25(33):5287-312.
Hayes DF. Clinical practice. Follow-up of patients with early breast cancer. N Engl J Med . 2007;356(24): 2505-13.
Hudis CA. Trastuzumab--mechanism of action and use in clinical practice. N Engl J Med. 2007; 357(1): 39-51.
Ives A, Saunders C, Bulsara M, Semmens J. Pregnancy after breast cancer: population based study. BMJ . 2007 Jan 27;334(7586):194. Epub 2006 Dec 8.
Jatoi I, Chen BE, Anderson WF, Rosenberg PS. Breast cancer mortality trends in the United States according to estrogen receptor status and age at diagnosis. J Clin Oncol . 2007 May 1;25(13):1683-90. Epub 2007 Apr 2.
Jørgensen KJ, Gøtzsche PC. Overdiagnosis in publicly organized mammography screening programmes: systematic review of incidence trends. BMJ . 2009 Jul 9;339:b2587. doi: 10.1136/bmj.b2587.
Kerlikowske K, Miglioretti DL, Buist DS, Walker R, Carney PA; National Cancer Institute-Sponsored Breast Cancer Surveillance Consortium. Declines in invasive breast cancer and use of postmenopausal hormone therapy in a screening mammography population. J Natl Cancer Inst . 2007 Sep 5;99(17):1335-9. Epub 2007 Aug 14.
Khatcheressian JL, Wolff AC, Smith TJ, Grunfeld E, Muss HB, Vogel VG, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol . 2006 Nov 1;24(31):5091-7. Epub 2006 Oct 10.
Lehman CD, DeMartini W, Anderson BO, Edge SB. Indications for breast MRI in the patient with newly diagnosed breast cancer. J Natl Compr Canc Netw . 2009 Feb;7(2):193-201.
Lehman CD, Gatsonis C, Kuhl CK, Hendrick RE, Pisano ED, Hanna L, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med . 2007 Mar 29;356(13):1295-303. Epub 2007 Mar 28.
Marchionni L, Wilson RF, Wolff AC, Marinopoulos S, Parmigiani G, Bass EB, et al.. Systematic review: gene expression profiling assays in early-stage breast cancer. Ann Intern Med . 2008;148(5): 358-69.
Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial. Lancet . 2006 Dec 9;368(9552):2053-60.
Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L; U.S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med . 2009 Nov 17;151(10):727-37, W237-42.
North American Menopause Society. Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society. Menopause . 2007 Mar-Apr;14(2):168-82.
Pierce JP, Natarajan L, Caan BJ, Parker BA, Greenberg ER, Flatt SW, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women's Healthy Eating and Living (WHEL) randomized trial. JAMA . 2007 Jul 18;298(3):289-98.
Punglia RS, Morrow M, Winer EP and Harris JR. Local therapy and survival in breast cancer. N Engl J Med . 2007;356(23): 2399-405.
Qaseem A, Snow V, Sherif K, Aronson M, Weiss KB, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians. Ann Intern Med . 2007 Apr 3;146(7):511-5.
Ravdin PM, Cronin KA, Howlader N, Berg CD, Chlebowski RT, Feuer EJ, et al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med . 2007 Apr 19;356(16):1670-4.
Reeves GK, Pirie K, Beral V, Green J, Spencer E, Bull D; Million Women Study Collaboration. Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ . 2007 Dec 1;335(7630):1134. Epub 2007 Nov 6.
Robson M and Offit K. Clinical practice. Management of an inherited predisposition to breast cancer. N Engl J Med . 2007;357(2): 154-62.
Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin . 2007 Mar-Apr;57(2):75-89.
Stuebe AM, Willett WC, Xue F, Michels KB. Lactation and incidence of premenopausal breast cancer: a longitudinal study. Arch Intern Med . 2009 Aug 10;169(15):1364-71.
Turner NC and Jones AL (2008). Management of breast cancer -- Part I. BMJ . 2008;337: a421.
Turner NC and Jones AL. Management of breast cancer -- Part II. BMJ . 2008;337: a540.
US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med . 2009 Nov 17;151(10):716-26, W-236.
Visvanathan K, Chlebowski RT, Hurley P, Col NF, Ropka M, Collyar D, et al. American society of clinical oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction. J Clin Oncol . 2009 Jul 1;27(19):3235-58. Epub 2009 May 26.
Wolff AC, Hammond ME, Schwartz JN, Hagerty KL, Allred DC, Cote RJ, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol . 2007 Jan 1;25(1):118-45. Epub 2006 Dec 11.


