Breast cancer

Breast cancer is the most common malignancy in women and the second leading cause of cancer death (exceeded by lung cancer in 1985). Breast cancer is three times more common than all gynecologic malignancies put together. The incidence of breast cancer has been increasing steadily from an incidence of 1:20 in 1960 to 1:7 women today.

The American Cancer Society estimates that 211,000 new cases of invasive breast cancer will be diagnosed this year and 43,300 patients will die from the disease. Breast cancer is truly an epidemic among women and we don’t know why.

Breast cancer is not exclusively a disease of women. For every 100 women with breast cancer, 1 male will develop the disease. The American Cancer society estimates that 1,600 men will develop the disease this year. The evaluation of men with breast masses is similar to that in women, including mammography.

The incidence of breast cancer is very low in the twenties (age) gradually increases and plateaus at the age of forty-five and increases dramatically after fifty. Fifty percent of breast cancer is diagnosed in women over sixty-five indicating the ongoing necessity of yearly screening throughout a woman’s life.

Breast cancer is considered a heterogenous disease, meaning that it is a different disease in different women, a different disease in different age groups and has different cell populations within the tumor itself. Generally, breast cancer is a much more aggressive disease in younger women. Autopsy studies show that 2% of the population has undiagnosed breast cancer at the time of death. Older women typically have much less aggressive disease than younger women.

Risk Factors

Early onset of menses and late menopause: Onset of the menstrual cycle prior to the age of 12 and menopause after 50 causes increased risk of developing breast cancer.

Diets high in saturated fat: The types of fat are important. Monounsaturated fats such as canola oil and olive oil do not appear to increase the risk of developing breast cancer like polyunsaturated fats; corn oil and meat.

Family history of breast cancer: Patients with a positive family history of breast cancer are at increased risk for developing the disease. However, 85% of women with breast cancer have a negative family history!

Family history only includes immediate relatives, mother, sisters and daughters. If a family member was post-menopausal (fifty or older) when she was diagnosed with breast cancer, the lifetime risk is only increased 5%. If the family member was premenopausal, the lifetime risk is 18.6%. If the family member was premenopausal and had bilateral breast cancer, the lifetime risk is 50%.

Women with a significantly positive family history of premenopausal breast cancer should begin screening mammography a decade sooner than their family member was diagnosed. BRCA-1 and BRCA-2 gene testing can identify those patients at increased risk, genetically, for developing not only breast cancer but also a variety of epithelial tumors including ovarian and colon cancer.

At this time genetic testing is investigational. If a woman is determined to have these genetic markers, should we recommend bilateral mastectomy and oophorectomy? Further, if her insurance company knows that she has these genetic markers of increased risk, she may lose her insurance coverage. If a woman decides to proceed with genetic testing, we recommend that this test be paid for by the individual to keep the results confidential.

Late or no pregnancies: Pregnancies prior to the age of twenty-six are somewhat protective. Nuns have a higher incidence of breast cancer.

Moderate alcohol intake: Greater than two alcoholic beverages per day.

Estrogen replacement therapy: Most studies indicate that taking estrogen longer than ten years may lead to a slight increase in risk for developing breast cancer. However, these studies indicate that the positive benefits of taking estrogen as far as reducing the risk for osteoporosis, heart disease and now more recently Alzheimer’s and colon cancer, far outweigh the slight increase in risk that may be associated with estrogen replacement therapy.

Caution should be exercised in those women with a significantly positive family history of breast cancer or atypical intraductal hyperplasia. Women with breast cancer are not currently give estrogen replacement. There are no scientific studies currently justifying this practice. However, until those studies are available, by convention, women are taken off estrogen.

History of prior breast cancer: Patients with a prior history of breast cancer are at increased risk for developing breast cancer in the other breast. This risk is 1% per year or a lifetime risk of 10%. The reason for close clinical follow-up after the diagnosis of breast cancer is not only to detect recurrence of the disease, but also to detect breast cancer in the opposite breast.

Female: The mere fact that being female increases the risk of developing breast cancer. However, for every 100 women with breast cancer, 1 male will develop the disease.

Therapeutic irradiation to chest wall i.e., for Hodgkins Disease (cancer of lymph nodes): Patients who have had therapeutic irradiation to the chest are at increased risk for developing breast cancer approximately 10 years later and consideration should be given to earlier screening in this population.

