Breast Cancer
"Your mammogram
is suspicious for breast cancer." "Your biopsy was positive for breast cancer."
These are among the most terrifying words a woman can hear from her doctor. Breast
cancer elicits so many fears, including those relating to surgery, death, loss
of body image and loss of sexuality. Managing these fears can be facilitated by
information and knowledge so that each woman can make the best decisions concerning
her care. Optimally, these issues are best discussed with the patient's doctor
on an individual basis. What follows is a review of information on breast cancer
intended to aid patients and their families in their navigation through the vast
ocean of breast cancer issues.
Who is at risk for breast cancer?
Currently, one in every eight women in the United States develops breast cancer.
The exact cause of breast cancer is not known and most likely involves many factors,
including genetic, environmental, nutritional and hormonal. Breast cancer is more
common in higher socioeconomic groups, unmarried women, urban areas and Jewish
women.
The most prominent risk factors for breast cancer are age and gender. Men can
develop breast cancer, but women are 200 times more likely to develop breast cancer
than men. Breast cancer is four hundred times more common in women who are 50
years old as compared to those who are 20 years old. Seventy-five percent of women
who develop breast cancer have no risk factors other than age.
A family history of breast cancer will increase the risk of developing breast
cancer in a woman by three to five times. Recently, a breast cancer gene (BR CA
1) has been identified. If a woman has this gene present in her chromosomes, there
is an 85% chance of developing breast or ovarian cancer, or both in her lifetime.
Fifty percent of these cancers will occur before the age of fifty. This gene is
felt to be responsible for only two to four percent of all breast cancer cases.
Currently, the test for this gene is available only at certain research centers,
and though it is highly predictive of some breast cancers, it is still not clear
how best to use this information in treating and counseling patients.
Women who started their menstrual periods before age 12, those who delayed menopause
until after age 55, and those who had their first pregnancy after age 30 have
a mildly increased risk of developing breast cancer (less than two times the normal
risk). Pregnancy and breast feeding have a protective effect in preventing breast
cancer. Some studies show that hormone
replacement therapy and birth
control pills cause a small increased risk of breast cancer, but this has
not been confirmed in all studies.
When a breast
biopsy demonstrates the development of abnormal cells that are not yet cancerous,
called atypical hyperplasia, there is a moderately increased risk of developing
breast cancer in the future.
Dietary factors such as high-fat diets and alcohol consumption have been implicated
as increased risk factors for breast cancer in some studies. More recent studies
have disproven high-fat diets as increasing the risk for breast cancer. Cigarette
smoking,
caffeine intake, and stress do not appear to increase the risk of breast cancer.
How is breast cancer diagnosed?
Currently, mammography and breast examination serve as the foundation in screening
for breast cancer. Mammography is an x-ray examination of the breast. It has the
ability to detect a cancer in the breast when it is quite small, long before it
may be felt by breast examination. Eighty-five to 90% of all breast cancers are
detectable by mammography. Approximately 10 to 15 percent of breast cancers are
not visible on mammography, but can be felt on physical examination of the breast.
Since a percentage of breast cancers is not seen on mammography, it is extremely
important for a woman to have regular breast examinations as well as mammograms
in order to most fully ensure she has no evidence of breast cancer. Breast examination
can be performed by the woman's health professional during the routine physical
checkup. It should also be performed monthly by the woman herself using the technique
of breast self- examination. It is best to do breast self-examination 3 days after
the menstrual period has stopped. Any detected change from the usual appearance
or feel is reported to the health professional.
An ultrasound
is a test that uses sound waves to visualize structures inside the body. It is
often used to distinguish between cysts and solid tumors in the breast. Fluid
within cysts can be aspirated (withdrawn with a needle and syringe) for analysis
in the laboratory.
If an area of the breast is suspicious for a cancer, a biopsy (removal of a piece
of tissue to analyze under the microscope) is usually performed to confirm or
deny the diagnosis. Eighty percent of biopsies are not cancerous.
How is the breast designed?
Breast cancer is not just one disease, but rather is a general term used to describe
a number of different types of cancers which occur in the breast. Each different
type of breast cancer behaves differently and has a different prognosis. Before
describing the different cancers and how they are treated, some background information
may be helpful.
The breast is an organ of the body designed to produce milk. The breast contains
glands called lobules which produce breast milk. There are also tubes or channels
called ducts which transport the milk from the glands to the nipple. The majority
of breast cancers begins in either the ducts or the lobules and cancer names are
based on their site of origin (i.e., ductal carcinoma of the breast or lobular
carcinoma of the breast). The lobules and ducts are supported in the breast by
surrounding fatty tissue and ligaments.