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Toyota, Honda, and Nissan have been placed on credit watch with what is termed negative implications by Standard & Poors, the New York ratings agency.
The move comes less than a week after Toyota - the third-biggest car maker in the world - warned it may lose money this year and Honda reported a 55 per cent profits slump. Last month Nissan decided to close a factory near Tokyo after losing Y108bn (pounds 692m) in the year to March.
Further evidence of the pressure on Japanese automotive exports was also provided yesterday by figures for July, showing a 13.9 per cent decline in vehicle shipments from a year earlier to 404,178.
Standard said its rating action reflected the 'dramatic worsening of already difficult auto industry conditions', noting that the share price of all three had fallen due to renewed competitiveness by American producers.
'The unexepected appreciation of the yen by 17 per cent in the last few months will further erode the earnings of the Japanese auto companies as well as erode their competitiveness if they continue to raise prices to offset the falling yen,' the agency warned.
According to recent research by DRI/McGraw-Hill, the consultancy group, every one yen increase in the strength of the Japanese currency costs Toyota dollars 50m ( pounds 33m).
Honda, which relies more heavily on exports than Toyota or Nissan, has already taken action to try to counter problems caused by the strong yen by raising prices in the US and cutting margins earned by dealers in the UK.
Japanese car workers, who have become accustomed to a jobs-for-life culture, have not yet had to face the prospect of redundancy.
However, many have lost the traditional 20 per cent overtime part of wage packets as companies have tried to cut costs.
Standard added that an additional problem facing the Japanese motor companies 'is that weak domestic demand is proving to be persistent. The European market, too, remains weak.'
Its credit watch covers the triple-A long-term rating of Toyota and its financial subsidiaries in the US, the Netherlands, Australia and Canada.
Also affected are the single-A long-term and A-1 short-term ratings of Nissan and the A-1 short-term rating of Honda for both parent companies as well as two subsidiaries each in the US and one each in the Netherlands.
Standard will meet the three companies before Christmas to review trends in earnings and their plans to cope with the stronger yen, to reduce costs and strengthen balance sheets.
The Japanese July automobile export figures mark the fourth consecutive month of year-on-year declines.
Car exports bore the brunt of the fall in July, dropping by 14.3 per cent to 311,839. Shipments of trucks fell by 13.4 per cent to 86,305, although buses edged up by 0.7 per cent to 6,034.
Exports to the European Community decreased for the sixth straight month, and markets in the Middle East, North and South America and Africa also declined.
The dual problems with currency and falling domestic demand are also hitting the steel industry.
Nippon Steel, the biggest producer in Japan, yesterday warned it was likely to incur a pre-tax loss in the year to March - its first in seven years.
Steel industry observers in Japan reckon that Nippon could lose as much as Y10bn in the six months to September, more than double previous estimates.
That would compare with the Y14.1bn profit the company made in the same period last year.
In 1987, the company lost Y12.6bn, principally due to the Japanese currency's surge against the dollar.
- More about:
- Automotive Equipment (car Industry)
- Honda
- Nissan
- Toyota

subset: commoncrawl


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Legacy Harbour Hotel & Suites
- Chilled Out
- History
Located in the Downtown Fort Myers River District. Waterfront Suites located on the Caloosahatchee River, overlooking Legacy Harbour Marina, with shopping/restaurants nearby. Close to Edison & Ford Winter Estates, Centennial Park and historic downtown Fort Myers. Standard hotel rooms available.


