Jesse’s story

Jesse, a 44-year-old professional horse trainer, had been extremely active all her life. She had no medical problems other than a broken leg as a child. One day, after several hours of riding, she noticed in the shower that her right breast was quite red. Jesse didn’t remember falling or hitting her chest. She examined herself and could not feel any lump. However, the skin on her breast looked different, thicker and a little warm. She saw her gynecologist, who immediately sent her for a mammogram which confirmed skin thickening on her breast only.

Jesse was referred to a breast cancer surgeon who did a breast biopsy and confirmed inflammatory cancer. She was seen by a medical oncologist who ordered a PET/CT scan that revealed no evidence of cancer spread. Jesse underwent 6 cycles of chemotherapy which rapidly decreased the redness and discomfort in her breast after the first 2 cycles. She underwent a mastectomy followed by 6 weeks of radiation therapy. Jesse tolerated her treatment well. We followed her up with her 3 cancer specialists for the last 3 years, she has been doing well with no evidence of recurrence of her cancer. She has retrained her horses regularly and enjoys life.

Possible Reasons for a Red Breast

There are several reasons why a woman or a man may develop acute breast flushing (rather sudden onset). Infection and inflammation are the two most common causes. Both conditions must be treated in a timely manner to improve health and minimize pain. They usually resolve within a week or two. However, there is one cause of breast redness that is always life-threatening: inflammatory breast cancer (IBC).

Warning signs

IBC is a particularly aggressive form of breast cancer. Among every 100 patients diagnosed with breast cancer, about 2 to 5 will have IBC. It is most commonly diagnosed in younger women and the redness can appear literally within a few days. While most people who develop a red breast will NOT have IBC, both patients and their primary care physicians should be aware of the possibility. This diagnosis should be especially suspected in patients who still have a red breast after treatment with antibiotics or anti-inflammatories for suspected infection or inflammation. The classic description of IBC’s appearance is orange peel.

Diagnosis and staging

The diagnosis is confirmed by a biopsy of the breast skin, usually done by a breast surgeon or radiologist. Pathologists, specially trained doctors who view biopsy tissue under a microscope, will usually describe tumor cells in the lymph channels of breast tissue and breast skin. Blockage of these channels is often the cause of breast redness in IBC. Often, there is no specific mass or lump in the breast, just thickened, diffuse red breast skin. The evaluation of the breast itself should include a mammogram, often an ultrasound (if a mass is felt), and sometimes an MRI. All patients with IBC are considered to have aggressive disease. As such, unless the patient is in very poor condition and is not tolerating treatment, staging studies should be done to assess whether the cancer has visibly spread elsewhere. These scans would include PET/CT or CT of the chest and abdomen and bone scan. Patients with symptoms such as severe headache, nausea, and vomiting should also undergo an MRI of the brain.

Treatment and result

As with all breast cancers, treatment for IBC can be divided into two categories: locoregional (breast and lymph nodes) and systemic (throughout the body). A common mistake a surgeon can make is to recommend a mastectomy (removal of the breast) first. Medically reasonable patients should almost always receive chemotherapy first, then mastectomy, and then radiation therapy (RT) to the chest wall and regional lymph nodes. All three treatments, chemotherapy, surgery, and RT, are necessary to provide the best chance for a cure. Hormonal and targeted therapies (such as Herceptin) may also be recommended, depending on the specific biology of the tumor. Among patients who have no evidence of metastasis (disease spread to distant areas of the body) at diagnosis and who are potentially curable, 40-50% are alive 5 years later. Awareness of this particularly aggressive form of breast cancer and its treatment is essential to ensure the best chance of cure.