There are also blood vessels and lymphatics present in the breast. Lymphatics
are small thin channels similar to blood vessels. They do not carry blood, but
collect and carry tissue fluid. This fluid ultimately re-enters the blood stream.
Breast tissue fluid drains through the lymphatics into the axillary lymph nodes,
located in the underarm. Lymph nodes are small glands through which lymphatic
channels enter. They filter the lymph fluid and can serve as a barrier to the
further spread of bacteria or cancer cells that may have entered the lymph fluid.
Lymph nodes are not completely effective in filtering out cancer cells and may
spread to other parts of the body despite their presence. Once cancer cells have
gained access to either the lymph channels or the blood stream, they have the
potential to spread to any area of the body. In breast cancer, these areas are
typically the bone, the lungs, the liver and the brain.
Breast cancer is also categorized as invasive (infiltrating) or non-invasive (in-situ).
Invasiveness, as it relates to cancer, refers to the cancer's ability to spread
to other parts of the body (metastasize). If a cancer is invasive, it has the
capability of growing directly into other parts of the body, or traveling in the
blood or lymph fluid to these areas. Non-invasive cancers (in situ cancers) are
those cancers which are defined by microscopic criteria as lacking the ability
to spread to other parts of the body.
What are the types of breast cancers?
The majority of breast cancers can be classified into one of the following categories;
infiltrating ductal carcinoma, infiltrating lobular carcinoma, ductal carcinoma
in situ, lobular carcinoma in situ, inflammatory carcinoma, Paget's disease, and
cystosarcoma phyllodes. There are other tumors of the breast, such as angiosarcoma,
squamous cell cancer and lymphoma, but they are quite rare. These categories are
based on the microscopic appearance of the breast tissue obtained with a biopsy
sample.
Infiltrating Ductal Carcinoma
Infiltrating Ductal Carcinoma begins in the cells forming the ducts of the breast.
It is the most common form of breast cancer, comprising about 65-85% of all cases.
On a mammogram, invasive ductal carcinoma is usually found as an irregular mass,
or as a group of small white irregular dots called microcalcifications, or a combination
of both. It may also appear as a lump in the breast. On physical examination,
this lump usually feels much harder or firmer than other benign causes of lumps
in the breast.
Infiltrating Lobular Carcinoma
Infiltrating Lobular Carcinoma comprises 5 to 10 percent of breast cancers. This
type of breast cancer can appear similar to infiltrating ductal carcinoma on mammography,
but on examination of the breast there is usually not a hard mass, but rather
a vague thickening of the breast tissue. Lobular carcinoma can occur in more than
one site in the breast (multicentric) or in both breasts simultaneously (bilateral).
Ductal Carcinoma In Situ (DCIS)
Ductal Carcinoma In Situ (DCIS) is a pre-invasive form of breast cancer. It is
commonly seen in association with an invasive breast cancer. If it occurs without
an invasive cancer there is usually no lump associated with it. On mammography,
there may be fine microcalcifications which can signal its presence. DCIS is frequently
multifocal, meaning it is located in more than one area of the breast. Approximately
one-third of DCIS cases are multifocal. If DCIS is treated with biopsy alone,
about 40% of women will ultimately develop an invasive cancer of that breast in
the future.
Lobular Carcinoma In Situ (LCIS)
Lobular Carcinoma In Situ (LCIS) is usually encountered as an incidental finding
in a breast biopsy. It has no symptoms, and has no characteristic pattern on mammography.
It has been found to occur in multiple sites in the same breast in 40 to 90% of
cases. In 50% of the cases, it may also occur in the opposite breast. The risk
of developing an invasive cancer of the breast with LCIS is approximately 1% per
year. The invasive cancer that develops has about an equal chance of being in
either breast regardless as to which breast the LCIS was initially found. A large
percentage (38%) of women with LCIS may not develop an invasive cancer until more
than 20 years after the initial diagnosis.
Inflammatory Carcinoma
Inflammatory carcinoma of the breast is a subtype of infiltrating ductal carcinoma,
but is named for its typical clinical presentation. The breast becomes red, swollen,
and warm, and the skin becomes quite thickened. The breast appears as if it were
infected. This appearance is due to the rapid growth of the cancer which blocks
the lymphatics in the breast, causing it to swell and appear infected. The cancer
has already spread to the lymph nodes in 90% of the cases at the time of diagnosis.
The prognosis for this cancer is very poor, and is fortunately relatively uncommon.