Moderate obesity: The relationship of breast cancer to obesity is more complex but associated with an increased risk .

Breast Cancer Types

Ductal Carcinoma in-situ: Generally divided into comedo (blackhead, the cut surface of the tumor demonstrates extrusion of dead and necrotic tumor cells similar to a blackhead) and non-comedo types. DCIS is early breast cancer confined to the inside of the ductal system. The distinction between comedo and non-comedo types is important as comedocarcinoma in-situ generally behaves more aggressively and may show areas of microinvasion (small areas of invasion through the ductal wall into surrounding tissue).

The surgical management is the same as for other types of breast cancer except axillary node sampling is not done, as only 1% of these lesions will have axillary metastasis. We recommend, however, that irradiation be given if treated with conservative breast surgery to reduce the recurrence rate from 21% without irradiation, to 5%-10% with irradiation. This is a controversial area of the treatment of breast cancer.

Infiltrating Ductal: The most common type of breast cancer representing 78% of all malignancies. These lesions can be stellate (star like in appearance on mammography) in appearance or well circumscribed (rounded). The stellate lesions generally have a poorer prognosis.

Medullary Carcinoma: Comprise 15% of breast cancers. These lesions are generally well circumscribed and may be difficult to distinguish from fibroadenoma by mammography or sonography. Medullary carcinoma is estrogen and progesterone receptor (prognostic indicator) negative 90% of the time. Medullary carcinoma usually has a better prognosis than ordinary breast cancer.

Infiltrating Lobular: Representing 15% of breast cancer these lesions generally present in the upper outer quadrant of the breast as a subtle thickening and are difficult to diagnose by mammography. Infiltrating lobular can be bilateral (involve both breasts). Microscopically, these tumors exhibit a linear array of cells (Indian filing) and grow around the ducts and lobules (targeting).

Tubular Carcinoma: Orderly or well differentiated carcinoma of the breast. These lesions make up about 2% of breast cancer. They have a favorable prognosis with nearly a 95% 10-year survival.

Mucinous Carcinoma: Represents 1%-2% of carcinoma of the breast and has a favorable prognosis. These lesions are usually well circumscribed (rounded).

Inflammatory Breast Cancer: A particularly aggressive type of breast cancer the presentation is usually noted in changes in the skin of the breast including redness (erythema), thickening of the skin and prominence of the hair follicles resembling an orange peel (peau d’ orange). The diagnosis is made by a skin biopsy, which reveals tumor in the lymphatic and vascular channels 50% of the time.

What are the Stages of Breast Cancer

No Matter Your Stage, You Have Many Options for Treatment
There are many different varieties of breast cancer. Some are fast-growing and unpredictable. Some are slow and steady. Some are stimulated by the estrogen in your body; some result from a wildly out-of-control oncogene (a cancer gene). You and your doctors will plan your treatment based on the special characteristics of your breast cancer. To help you understand the traits of your cancer, and your treatment options, here’s information from the National Cancer Institute.

Overview: When Cancer Is Found

The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called lobular carcinoma, arises in the lobules. When cancer is found, the pathologist can tell what kind of cancer it is (whether it began in a duct or a lobule) and whether it is invasive (has invaded nearby tissues in the breast).

Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help determine whether hormones help the cancer to grow. If test results show that hormones do affect the cancer’s growth (a positive test result), the cancer is likely to respond to hormonal therapy. This therapy deprives the cancer cells of estrogen.

Other tests are sometimes done to help the doctor predict whether the cancer is likely to progress. For example, the doctor may order x-rays and lab tests. Sometimes a sample of breast tissue is checked for a gene (the human epidermal growth factor receptor-2 or HER-2 gene) that is associated with a higher risk that the breast cancer will come back. The doctor may also order special exams of the bones, liver, or lungs because breast cancer may spread to these areas.

A woman’s treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size and location of the tumor and the stage of the cancer; the results of lab tests; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered.

In most cases, the most important factor is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread. The following are brief descriptions of the stages of breast cancer and the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

Stage 0

Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may take a drug called tamoxifen, which can reduce the risk of developing breast cancer. Others may take part in studies of other promising new preventive treatments. Some women may choose not to have treatment, but to return to the doctor regularly for checkups. And, occasionally, women with LCIS may decide to have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)

Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct to invade the surrounding breast tissue. However, women with DCIS are at an increased risk of getting invasive breast cancer. Some women with DCIS have breast-sparing surgery followed by radiation therapy. Or they may choose to have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Underarm lymph nodes are not usually removed. Also, women with DCIS may want to talk with their doctor about tamoxifen to reduce the risk of developing invasive breast cancer.

