Breast Cancer Awareness (Part I)

Breast cancer – also known malignant breast neoplasm – is a form of cancer originating in breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. These types of cancer are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas . Breast cancer occurs in both humans and other mammals; while the overwhelming majority of cases in humans are women, men can also develop breast cancer1 .

The size, stage, rate of growth, and other characteristics of the tumor determine the type of treatment. Treatment can include surgery, drugs (hormonal therapy and/or chemotherapy), radiation and/or immunotherapy2 . Surgical removal of the tumor provides the single largest benefit, with surgery alone being capable of producing a cure in many cases. To somewhat increase the likelihood of long-term disease-free survival, several chemotherapy regimens are commonly given in addition to the surgery. Most forms of chemotherapy kill cells that are dividing rapidly anywhere in the body, and as a result, cause temporary hair loss as well as digestive disturbances. Radiation may also be added to kill any cancer cells in the breast that might have been missed by the surgery. One of the main drawbacks to using radiation therapy is that it can predispose the patient to the risk of heart failure in the future3 . Some forms of breast cancer are sensitive to hormones such as estrogen and/or progesterone which makes it possible to treat them by blocking the effects of these hormones.

The prognosis and survival rate (of breast cancer) varies greatly depending on the type of cancer and staging. With best treatment and dependent on staging, five-year relative survival varies from ninety-eight percent (98%) to twenty-three percent (23%), with an overall survival rate of eighty-five percent (85%).

The first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More than eighty percent (80%) of breast cancer cases are discovered when a woman feels a lump. The earliest cancers are detected by mammogram (pictured at right). Additionally the presence of lumps in the lymph nodes located in the armpit can also be an indicator of breast cancer.

Other indications of breast cancer – other than a lump – may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge. Pain (” mastodynia “) is an unreliable tool for determining the presence (or absence) of breast cancer, but may be indicative of other breast health issues4

Inflammatory breast cancer or IBC for short, is a specific type of breast cancer that can pose a substantial diagnostic challenge. ( http://www.helium.com/items/1349054-inflammatory-breast-cancer-ibc ). Symptoms of IFB are similar to those experienced with breast inflammation and may include: itching, pain, swelling, nipple inversion, warmth, and redness throughout the affected breast. In addition, most patients experience an orange-peel texture to the skin referred to as peau d’orange (pictured above). Often detection of IBC is delayed because of the absence of a discernible lump.

Another reported symptom complex associated with breast cancer is Paget’s disease of the breast5 . This condition presents with eczema-like skin changes such as redness and mild flaking of the nipple skin. As Paget’s progresses, symptoms may include: tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the affected nipple. Research has shown that of the women diagnosed with Paget’s, approximately half also were determined to have a lump.

There can be rare cases where what initially appears as a fibrodenoma (a hard, movable lump) could in fact be a phyllodes tumor (pictured at left). This type of tumor is formed within the stroma (connective tissue) of the breast and contain grandular as well as stromal tissue. Phyllodes are not staged in the usual sense; instead they are classified on the basis of their appearance under the microscope as benign, borderline, or malignant.

Occasionally, breast cancer with present as a metastatic disease or cancer that has spread beyond the original organ. Metastasized breast cancer will cause symptoms that are dependent on the location of metastasis. Common sites include: bone, liver, lung, and brain. Unexplained weight loss can occasionally indicate an occult – that is, not visible – breast cancer as can symptoms of fever or chills. Pain in the bones or joints can also sometimes be manifestations of metastatic breast cancer as can be jaundice or neurological symptoms. These symptoms are known as non-specific , meaning they could be manifestations of many other illnesses.

What is the pathophysiology and risk factors associated with breast cancer?

Breast cancer, like other forms of cancer, occurs because of an interaction between the environment and a defective gene. Normal cells divide a finite number of times and stop. They attach to other cells and stay in place within body tissues. A cell becomes cancerous when a mutation or mutations destroy it’s ability to stop dividing, to attach to other cells, and to stay where they belong. When a cell (or cells) divide, their DNA is normally copied with many mistakes. Error-correcting proteins then fix these mistakes. The mutations that are known to cause cancer, such as p53, BRCA1 and BRCA2, occur within these error-correcting mechanisms. These mutations are either inherited or acquired after birth. Presumably, they then allow other mutations, which result in uncontrolled division, lack of attachment, and metastasis to distant organs.

The primary risk factors for breast cancer include: age, lack of childbearing or breast feeding, elevated hormone levels, race, economic status, and dietary iodine deficiency. Smoking tobacco may also increase the risk of breast cancer. This is influenced by how much the person smokes and how early in life they began smoking.

