Carcinoma of the breast

Definition: A malignant form of cancer that develops in breast tissue.

Causes, incidence, and risk factors:

The most common type of breast cancer begins in the lining of the ducts and is called ductal carcinoma. Another type, called lobular carcinoma, arises in the lobules. For most types of breast cancer the cause is unknown.

Recently two genes, BRC1 and BRC2 have been implicated in a familial type of breast cancer. A number of other predisposing factors have been identified including obesity, early menarche, and delayed or absent child bearing. Breast cancer may occur in men as well as women, but is much more common in women. 

The risk increases exponentially after age 30. The average age of women diagnosed with breast cancer is 60 years. In general, the rate of breast cancer is lower in underdeveloped countries than the western countries.

Other risk factors include:

Having a family history of breast cancer, particularly in mother or siblings

A past medical history of breast cancer, ovarian cancer, uterine cancer, or colon cancer

Early menarche (start of menstruation before age 12) and/or late menopause (after age 55)

No pregnancies or a first pregnancy after age 30

Radiation exposure. 

Post-menopausal estrogen therapy and oral contraceptive use (such as estrogens and progestin oral contraceptives) were considered possible risk factors, but the majority of recent studies do not confirm such risk.

Research suggests that a person's diet may affect the chances of getting some types of cancer. Breast cancer appears to be more likely to develop in women whose diet is very high in fat. Older women who are overweight also seem to have a greater risk. Some scientists believe that a low-fat diet eating well-balanced meals with plenty of fruits and vegetables, and maintaining ideal weight can lower a woman's risk.

There are also studies that suggest a slightly higher risk of breast cancer among women who drink alcohol. The risk appears to go up with the amount of alcohol consumed. So women who drink should do so in moderation.

The possible link between diet and breast cancer is still under study.

The common symptoms of breast cancer are:

Breast lump or breast mass noted upon breast self exam (BSE)

Usually painless, firm to hard, with irregular borders

Lump or mass in the armpit

A change in the size or shape of the breast

Abnormal nipple discharge usually bloody or clear-to-yellow fluid may look like pus (purulent)

Change in the color or feel of the skin of the breast, nipple, or areola: dimpled, puckered, or scaly, retraction of the nipple, "orange peel" appearance of the skin of the breast

Redness, Accentuated veins on breast surface

Eventually (with late disease) skin ulceration

Change in appearance or sensation of the nipple pulled in (retraction), enlargement or itching

Breast discomfort on one side only; Breast enlargement on one side only

Bone pain (due to spread of the cancer to the bones)

Weight loss, Swelling of arm, Breast pain, Breast enlargement with above symptoms in males.

Diagnosing breast cancer:

After clinically examining you, if the doctor feels that you might have breast cancer, he asks for the following tests:

Mammography may help identify the breast mass.

Ultra-sonography can show whether the lump is solid or filled with fluid.

Thermographs may also help identify the mass.

Needle aspiration or needle biopsy of the mass will either yield fluid indicating a cyst, or it will indicate a solid mass, which may or may not be cancer.

Needle biopsy removes cells directly from the mass for evaluation (can be done in conjunction with the needle aspiration procedure). The material removed will be sent to a lab.

Surgical biopsy removes a portion of the mass for further evaluation. Incision biopsy involves surgical removal of a portion of the mass for evaluation. Excision biopsy involves surgical removal of the entire mass for evaluation.

Biopsy is the investigation, which confirms the presence of breast cancer. Recent advancements in medical imaging allows the detection of cancers as small as 1mm, when it can be cured completely.

Treatment - Overview

The choice of initial treatment is based upon the extent and aggressiveness of the disease. Currently breast cancer is viewed as a systemic disease that requires both local and systemic treatment.

Local treatment may include lumpectomy, mastectomy (partial, total, or radical with auxiliary dissection) and radiation therapy - all directed at the breast and immediately surrounding tissue.

Systemic treatment includes chemotherapy and hormonal therapy, which circulate drugs and hormones throughout the entire body in an attempt to eliminate cancer cells that may be present in distant parts of the body.

Most women receive a combination of treatments including surgery, radiation, chemotherapy, and/or hormonal therapy. Current recommendations for potentially curable breast cancer usually suggest that the best primary treatment is partial mastectomy plus auxiliary dissection and radiation therapy.

Medications:

Chemotherapy may be used as additional, systemic treatment in patients with curable breast cancer. Hormonal adjunctive therapy includes the use of anti-estrogen drugs (such as tamoxifen), which may be prescribed for individuals found to have estrogen-dependent cancers.

Surgery:

Lumpectomy (surgical removal of the lump) with radiation may be considered for individuals with stage 1 disease. However, auxiliary dissection is still recommended with the surgery.

Complications - Lifestyle changes

Even with aggressive and appropriate treatments, breast cancer often metastasizes to distant sites such as the lungs, liver, and bones. The local recurrence rate is about 5% after total mastectomy and auxiliary dissection when the nodes are found not to be involved. The local recurrence rate is 25% in those with similar treatment found to have nodal involvement.

Expectations (prognosis)

The clinical stage of breast cancer is the best indicator for prognosis (probable outcome). Five-year survival rates for individuals with breast cancer who receive appropriate treatment are approximately:

85% for stage 1
66% for stage 2
41% for stage 3
10% for stage 4

When the auxiliary lymph nodes are involved, the survival rate drops to approximately 40 to 50% at 5 years and probably less than 25% at 10 years.

Call for an appointment with your health care provider if symptoms of breast cancer occur:

If you are a woman, 40 years or older, and have not had a baseline mammogram performed

If you are a woman, 35 years or older, and have a mother or sister with breast cancer, or a past medical history of prior breast cancer, uterine cancer, endometrial cancer, ovarian cancer, or colon cancer

If you are a woman, 20 years or older, and are unfamiliar with how to perform a breast self-examination. 

Breast cancer - a Hand book

Published on 6th November 2002

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