Breast cancer

Definition

Breast cancer is the abnormal growth and uncontrolled division of cells in the breast. Cancer cells invade and destroy surrounding normal tissue, and can spread throughout the body via blood or lymph fluid (clear fluid bathing body cells) to start a new cancer in another part of the body.

Description

Every woman is at risk for breast cancer and the disease was diagnosed more than 200,000 times in 2002 in the United States. When a woman lives to be 85, there is a one out of nine chance that she will develop the condition sometime during the rest of her life. As a woman ages, her risk of developing breast cancer rises dramatically regardless of her family history. The breast cancer risk of a 25-year-old woman is only one out of 19,608; by age 45, it is one in 93. In fact, 80% of all breast cancers are found in women over age 50.

Causes & symptoms

There are a number of risk factors for the development of breast cancer, including:

• family history of breast cancer in mother or sister
• early onset of menstruation and late menopause
• reproductive history (women who had no children or have children late in life and women who have never breastfed have increased risk)
• history of abnormal breast biopsies

However, more than 70% of women who get breast cancer have no known risk factors. While a breast cancer gene was discovered in 1994, only about 5% of breast cancers are believed to be related to the gene.

In addition, some studies suggest that high fat diets, bottle feeding instead of breastfeeding, or consuming alcohol may contribute to the risk profile. Other aspects of nutrition and lifestyle in Western countries may be responsible for higher rates of breast cancer in our societies. For example, aromatic hydrocarbons in tobacco and certain hydrocarbons in well-done meat may act as carcinogens. While some studies had suggested a link between hormone replacement therapies (HRTs) contributing to breast cancer, many did not take them seriously. However, a landmark study released in 2003 proved the risk was greater than thought. The Women's Health Initiative found that even relatively short-term use of estrogen plus progestin is associated with increased risk of breast cancer, diagnosis at a more advanced stage of the disease, and a higher number of abnormal mammograms. The longer a woman used HRT, the more her risk increased.

It is important to realize that not all lumps detected in the breast are cancerous. Many are benign and require

only the removal of the lump. While having several risk factors may boost a woman's chances of having breast cancer, the interplay of factors is complex. The best way to assess breast cancer risk is by doing monthly self examinations to detect any lump at an early stage. The second is to have a regular mammogram, an x ray of the front and side of the breast that will detect cysts or tumors at the earliest possible stage. Seeking risk assessment consultation at one of the many breast cancer centers located throughout the United States is also helpful.

Changes in the breast that may indicate breast cancer include:

• lump or thickening in breast or armpit
• changes in a nipple (thickening, pulling in, bleeding, or discharge)
• dimpled or reddened skin over the breast
• change in size or shape
• abnormality on a mammogram

Diagnosis

More than 90% of all breast cancers are detected by mammogram (a low-dose x ray of the breast). Mammograms should be done to evaluate a suspicious lump. Screening mammograms should be ordered according to the doctor's guidelines. Despite the controversy about the cost-effectiveness of mammograms for women in their 40s, most doctors agree with the current American Cancer Society guidelines that recommend screening mammograms every year or two for women between 40 and 49, and every year after age 50. Women with a family history of breast cancer may want to have a mammogram every year after age 40.

A typical mammography screening includes two views of each breast (one from above, and one from the side). Normally, the technologist examines the x-ray films immediately to make sure views are complete. A radiologist determines if further views or follow-up ultrasound studies are needed.

If anything irregular is detected, such as a mass, changes from earlier mammograms, abnormalities of the skin, or enlargement of the lymph nodes, further testing may be recommended. This could include an ultrasound of the breast, a biopsy or needle sampling, or consultation with a breast surgeon.

Biopsy of the breast is a removal of breast tissue for examination by a pathologist. An excisional biopsy is a surgical procedure in which the entire lump area and some surrounding tissue is removed for examination. If the mass is very large, an incisional biopsy is done where only a portion of the area is removed and analyzed. Needle biopsy can be done in two methods. An aspiration needle biopsy uses a very fine needle to withdraw cells and fluid from the mass for analysis. A large core needle biopsy uses a larger diameter needle to remove small pieces of tissue from the mass that can be analyzed. These analyses can determine whether the mass is benign (noncancerous) or cancerous and therefore, whether further treatment is required.