Stage I and II

Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct and invaded nearby tissue. Stage I means that the tumor is no more than about an inch across and cancer cells have not spread beyond the breast. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; or the tumor is between 1 and 2 inches (with or without spread to the lymph nodes under the arm); or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy to the breast, or they may have a mastectomy, with or without breast reconstruction to rebuild the breast. These approaches are equally effective in treating early stage breast cancer. (Sometimes radiation therapy is also given after mastectomy.)

The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman’s breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.

Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy after primary treatment with surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. If the systemic therapy is given to shrink the tumor before surgery, this is called neoadjuvant therapy. Systemic treatment is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back, in the breast or elsewhere

Stage III

Stage III is also called locally advanced cancer. In this stage, the tumor in the breast is large (more than 2 inches across) and the cancer has spread to the underarm lymph nodes; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.

Inflammatory breast cancer is a type of locally advanced breast cancer. In this type of cancer the breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both. Systemic therapy may be given before local therapy to shrink the tumor or afterward to prevent the disease from recurring in the breast or elsewhere.

Stage IV

Stage IV is metastatic cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the body.

Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.

Recurrent Cancer

Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

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Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.

Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, the distant recurrence is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments for recurrent cancer.

Source: National Cancer Institute

Prognastic Indicators
Tumor size: As the size of the tumor increases the risk of axillary and systemic metastasis increases.

Histologic Grade: the appearance of the tumor cells under the microscope and graded from 1) well differentiated, 2) Moderately differentiated and 3) poorly differentiated. The survival diminishes with increasing histologic grade.

Estrogen and Progesterone Receptors: Protein plugs on the surface of the tumor cells to which estrogen and progesterone bind. This complex moves inside the cell causing cellular division. The presence of estrogen and progesterone receptors is a good prognostic indicator. Tumors displaying these receptors will respond to hormonal manipulation, i.e., Tamoxifen.

Axillary Nodes: The most important prognostic indicator. Patients with negative axillary nodes (microscopically) have improved disease free and long-term survival.

DNA Flow Cytometry: Test that determines the genetic material within the cell. Tumors with a normal amount of DNA (diploid) have a better disease free and long-term survival than those with an abnormal amount of DNA (aneuploid). This study also determines the percentage of cells in active division. Tumors with active cellular division of <10% have a better prognosis. Her-2/neu: Protein product secreted by the tumor indicating a decreased disease free and long term survival. Breast Cancer staging Tumor Size or Characteristics: TX = Primary tumor cannot be assessed TIS = Carcinoma in-situ T0 = No evidence of primary tumor TIS = Paget’s Disease without a tumor, Carcinoma in-situ T1 = Tumor less than 2 cm. in greatest dimension T2 = Tumor larger than 2 cm. in size but less than 5cm. T3 = Tumor larger than 5 cm. in size T4 = Tumor of any size extending to the chest wall or skin Lymph Nodes: N0 = no metastasis to axillary nodes N1 = Metastasis to moveable axillary nodes N2 = Metastasis to fixed or matted axillary nodes N3 = Metastasis to supraclavicular, infraclavicular or internal mammary nodes Metastasis: M0 = no distant metastasis M1 = distant metastasis Stages of Breast Cancer Stage Tumor (T) Nodes (N) Metastasis (M) Stage 0 TIS N/A M0 Stage I T1 N0 M0 Stage II T0 T1 T2 N1 N1 N0, N1 M0 M0 M0 Stage IIIA T0 T1 T2 T3 N2 N2 N2 N0,N1,N2 M0 M0 M0 M0 Stage IIIB Any T T4 N3 Any N M0 M0 Stage IV Any T Any N M1 Five Year Survival Rate by Stage Stage Survival Rate Stage 0 100% Stage I 98% Stage II 88% Stage IIIA 56% Stage IIIB 49% Stage IV 16% Quick Facts: Mammography should continue yearly after age 40 throughout a woman’s life. For every 100 women that develop breast cancer, one man will. 85% of women with breast cancer have a negative family history.

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