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|Government & Organizations
Keep up with all of President Obama's remarks, town halls, and press conferences in this comprehensive podcast. This feed will occasionally include remarks from other principals like Vice President Biden and First Lady Michelle Obama.
March 19th, 2015
Episode 186 of 668 episodes
On March 18, 2015, President Obama traveled to Cleveland, Ohio where he toured MAGNET's Manufacturing Innovation Center at Cleveland State University, the Ohio Manufacturing Extension Partnership affiliate.
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Welcome to the daily audio workout for your head.


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One parenting mistake that will trip up even the best intentions of parents of teens is a lack of consistency. Not that any of us start out wanting to be inconsistent in our communication or discipline with our teenagers, but it happens when we aren't paying enough attention to what we are saying or doing. Unfortunately, the consequences of being inconsistent can mean arguments, broken rules and hurt feelings, lack of trust and a bruised relationship between you and your teen. All of these things can be avoided if you employ some consistency in your communication and discipline with your teenager.

What if you are already having a difficult time with your teen and you think lack of parental consistency might be part of the problem? Will changing the way you act change the way your teen acts? Yes, it will. When you start to use consistency in talking with your teen, they will begin to listen to what you have to say. When you use consistency in discipline, they will understand what the rules are and trust that you will uphold them. It may not happen overnight, but by remaining consistent, it won't take long.

Consistency in Communication with Your Teen

Do you want your teen to listen to you? It isn't overly difficult to do! You simply need to be in the good parenting habit of meaning what you say and saying what you mean. Because when adults start to lecture, exaggerate or yell, it turns teens off and they stop listening. When they stop listening, they don't hear what you want them to know. Without knowing what you want, they don't do what they should and get into trouble with you. You get frustrated, they get frustrated and your relationship suffers.

Here are the steps to take to be consistent when talking to your teen:

Stop what you are doing. Take time to think through exactly what it is you want your teen to do.

Take a deep breath before speaking. Verbalize what you would like your teen to do without raising your voice or using exaggeration.

Ask your teen if they understand what you are asking them to do. If not clarify.

Thank your teen.

It sounds so formal, doesn't it? But in practice, it really isn't. I've gotten so used to communicating this way with my teenagers that this is almost an automatic process. Here is a conversation that happens weekly with my teen daughter:

Daughter: "Can I go to my boyfriend's house after school today?"
Me: "Is his mother going to be home? Will you be staying for dinner?"
Daughter: "Yes, his mom will be home and we are going to walk to the sub shop for dinner."
Me: "Call me when you get to his house. Okay?"
Daughter: "Sure. I'll call you."
Me: "Thanks for letting me know. Have fun."

Note that I reminded her of the rules when I asked her if her boyfriend's mother was going to be home and I verbalized what I wanted her to do: call me when she got to his house. I did this without raising my voice or using exaggeration, like if I would have said, "Call me or you'll be grounded for a month."

Consistency in Disciplining Your Teen

Contrary to the old adage, rules were not made to be broken. Family rules are made to ensure the safety and welfare of each family member and the family as a whole. When rules fit this form and are followed, the family gets along and the household runs smoothly. When rules are made haphazardly and changed often, or teens are unaware of the rules, family members do not get along and the household ends up in chaos.

Teens like when parents set realistic rules and make clear what the consequences are for not following them - as opposed to not knowing what you want from them or what will happen if they break the rule. Teens get very frustrated when they indiscriminately get into trouble. Consistency in discipline provides a firm foundation for your teen's actions. Knowing what is okay and what is not okay to do helps them to feel safe and secure when making decisions.

So how do you use consistency in disciplining teens? First, be consistent in communicating the rules and the consequences for not following the rule. Parenting contracts are good for this purpose. Then, follow through by checking that your teen is following the rules and use the predetermined consequence if not. Following through with what you have said tells your teen that you mean what you say, so it is very important. When you don't follow through with the consequences you have set they can't trust what you tell them in the future. This will breakdown your ability to discipline your teen and hurt your relationship.