Paget's Disease
Paget's disease of the breast accounts for about one to four percent of all breast
cancers. It occurs typically as a crusting and scaling of the nipple. It can be
mistaken for a benign skin condition unless there is a high index of suspicion.
Cystosarcoma Phyllodes
Cystosarcoma Phyllodes is a firm tumor that resembles a benign fibroedenoma. This
cancer is very different than other cancers of the breast. It seldom spreads to
the lymph nodes, but can metastasize to other parts of the body by way of the
bloodstream.
What treatments are used for invasive breast cancer?
Currently, when breast cancer is detected it is already an invasive cancer in
the majority of cases. The treatment of invasive breast cancer is similar, whether
it be invasive ductal or invasive lobular carcinoma.
The treatment plans are divided into local therapy and systemic therapy. Local
therapy is designed to remove or kill the cancer cells in the breast and adjacent
lymph nodes. If the cancer has not spread outside these areas, the patient can
be cured by local therapy alone. Unfortunately, breast cancer can metastasize
or spread to other areas of the body even though the primary cancer is quite small
and there is no evidence of cancer spread to the lymph nodes. Breast cancer does
not always follow a predictable pattern of growth. From many studies, estimates
of the risk of metastasis and recurrence of the cancer are given based on factors,
such as tumor size, cell type, lymph node status, and hormone receptors. But in
any individual woman, an outcome (or prognosis) cannot be predicted with certainty.
Due to this uncertainty, a systemic therapy is incorporated to treat the potential
and actual risk of cancer cells spreading elsewhere. This systemic therapy is
called chemotherapy,
and utilizes drugs to kill cancer cells.
Local therapy involves surgery, radiation, or both. There are many terms used
in connection with breast cancer surgery. Mastectomy is a general term for removal
of the breast. A modified radical mastectomy involves removal of the breast and
the axillary lymph nodes. A simple mastectomy removes the breast, but not the
lymph nodes. Lumpectomy, partial mastectomy, and quadrentectomy refer to removing
only a portion of the breast. An axillary dissection means removal of a portion
of the lymph nodes under the arm.
Radiation
therapy is the use of special high energy x-ray beams to kill rapidly growing
cells, such as cancer cells. It is a generally a painless treatment and is given
in an outpatient setting without the need for hospitalization.
A woman who has developed an invasive breast cancer usually has several surgical
options for treatment. A modified radical mastectomy or removal of the entire
breast, nipple complex and lymph nodes, is one well established option. This is
inherently quite a physically deforming operation and less disfiguring treatments
for breast cancer now exist. Breast conservation treatment for invasive breast
cancer consists of lumpectomy (removal of the breast cancer and a surrounding
rim of normal tissue), axillary dissection (removal of a portion of the lymph
nodes under the arm), and radiation therapy to the remaining breast tissue. This
maintains the majority of a woman's breast and often the shape is not altered
significantly. Many studies have compared these two techniques of therapy and
both are equally effective in the treatment of invasive breast cancer. The survival
rates at 5 and 10 years for both these therapies are the same. Neither therapy
can guarantee a cure of the breast cancer as approximately 25-30% of women will
ultimately die from their disease.
The choice of breast conservation therapy or modified radical mastectomy is usually
an option available to most women with breast cancer. There are some conditions
which pose relatively higher risks with breast conservation therapy. These include
multiple sites of invasive breast cancer in the same breast, multiple sites of
associated ductal carcinoma in situ, a primary breast cancer that was not detected
on mammography, a breast that is difficult to evaluate on physical examination
or by mammography, the inability to obtain margins that are clear of cancer at
the time of lumpectomy, and cancers that are large in comparison to the breast
size, which when removed, would lead to severe breast deformity. These conditions
tend to have either a higher risk of local recurrence or make the early detection
of a local recurrence in the conserved breast difficult if treated with breast
conservation therapy. The risk of local recurrence with breast conservation therapy
is about 5-7%. The local recurrence rate following modified radical mastectomy
is 1- 2%.
If modified radical mastectomy is chosen by a woman as the treatment of her breast
cancer, then reconstructive surgery to recreate the breast mound can be done either
at the time of mastectomy or at a later time. There are several operations that
can be performed to reconstruct the breast. Reconstruction can be done with a
woman's own tissue (autologous reconstruction) or a prosthetic implant can be
placed.
A prosthetic implant is usually inserted beneath the pectoralis muscle of the
chest. There is usually not enough skin left after a mastectomy to place an adequately
sized implant. Therefore, a tissue expander is commonly used. This is a balloon-
shaped silicone implant which when initially inserted is flat. The tissue expander
can be then filled with fluid externally by means of a small valve under the skin.