In most cases, breast cancer cannot be prevented through any action on the part of the affected person. The World Cancer Research Fund estimates that thirty-eight percent (38%) of the breast cancer cases in the U.S. are preventable through reducing alcohol intake, increasing physical activity levels and maintaining a healthy body weight. In addition, it’s estimated that forty-two percent (42%) of breast cancer cases in the United Kingdom (UK) could also be prevented in this same way.

In a study of attributable risk and epidemiological factors published in 1995, delaying the birth of the first child and not having children accounted for 29.5% of United States breast cancer cases, a family history of breast cancer accounted for 9.1% and factors correlated with higher income contributed 18.9% of cases6 . Attempts to explain the increased incidence (but lower mortality) correlated with higher income include epidemiological observations such as lower birth rates correlated with higher income and better education, possible over-diagnosis as well as possible over-treatment due to better access to breast cancer screening, and the postulation of as yet unexplained lifestyle and dietary factors correlated with higher income. One such factor might be past hormone replacement therapy, which was typically more widespread in higher income groups.

The genetics associated with hereditary breast-ovarian cancer syndromes usually increase the risk slightly or moderately; the exception to this is women and men who are carriers of BRCA mutations. These people have a very high lifetime risk for both breast and ovarian cancer – depending on the portion of the protein(s) where the mutation occurs. Instead of a twelve percent (12%) lifetime risk of breast cancer, women with one of these genes have a risk of approximately sixty percent (60%)7 .

In recent years, research has shown the impact of diet, as well as our behaviors, on breast cancer. Among the additional factors noted were: a high fat diet8 , alcohol intake, obesity, and environmental factors such as tobacco use, radiation9 , endocrine disruptors, and shift work. Also, although it’s a low-dosage, the cumulative effect of radiation from a mammogram can also cause cancer.

In addition to the risk factors named above, there are also demographic and medical risk factors. These include: 1) Personal history of breast cancer: A woman who has previously had cancer in one breast has an increased risk of getting a second breast cancer; 2) Family history: A woman’s risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is also higher if a family member developed breast cancer prior to age 40; and 3) Certain breast changes: Atypical hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are related with an increased breast cancer risk.

How is cancer diagnosed & classified?

While screening techniques are useful in determining the possibility of cancer, further testing is necessary to confirm whether a lump detected is cancerous, as opposed to a benign alternative such as a cyst. Very often the results of a non-invasive examination, mammography, as well as additional tests that are performed under special circumstances – such as ultrasound or Magnetic Resonance Imaging (MRI) – are sufficient to warrant excisional biopsy as the definitive diagnosis and curative method.

Both mammography and clinical breast exam, which are also used for screening, can indicate an approximate likelihood that a lump is cancerous and may also be able to detect some other lesions. When other tests are inconclusive, Fine Needle Aspiration and Cytology (FNAC) may be utilized. Done under a local anesthetic – if necessary – the procedure extracts a small amount of fluid from the lump. If the fluid withdrawn is clear, it’s highly unlikely that the mass is cancerous. Alternatively, if the withdrawn fluid is bloody, there is a chance that it could be cancerous and is sent off for additional evaluation.

Other options for biopsy include a core biopsy, where a section of the breast lump is removed, or an excisional biopsy where the entire lump is removed. One other option is a vacuum-assisted breast biopsy (VAB) which may assist in diagnosing breast cancer among patients where something has been detected mammographically.

Breast cancer(s) are classified by several grading systems. Each of these influences the prognosis and can affect treatment response. Description of a breast cancer optimally includes all of these factors:

1″Male Breast Cancer” (National Institute of Health)

2 A. Florescu; E. Amir, et. Al (January 2011) “Immune therapy for breast cancer in 2010 – hype or hope? “, Current Oncology, pp. 9-18

3 Buchholz, T.A. (January 2009) “Radiation therapy for early-stage breast cancer after breast-conserving surgery,” New England Journal of Medicine

4″Cancer Facts & Figures 2007” (American Cancer Society)

5Paget’s Disease of the Breast is a malignant condition which outwardly may resemble eczema with skin changes involving the nipple of the breast. s ource: wikipedia.com ( http://en.wikipedia.org/wiki/Paget%27s_disease_of_the_breast )

6Madigan, MP, (1995) “Proportion of breast cancer cases in the United States explained by well-established risk factorsJournal of the National Cancer Institute , pp 1681 – 1685

7″BRCA1 and BRCA2: Cancer Risk and Genetic Testing ” (National Cancer Institute)

8 Blackburn, G.L. (2006) “Dietary fat reduction and breast cancer outcome: interim efficacy results from the Women’s Intervention Nutrition Study,”

9″Breast Cancer Facts & Figures 2005-2006 ” (American Cancer Society)


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