Consistency Will Strengthen Your Relationship with Your Teen

When parents are striving to provide fair and firm discipline by keeping the lines of communication with their teen open and using consistent rules, like curfews, teens feel safe and trust that their parent means what they say and will follow through. This provides security to a child who is going through the pandemonium of adolescence. Consistency builds trust and will strengthen your parent-child relationship.


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Do iris possibly smell differently in different climates/soils? I wonder because some I have that smell a certain way for me are described as smelling differently by those introducing them (rarely, but sometimes)
Mike in SC
-----Original Message-----
From: email@example.com [mailto:firstname.lastname@example.com] On Behalf Of Paul Archer
Sent: Monday, May 17, 2010 6:23 AM
To: Iris chat forum
Subject: [iris] Iris fragrance... sort of.
I was debating whether to mention this or not but maybe as a group we can sway Hybridizers/Introducers opinion on this. And maybe I have some clout now that many of you have seen my seedlings I've been working on and yet have still not Introduced a single one.
During my breeding efforts I have been purchasing new varieties over the years for one reason or another. Some were based on the applauded, described or registered fragrance.
I came across one variety I had purchased last year (not a 2009 Intro though) that had a distinct fragrance when it bloomed. Granted the description on their website has no mention of a fragrance and it is not registered to have one. This variety is from a well know Hybridizer. And no, no matter how much you ask I will not tell you who it is but I have seen them post in this forum. That also means I cannot tell you which variety it is either. That is beside my point.
The flower is nice, a little different than others I've seen recently, but not so spectacular that others from the same cross or near sibs could not have been chosen with a better fragrance I am most sure.
So you ask... What does it smell like? Well I smelled it and I asked a friend to smell it for me and tell me what they think. We both agreed without a doubt... STALE CIGARETTE SMOKE. And you would never guess from the registered name that it smells like that and actually the name suggests quite the opposite.
Lots of things come to mind why a hybridizer would introduce one like this. The obvious is to sell it an make money. The second might be they just aren't paying attention to fragrance as a selectable character. Third, they might actually be a smoker and can't smell it...haha. Fourth, maybe they thought they could get away with it (so far they have, right). I think those might be fair assessments for starters.
However, if a fragrance like this has not been caught during the seedling evaluation stage, it certainly could if the effort was made during the production phase or just prior to it and it's Registration.
Yes, I understand some may like that smell and waft nostalgic on the good- ol'-days-way-back-when. However, if one is going to Register and Introduce a flower that people are bound to want to smell this should be checked. And if a hybridizer wants to Introduce it knowing that is smells like that they should have the guts to describe it that way.
I'm merely making a simple request for Hybridizers/Introducers to check their fragrances and just be honest. People are paying you good money to purchase your plants and make their decisions on what to buy. They put their trust in you based on your judgement and experience.
Nuff said on my part.
To sign-off this list, send email to firstname.lastname@example.com with the
message text UNSUBSCRIBE IRIS
To sign-off this list, send email to email@example.com with the
message text UNSUBSCRIBE IRIS


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Sir Hew Dalrymple, 3rd Baronet
From Wikipedia, the free encyclopedia
Sir Hew Dalrymple, 3rd Baronet (26 October 1746 – 13 February 1800) was the Member of Parliament (MP) for Haddingtonshire 1780-1786.
He was the son of Sir Hew Dalrymple, 2nd Baronet.
He was an army officer, serving as in ensign in the 31st Foot from 1763, a captain in the 1st Foot from 1768, and the 92nd Foot from 1779.[1]
He stepped down as MP in 1786, when he was appointed Auditor of the Excise in Scotland 1786, holding this post until his death. He changed his name to Hamilton-Dalrymple in 1796 when he inherited the estate of Bargany from his uncle, John Hamilton (formerly Dalrymple).[2]
- Leigh Rayment's Historical List of MPs [self-published source][better source needed]
- Leigh Rayment's list of baronets [self-published source][better source needed]
- ^ "British Armorial Bindings". The Bibliographical Society of London. Retrieved 9 January 2013.
- ^ Jenkins, Nicholas. "W. H. Auden - 'Family Ghosts'". Retrieved 9 January 2013.
|Parliament of Great Britain
|Preceded by
William Hamilton Nisbet
|Member of Parliament for Haddingtonshire
|Succeeded by
John Hamilton
|Baronetage of Nova Scotia
|Preceded by
Hew Dalrymple
(of Bargeny)
|Succeeded by
Hew Dalrymple-Hamilton
|This article about a Member of the Parliament of Great Britain (1707–1800) representing a Scottish constituency is a stub. You can help Wikipedia by expanding it.