The implant is filled over a period of several months after the operation. This
enlarges the tissue expander and stretches the skin until an appropriately sized
permanent implant can be placed which simulates the size of the opposite breast.
In autologous reconstruction, the woman's own tissue is used to reconstruct the
breast. A transverse rectus abdominis myocutaneous flap (TRAM flap) or a latissimus
dorsi myocutaneous flap are currently the most used. The TRAM flap uses a portion
of the abdominal muscles, fat and skin to reconstruct the breast. The latissimus
dorsi myocutaneous flap uses a muscle of the upper back along with its overlying
skin to reform the breast.
Nipple reconstruction can also be done in conjunction with any of the reconstructive
breast procedures.
What happens after the surgical procedure?
Once the surgical procedure has been completed, whether it has been a breast conservation
technique or a modified radical mastectomy, the status of the lymph nodes will
be known. The presence or absence of cancer in the lymph nodes plays an important
role in determining further treatment. If the cancer has spread to the lymph nodes,
the risk of the cancer recurring is much higher and the addition of chemotherapy
and/or hormonal therapy is usually indicated.
Chemotherapy and hormonal therapy, used in addition to surgery, is known as adjuvant
systemic therapy. The purpose of this therapy is to eradicate microscopic deposits
of breast cancer cells which still may be present in other areas of the body.
The risk of these metastatic cancer cells roughly increases with the size of the
original tumor, whether or not there is spread to the lymph nodes, the number
of lymph nodes involved, and the microscopic characteristics of the cancer. There
are no tests currently available which can tell doctors precisely whether there
is microscopic spread of breast cancer. This is important because even when the
cancerous tumor is small and there is no evidence of spread to the lymph nodes,
there may be reasons to use adjuvant systemic therapy, since approximately 10%-15%
of women in this group will still develop metastatic breast cancer.
Chemotherapy in adjuvant breast cancer treatment usually involves using a combination
of drugs, typically, cyclophosphamide
(Cytoxan or Neosar), methotrexate,
and 5-flourouracil (CMF), or cyclophosphamide, doxorubicin (Adriamycin, Rubex)
and 5-flourouracil. Currently, six cycles of chemotherapy which encompasses about
six months of therapy is standard.
Breast cancer tissue is also tested for estrogen and progesterone receptors, or
the so-called hormone receptors. A certain percentage of breast cancers will have
molecular sites in their cells to which these hormones will attach. The hormones
have a role in promoting the growth of cancerous cells. If these hormone receptors
are present, the use of an anti-estrogenic agent called tamoxifen
can be used. In older, post-menopausal women it can decrease the risk of recurrent
breast cancer similar to the decrease seen with the use of chemotherapy. This
avoids many of the side effects of chemotherapy which may include nausea, vomiting,
hair
loss, loss of energy, susceptibility to infection, and heart toxicity. Tamoxifen,
however, can increase the risk of uterine cancer. Tamoxifen can also be given
following the completion of chemotherapy because in certain women it can decrease
the risk of cancer recurrence even further than with just chemotherapy alone.
The optimal duration of treatment with tamoxifen is not known and most regimens
range from two to five years. There are ongoing studies to help answer this question.
Inflammatory cancer of the breast is a rapidly growing cancer which has often
metastasized at the time of diagnosis. A combination of surgery, radiation therapy
and chemotherapy is currently now used. Mastectomy is not performed first as is
typically the case in breast cancer. Rather, chemotherapy is started immediately.
Radiation therapy to the breast follows and surgery is performed subsequently.
This sequencing of treatment has shown to provide the best survival statistics
compared to other regimens.
Paget's disease of the breast is treated similarly to other forms of invasive
breast cancer. A modified radical mastectomy is the usual treatment of choice.
Lumpectomy which includes removing the nipple complex, followed by radiation therapy
is sometimes used.
Cystosarcoma phyllodes cancer of the breast spreads somewhat differently than
other breast cancers. It is rare for this cancer to ever spread to the lymph nodes,
but it does spread through the blood stream. Since it does not involve the lymph
nodes, treatment does not involve removing the lymph nodes, even if the tumor
is quite large. Treatment consists of removing the tumor with a rim of normal
breast tissue or simple mastectomy (removal of the entire breast, but without
removing the axillary lymph nodes).
What treatments are used for non-invasive breast cancer?
The management of non-invasive breast cancer, ductal carcinoma in situ and lobular
carcinoma in situ, is much different than with invasive cancer of the breast.
Treatment options are less clear cut in non- invasive cancer of the breast.
Ductal carcinoma in situ is a pre-invasive cancer. Its treatment is based on the
risk of this disease evolving into an invasive cancer which is then life- threatening.