To find out if the cancer has spread to other parts of the body (metastasized), doctors remove some underarm lymph nodes to test for cancer cells that have spread and to assist in making decisions for treatment. A newer technique, called sentinel lymph node biopsy, allows physicians to check the sentinel node, or the one that first receives fluid drained from the cancerous area, to preserve as many lymph nodes as possible. If this node is free of cancer cells, the cancer should not have spread any further than locally. Checking to see if there are cancer cells in the lymph nodes is also a way to tell how advanced the cancer is ("staging" cancer). Breast cancer is rated from Stage 0 to Stage IV. Staging uses the diagnostic information to tell the cancer physician (oncologist) how widespread the disease is and includes:

• Stage I. The cancer is no larger than 2 cm and no cancer cells are found in the lymph nodes.
• Stage II. The cancer is no larger than 2 cm but has spread to the lymph nodes or is larger than 2 cm but has not spread to the lymph nodes.
• Stage IIIA. Tumor is larger than 5 cm and has spread to the lymph nodes or is smaller than 5 cm, but has spread to the lymph nodes, which have grown into each other.
• Stage IIIB. Cancer has spread to tissues near the breast or to lymph nodes inside the chest wall, along the breastbone.
• Stage IV. Cancer has spread to skin and lymph nodes near the collarbone or to other organs of the body.

Treatment

The best chance for successful treatment is to find breast cancer early. Breast cancer is a life-threatening disease, and a correct diagnosis and appropriate treatment with surgery, chemotherapy, and/or radiation is critical to controlling the illness.

Acupuncture and guided imagery may be useful tools in treating pain symptoms and side effects of chemotherapy associated with breast cancer. Acupuncture involves the placement of a series of thin needles into the skin at targeted locations on the body, known as acupoints, in order to harmonize the energy flow within the human body.

Guided imagery involves creating a visual mental image of pain. Once the pain can be visualized, the patient can adjust the image to make it more pleasing, and thus more manageable, to them.

A number of herbal remedies are also available to lessen pain symptoms and chemotherapy side effects, and to promote relaxation and healing. However, breast cancer patients should consult with their healthcare professional before taking them. Depending on the preparation and the type of herb, these remedies may interact with or enhance the effects of other prescribed medications.

Results of a clinical trial performed at the National Cancer Institute of Milan, Italy, have indicated that homeopathic remedies of belladonna (Atropa belladonna) can be useful in relieving the discomfort, warmth, and swelling of the skin associated with radiotherapy for breast cancer (i.e., radiodermatitis). As with all homeopathic remedies, the prescription of belladonna depends on an individual's overall symptom picture, mood, and temperament, and should be prepared by a trained homeopathic professional. When used as a homeopathic remedy, belladonna is administered in a highly diluted form to trigger the body's natural healing response without risk of belladonna poisoning or overdose. There are many other herbs that help in relieving the nausea that accompanies chemotherapy, including ginger (Zingiber officinale).

Allopathic treatment

Treatment options include surgery, chemotherapy, and radiation. Breast cancer is treated in two ways: locally to eliminate tumor cells from the breast by surgery and radiation, and to systemically destroy cancer cells that have traveled to other parts of the body. Systemic therapy includes the use of drugs in chemotherapy and hormonal treatments to reduce the amount of estrogen circulating in the blood.

Surgery

The extent of surgery depends on the type of breast cancer, whether the disease has spread, and the patient's age and health. If the tumor is less than about 1.6 in (4.1 cm) or there is not much chance it will return, then the patient and doctor may opt for removal of the tumor alone (lumpectomy) followed by radiation therapy.

Studies have shown that conservative treatment (a lumpectomy or partial mastectomy) offers the same odds of survival as does removal of the entire breast (total mastectomy) in someone with a small breast tumor that has not spread into the nearby lymph nodes. New studies suggest that after lumpectomy, a combination of chemotherapy and radiation offers the best chance of long–term survival. Recent studies also show that breast conserving surgery leads to better quality of life following breast cancer for women of all ages.

If the tumor is larger, a total (or simple) mastectomy may be needed. If the cancer has spread to the chest muscles, most doctors believe a radical mastectomy is the best solution. This operation is now used only when the cancer has spread to the chest muscle.

In a lumpectomy, the doctor removes:

• the lump
• some of the tissue around the lump
• some of the lymph nodes under the arm may be removed (auxillary dissection) and tested to see if the cancer has spread there

Even if no cancer is found in the nodes, radiation always follows lumpectomy and treatment may include chemotherapy.

In a modified radical mastectomy, the doctor removes:

• the entire breast
• the underarm lymph nodes
• the lining over the chest muscle (but not the muscles themselves)

A radical mastectomy is almost never done, but if necessary the doctor removes:

• the breast
• the chest muscles
• all of the lymph nodes under the arm

Surgery can be combined with breast reconstruction (creating a new breast-shaped mound), either right away or later on. Patients who want breast reconstruction should tell the doctor before surgery, since this could change the way the surgeon operates.