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Hailee Steinfeld looked all grown up with a sexy smoky eye at the Teen Choice Awards
Hailee Steinfeld attended the Teen Choice Awards last night, sporting a very grown-up eye makeup look.
We've been seeing the 16-year-old actress (and budding fashionista) all over the red carpets as of late, but her beauty look usually errs on the side of youthful and refreshing.
Last night, all bets were off, and Hailee went for a super-dark, super-intense dark navy-gray smoky eye that, we must say, was pretty smoldering. The shadow matched her whimsical orange and navy House of Holland dress from the label's most recent resort collection.
We think we like Hailee with this dark and stormy vibe going on, but we really want to know what you think. Vote on Hailee's eye makeup in the poll below!


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This handsome leather sectional sofa will be a most welcoming addition to your traditional living room. Classic bun feet, rolled arms, and a beautiful brass nailhead trim make the design of this sofa come to life. Choose for a wide variety of leathers to dress your sofa up with and create the perfect complement to your existing home decor. Loose box edge with welt pillow backs and sinuous spring construction ensures that every time you sit upon this sofa it will be a most comfortable experience. Like the look but don't see this particular arrangement working in your home? Don't fret! Foster offers other separate sectional pieces for you to build the best sofa possible.
The Foster Leather Sectional Sofa with Nailhead Trim by Bernhardt at Baer's Furniture in the Ft. Lauderdale, Ft. Myers, Orlando, Naples, Miami, Florida area. Product availability may vary. Contact us for the most current availability on this product.
The Foster Collection is a group of living room seating featuring stylish mid-priced home furnishings, in fabric and leather upholstery options. It has features like plush rolled arms, nailhead trim, exposed wood turned bun feet and comfortable, plush cushions. You will love the elegant style this living room furniture offers you and with the ability to choose the upholstery, you can customize it to fit in your home perfectly. The Foster Collection includes a stationary sofa, a sectional, a chair 1/2, a gorgeous chair and ottoman and a love seat. Plenty of choices to help make your home design everything you dream about!
The Foster collection is a great option if you are looking for Casual furniture in the Ft. Lauderdale, Ft. Myers, Orlando, Naples, Miami, Florida area.
These images are representative of this group as a whole and may differ from this item.
Browse other items in the Foster collection from Baer's Furniture in the Ft. Lauderdale, Ft. Myers, Orlando, Naples, Miami, Florida area.
This item has been tagged as: Sectional, Couch, Sofa, Large Couches, Large Sofa, Sectional Couch, Sectional Sofa, Chaise Sectional, Sectional with Chaise, Couch with Chaise, Sofa with Chaise, Chaise Sofa, Chaise Couch, Sectional with Recliner, Recliner Sectional, Reclining Sectional, Modular Sectional, Modular Sofa Pieces, Stand Alone Couch Pieces, Curved Sectional, Conversation Sofa, Conversational Sofa, Sectional Furniture, Home Theatre Sectional, Home Theater Sectional, Sectional with Ottoman
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Max Axiom
Section of Max Axiom comic on the scientific method. Max Axiom is the one on the left with all the rippling muscles. A sort of super-hero scientist.
The comics are reasonably popular in the US, well 'popular' as kids science books can be... The lady at the Exploratorum gift shop said they were a huge seller. There is a whole series. I have one on climate change too.
Blogged here. See also this pic of a Japanese science comic (and blogpost) and this article by an old student of mine.
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Taken on November 6, 2009