Treatment options for ductal carcinoma in situ include lumpectomy, lumpectomy
combined with radiation therapy, and simple mastectomy. A simple mastectomy is
an operation which removes the entire breast, but does not remove the axillary
lymph nodes as is done in a modified radical mastectomy.
If the area involved with ductal carcinoma is quite small (one centimeter or less)
then simply removing this area alone may suffice. If the area of breast involved
is larger, then further therapy is usually indicated, because the risk of the
breast cancer recurring is reasonably high over the ensuing years. When the cancer
recurs, 50% of the time the cancer is invasive. If a simple mastectomy is used
to treat carcinoma in situ, the cure rate is 98-99%. Since all the remaining breast
tissue is removed, there is no further breast tissue that remains in which a breast
cancer can form. Why isn't the cure rate 100%? This is due to the fact that a
microscopic analysis of the cancer can miss a small area of invasive cancer. Therefore,
there is a chance that the cancer can metastasize. Secondly, even with the best
surgical technique, some breast tissue may remain after a mastectomy.
If a woman wishes to pursue breast conservation therapy and not mastectomy, then
lumpectomy and radiation therapy to the remaining breast tissue is used. Data
does not yet exist which confirms that this form of therapy is as effective as
a simple mastectomy. The results of clinical trials which compare these two forms
of therapy should be available within the next several years. Most doctors expect
lumpectomy and radiation to compare quite favorably to mastectomy as it does with
invasive cancer. There are some forms of ductal carcinoma in situ that are resistant
to radiation therapy. The treatment for carcinoma in situ must be individualized
in each woman's case and she should be made aware of the relative risks and benefits
of each treatment modality.
Lobular carcinoma in situ is not a pre-invasive cancer as is ductal carcinoma
in situ. Rather, it represents a high risk potential for the development of invasive
breast cancer. This risk is estimated to be approximately one percent per year.
This risk is for both breasts because 50% of the time the invasive cancer will
occur in the opposite breast in which the lobular carcinoma in situ was found.
Additionally, lobular carcinoma in situ is multifocal (it occurs in many places
or throughout the breast).
Since the risk of developing an invasive cancer is acceptably low to most women
and their doctors, the usual recommendation is to perform yearly mammograms and
to have a breast examination every six months for life. If a more aggressive approach
is taken, the only logical choice that exists at this time is the removal of both
breasts (bilateral simple mastectomy). This approach is sometimes justified in
a woman with a strong family history of breast cancer, and/or the woman who is
young at the time of the diagnosis. This is because the cumulative 1% per year
risk of developing invasive cancer can be substantial after many years.
Lumpectomy with or without radiation does not significantly decrease the risk
of developing an invasive breast cancer with lobular carcinoma in situ. A single
mastectomy does not seem to be the answer either, since the invasive cancer can
occur in either breast. This is yet another area of breast disease that requires
more research and knowledge to optimize management and offer treatment options.
Can women help themselves address breast cancer issues?
As can be seen, the management of breast cancer is quite varied and complex. The
subtleties of each case make it most important for each woman to discuss her options
with the health professionals involved in her care.
The best chance of eliminating breast cancer is prevention. However, we currently
do not have the knowledge to prevent breast cancer. The capability of diagnosing
breast cancer in a much earlier stage than in previous years does exist. Early
diagnosis of breast cancer can be achieved with routine mammography and early
biopsy of suspicious lesions. The earlier a breast cancer is found, the better
the chances of a cure.
Current American Cancer Society guidelines for mammography recommend that a woman
should have a baseline mammogram between the ages of 35 and 40. She should have
a mammogram every other year between the ages of 40 and 50. Beyond the age of
50, a woman should have a yearly mammogram.
The more the community is educated about breast cancer issues, the greater the
likelihood of controlling this deadly disease.
Breast Cancer At A Glance
- One in every eight women
in the United States develops breast cancer.
- The causes of breast cancer
are not yet fully known although a number of risk factors have been identified.
- Breast cancer is diagnosed
with self- and physician- examination of the breasts, mammography, ultrasound
testing, and biopsy.
- There are many types of
breast cancer that differ in their capability of spreading (metastasize) to other
body tissues.
- Treatment of breast cancer
depends on the type and location of the breast cancer, as well as the age and
health of the patient.
- The American Cancer Society
recommends that a woman should have a baseline mammogram between the ages of 35
and 40 years. Between 40 and 50 years of age mammograms are recommended every
other year. After age 50 years, yearly mammograms are recommended.
© 1996-2001 MedicineNet,
Inc.
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