Removing the tumor and a border of normal tissue around it will remove the cancer while saving most of the breast tissue. However, the longer a tumor has been growing in the breast, the more likely it will be that the cancer cells have spread to the lymph nodes. These nodes under the arm or in the chest are a common place for breast cancer cells to spread. During surgery, some of the nodes are removed to check for cancer cells.

The presence of cancer cells in the lymph nodes may require more extensive surgery. If the cancer has spread to the nodes, the patient will need either radiation, chemotherapy, hormone therapy, or a combination of all three after surgery. This is called "adjuvant therapy."

Radiation

Once the cancer has been removed, the doctor may recommend radiation to destroy or shrink any remaining breast cancer cells. Radiation stops the cancer cells from dividing. It works especially well on fast-growing tumors. Unfortunately, it also stops some types of healthy cells from dividing. Healthy cells that divide quickly, like those of the skin and hair, are affected the most. This is why radiation can cause fatigue, skin problems, and hair loss.

Chemotherapy

Breast cancer surgery may be followed by chemotherapy in even the earliest stages. Chemotherapy is administered either orally or by injection into a blood vessel. It is usually given in cycles, followed by a period of time for recovery, followed by another course of drugs. Treatment time may range between four to nine months.

There may be significant side effects with some types of chemotherapy, including nausea and vomiting, temporary hair loss, mouth or vaginal sores, fatigue, weakened immune system, and infertility. However, chemotherapy for early breast cancer uses medications that cause fewer side effects.

Hormone therapy

The growth of some breast cancer cells may be slowed by the drug tamoxifen, an anti-estrogen medication. Given each day as a pill, tamoxifen travels throughout the bloodstream, slowing or stopping cancer cell growth. Tamoxifen treatment lasts at least two years, and often as long as five. Research suggests that tamoxifen may lower the chance that a breast cancer can return by between 25% and 35%.

Side effects of tamoxifen may include a slightly higher risk of cancer of the lining of the uterus (endometrial cancer). The risk increases if the drug is taken for more than five years. Other side effects include menopause-like symptoms, such as weight gain, hot flashes, and mood swings.

In rare cases, the surgeon may suggest removal of the ovaries (oophorectomy) in premenopausal women as a way of eliminating the main source of estrogen, which can boost the growth of some breast tumors.

Stem cell treatment

Stem cell treatment is used to treat advanced breast cancer. By first removing a woman's stem cells from her bone marrow or blood, the doctor can use very high doses of chemotherapy or radiation to kill cancer cells. Because this also kills healthy white blood cells, leaving the woman vulnerable to infection, the stem cells are then replaced, where they restore the body's ability to fight infection.

Expected results

The prognosis for breast cancer depends on the type and stage of cancer. Most patients can return to a normal lifestyle within a month or so after surgery. Exercises can help the patient regain strength and flexibility, and avoid building up too much fluid. Arm, shoulder, and chest exercises may aid in the patient's recovery.

It is normal after breast cancer treatment to be depressed or moody, to cry, lose appetite, or feel unworthy or less interested in sex. If these problems last for an extended time, individual counseling is appropriate. Many women have also found that attending a support group of breast cancer survivors to be an invaluable help during this stage.

Prevention

While breast cancer cannot be prevented, it can be diagnosed from a mammogram at an early stage when it is most treatable. Despite recent questions about the effectiveness of mammography in preventing breast cancer, it remains effective in screening for and detecting signs of breast cancer. A baseline mammogram should be done by age 35, so that a normal x ray can be used to compare future mammograms, even when there is no reason to believe there is a lump or cyst. In addition, women should check their own breasts at the same time each month. The American Cancer Society (ACS) publishes guidelines recommending how often and at what ages women should have screening mammograms. The ACS updated its guidelines in 2003 to recommend annual screening mammograms for women beginning at age 40.

In 1998, the National Surgical Adjuvant Breast and Bowel Project (NSABP) released the results of a six-year study called the Breast Cancer Prevention Trial (BCPT) that analyzed the breast cancer prevention qualities of the drug tamoxifen (Novadex). The study concluded that tamoxifen reduced the incidence of breast cancer in women at high risk of developing this disease. Researchers reported a 49% reduction in diagnoses of invasive breast cancer among women who took tamoxifen, and a 50% decrease in diagnoses of noninvasive breast tumors, such as ductal or lobular carcinoma in situ. More recent studies suggest that tamoxifen also helps prevent breast cancer in women over age 60. However, the drug has also been associated with blood clotting problems and an increased risk of uterine cancer in some patients.

A clinical study comparing tamoxifen and raloxifene, an osteoporosis drug, began in 1999. Raloxifene is thought to have breast cancer prevention properties similar to tamoxifen, but with fewer harmful side effects.

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