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June 16, 2016 · Print This Article
June 18, 2016, 7-10PM
Work by: Alberto Aguilar, Basma Alsharif, Robert Burnier, Alex Chitty, Katy Cowan, Assaf Evron, Danny Giles, Gordon Hall, Sofia Leiby, Jose Lerma, Shana Lutker, Matt Morris, Gina Osterloh, Claire Pentecost, Tim Portlock, Josh Reames, Amanda Ross-Ho, Sanaz Sohrabi, Stephanie Syjuco, Tony Tasset, and Lori Waxman, among many others.
Mana Contemporary: 2233 S Throop St, Chicago, Illinois 60608
2. House Shoes
June 18, 2016, 7-10PM
Work by: Mariam Ezzat, Viki Hicky, Emily Kostrzewa, and Matthew Luther (Curated by Crystal Palmer)
cornerstore:1903 S Allport #3F, Chicago, IL 60608
June 22, 2016, 6-8PM
Work by: James Barnor (Curated by Renée Mussai)
Stony Island Arts Bank: 6760 S Stony Island Ave, Chicago, Illinois 60649
June 17, 2016, 5-8PM
Work by: Jessica Caponigro, Diane Christiansen, Deborah Handler, Anna Kunz, Zoe Nelson, Josue Pellot, Josh Reames, Allison Reimus, Ryan Richey, Philip von Zweck, Erin Washington, and Amanda Williams (Curated by Jessica Cochran)
McCormick Gallery: 835 West Washington Blvd, Chicago, IL 60607
5. Yollocalli Youth Graffiti Battle
June 18, 2016, 2-5PM
Yollocalli Arts Reach: Barrett Park 2022 W Cermak Rd, Chicago, IL 60608
The Visualist will occasionally feature an additional project that happens to be situated away from Chicago.
Special Mention: HOMOCCULT 2.0 – S+S PROJECT in MEXICO CITY
On view through Sunday, June 19th
Work by: Adam Rose + April Lynn, Asher Asher, Gio Black Peter, Erika Bulle, Elijah Burgher, Tania Chavez, Jos Demme Howard, Cristian Diaz, Felix d'Eon, Clothilde Double, Orlando Estrada, Rosé Hernandez, Serena Jara, Vycktorya Letal, Armando Lozano, Meg McCarville, Daniel McKernan, David Nasca, Mipanocha Rurru, Keijaun Thomas, Tsade Trigo, Lechedevirgen Trimegisto, Caleb Yono, and Sara Zalek
@ Los Insurgentes, Fundación del Centro Cultural del México Contemporáneo, ArtSpace Mexico, and Museu de la Ciudad
Top 5 Weekend Picks! ((12/6-12/8)
December 5, 2013 · Print This Article
1. Boy, Pig, Power at PeregrineProgram
Work by Doug Ischar.
PeregrineProgram is located at 3311 W. Carroll Ave. Reception Sunday, 1-4pm.
2. THE COLLECTORS / VISITATION RITES II at The Franklin
The Collectors features work by Corinne Halbert, Chris Lin and Ryan Richey. Visitation Rites II is curated by Chris Smith and E. Aaron Ross.
The Franklin is located at 3522 W. Franklin Blvd. Reception Saturday, 6-10pm.
Work by Holly Murkerson and Neal Vanderbergh.
Roots & Culture is located at 1034 N. Milwaukee Ave. Reception Friday, 6-9pm.
4. Chicago Style at David Weinberg Photography
Work by Zacharias Abubeker, Matt Austin, Matthew Avignone, Clarissa Bonet, Kate Bowen, Dan Bradica, Molly Brandt, Billy Buck, Debbie Carlos, Claire Demos, KK Depaul, Todd Diederich, Thomson Dryjanski, Jackie Furtado, Daniel Hojnacki, Kelly Kristen Jones, Kimberly Kim, Natalie Krick, Megan Lee Miller, Meg T. Noe, Jessica Pierotti, Jonathan Pivovar, Josh Poehlein, Greg Ruffing, Justin Schmitz, Christopher Semel, Rafael Soldi, Sonja Thomsen, Michelle Wang, David Weinberg, Nicole White, Krista Wortendyke, Victor Yanez-Lazcano and Gurl Don't Be Dumb.
David Weinberg Photography is located at 300 W. Superior St. Reception Friday, 5-8pm.
Work by John Marks.
Roman Susan is located at 1224 W. Loyola Ave. Reception Saturday, 7-9pm.
Top 5 Weekend Picks (2/17-2/19)
February 17, 2012 · Print This Article
1. Living By Example at Northeastern Illinois University Fine Arts Center
Work by Jeroen Nelemans, Ryan Richey, Ryan Travis Christian, Molly Zuckerman-Hartung, Deborah Boardman, Dana Carter, Kirsten Leenaars, Zachary Cahill, Ann Toebbe, Melissa Oresky, Alberto Alguilar, Corinne Halbert, Meg Duguid, Heidi Norton, Paul Nudd, Maria Gaspar, Mindy Rose-Schwartz, Eric Brown, Catie Olsen, and Michael Rea.
Northeastern Illinois University Fine Arts Center is located at 5500 N St. Louis. Reception Friday from 6-9pm.
2. the big stink moves like a moth towards the light at HungryMan Gallery
Work by Ethan Cook, McKeever Donovan, Michael Hunter, Andrew Laumann, Mallory Anita Lawson, Sofia Leiby, John Roebas, Letha Wilson, and Eric Veit.
HungryMan Gallery is located at 2135 N. Rockwell St. Reception Saturday from 7-10pm.
3. The Warmest Guest at Autumn Space Gallery
Work by Magalie Guérin.
Autumn Space Gallery is located at 1700 Irving Park #207. Reception Saturday from 6-9pm.
4. Honk If You Love Painting at Terrain
Work by Anna Kunz.
Terrain is located at 704 Highland Ave., Oak Park. Reception is Sunday from 2-4pm.
5. Accidents in Gravity at ACRE Projects
Work by Michelle Anne Harris.
ACRE Projects is located at 1913 W 17th St. Reception is Sunday from 4-8pm.
Top 5 Weekend Picks Are Back!
January 12, 2012 · Print This Article
1. NEW FORMALISMS 2 at 65GRAND
Work by Samantha Bittman, Todd Chilton, Steven Husby, and Melissa Oresky.
65GRAND is located at 1369 W Grand Ave. Reception is Friday from 7-10pm.
2. I'M HERE TO MAKE FRIENDS at Happy Collaborationists Exhibition Space
Work by Aay Preston-Myint.
Happy Collaborationists Exhibition Space is located at 1254 N Noble St. Reception is Saturday from 6-10pm.
3. Group Exhibition at Hinge Gallery
Work by work by Corydon Cowansage, Aaron Delehanty, Brent Houston, Charles MaHaffee, MaryKate Maher, and Ryan Richey.
Hinge Gallery is located at 1955 W Chicago Ave. Reception is Saturday from 6-9pm.
4. SUPERSTRUCTURES at The Mission Projects
Work by Susan Giles, Jeroen Nelemans, and David Salkin.
The Mission Projects is located at 1431 W Chicago Ave. Reception is Friday from 6-9pm.
Work by Laura Mackin.
Threewalls is located at 119 N Peoria St. Reception is Friday from 6-9pm.


text:
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Opera Mini 5 Final(Handler Mod UI)
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Cheap flights from Sheremetyevo to Bishkek
Information about flights from Sheremetyevo to Bishkek
Bravofly's flight search finds you all available low cost flights from Sheremetyevo to Bishkek in just a few clicks. When looking for a low cost flight Sheremetyevo-Bishkek, simply specify departure and arrival dates and the maximum price you want to pay. It's that simple!
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