Breast Cancer I

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Breast cancer is the most common cancer occurring in women (excluding cancers of the skin) and the second most common cause of death from cancer in women, after lung cancer. Men can also develop breast cancer, but male breast canceris rare, accounting for less than 1% of all breast cancer cases. If diagnosed at an early stage, breast cancer has a hopeful cure rate. Up to approximately 97% of women diagnosed with localized breast cancer will be alive five years after their diagnosis.Note: Estimated new cases and deaths from breast cancer (women only) in the United States in 2004:New cases: 215,990.
Deaths: 40,110.
The breast is comprised mainly of fatty tissue. Within this tissue is a network of lobes, which are made up of many tiny lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes and carry the milk from the lobes to the nipple, located in the middle of the areola. Blood and lymph vessels run throughout the breast; the blood nourishes the cells, and the lymph drains the waste.
About 90% of all breast cancers occur in the ducts or lobes, with almost 75% of all breast cancers beginning in the cells lining the milk ducts. These cancers are called ductal carcinomas. Cancers that begin in the lobes are called lobular carcinoma and are more likely to be found in both breasts.
If the disease has spread away from its place of origin, it is called invasive or infiltrating ductal or lobular carcinoma. Disease that has not spread is called in situ, meaning "in place." The course of in situ disease, as well as its treatment, varies, depending on its place of origin. Currently, oncologists recommend that ductal carcinoma in situ (DCIS), which accounts for the majority of in situ breast cancers, be surgically removed to prevent progression to invasive disease.
Breast cancers grow at different rates, but some oncologists estimate the average tumor doubles in size every 100 days. Since cancers start with one irregular cell, even with this doubling time, they may not be palpable (able to be felt) for years. Mammography can find tumors that are too small to be felt, but even so, the tumors have probably been growing for years before they are large enough to be visible on a mammogram.
Breast cancer cells migrate to the lymph nodes under the arm (axillary), in the neck (cervical), or those just below the collarbone (supra-clavicular). The most common sites of metastasis, or spread, of breast cancer are skin, distant lymph nodes, bone, lung, and liver.
As we well know, there are many kinds of cancer; unfortunately they all come about because of the out-of-control growth of abnormal cells.
Healthy Cells vs. Cancer Cells
Healthy cells are like a cat. They need structure to determine the size of bones and shape of the body, tail and whiskers. The DNA in genes and chromosomes determine this. They need energy to play and prowl and sustain life. This is derived from chemicals in food. Cats need a system to deliver chemicals (food nutrients like amino acids, carbohydrates, fats, vitamins and minerals) to all parts of their body. These are the blood vessels. Growth factors take a kitten into a lazy old cat, all the while helping it to function normally.
The body and its cells are mostly made up of protein. The building blocks of proteins are substances called amino acids that in the form of enzymes and hormones literally control every chemical reaction within the cells. When these are modified, different messages are sent to a complex control system that can alter their function. There are twenty different kinds of amino acids that are essential to life. Twelve of these can be synthesized within the body however; eight must be supplied by the daily diet.
Age and health history can affect the risk of developing breast cancer.Anything that increases your chance of getting a disease is called a risk factor. Risk factors for breast cancer include the following:
Older age.
Menstruating at an early age.
Older age at first birth or never having given birth.
A personal history of breast cancer or benign (noncancer) breast disease.
A mother or sister with breast cancer.
Treatment with radiation therapy to the breast/chest.
Breast tissue that is dense on a mammogram.
Hormone use (such as estrogen and progesterone).
Drinking alcoholic beverages.
Being white. Breast cancer is sometimes caused by inherited gene mutations (changes). The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up approximately 5% to 10% of all breast cancer. Some altered genes related to breast cancer are more common in certain ethnic groups.Women who have an altered gene related to breast cancer and who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of developing ovarian cancer, and may have an increased risk of developing other cancers. Men who have an altered gene related to breast cancer also have an increased risk of developing this disease.Tests that examine the breasts are used to detect (find) and diagnose breast cancer.A doctor should be seen if changes in the breast are noticed. The following tests and procedures may be used:
Mammogram: An x-ray of the breast.
Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. If a lump in the breast is found, the doctor may need to cut out a small piece of the lump. A pathologist views the tissue under a microscope to look for cancer cells. Four types of biopsies are as follows:
Excisional biopsy: The removal of an entire lump or suspicious tissue.
Incisional biopsy: The removal of part of a lump or suspicious tissue.
Core biopsy: The removal of part of a lump or suspicious tissue using a wide needle.
Needle biopsy or fine-needle aspiration biopsy: The removal of part of a lump, suspicious tissue, or fluid, using a thin needle.
Estrogen and progesterone receptor test: A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If cancer is found in the breast, tissue from the tumor is examined in the laboratory to find out whether estrogen and progesterone could affect the way cancer grows. The test results show whether hormone therapy may stop the cancer from growing. Certain factors affect prognosis (chance of recovery) and treatment options.The prognosis (chance of recovery) and treatment options depend on the following:
The stage of the cancer (whether it is in the breast only or has spread to lymph nodes or other places in the body).
The type of breast cancer.
Estrogen-receptor and progesterone-receptor levels in the tumor tissue.
A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
Whether the cancer has just been diagnosed or has recurred (come back). After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body. The process used to find out whether the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.The following stages are used for breast cancer:Stage 0 (carcinoma in situ)There are 2 types of breast carcinoma in situ:
Ductal carcinoma in situ (DCIS) is a noninvasive, precancerous condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.
Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast. Stage IIn stage I, the tumor is 2 centimeters or smaller and has not spread outside the breast.Stage IIAIn stage IIA:
no tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
the tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
the tumor is between 2 and 5 centimeters but has not spread to the axillary lymph nodes. Stage IIBIn stage IIB, the tumor is either:
between 2 and 5 centimeters and has spread to the axillary lymph nodes; or
larger than 5 centimeters but has not spread to the axillary lymph nodes. Stage IIIAIn stage IIIA:
no tumor is found in the breast, but cancer is found in axillary lymph nodes that are attached to each other or to other structures; or
the tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are attached to each other or to other structures; or
the tumor is larger than 5 centimeters and has spread to axillary lymph nodes that may or may not be attached to each other or to other structures. Stage IIIBIn stage IIIB, the cancer may be any size and:
has spread to tissues near the breast (the skin or chest wall, including the ribs and muscles in the chest); and
may have spread to lymph nodes within the breast or under the arm. Stage IIICIn stage IIIC, the cancer:
has spread to lymph nodes beneath the collarbone and near the neck; and
may have spread to lymph nodes within the breast or under the arm and to tissues near the breast. Stage IIIC breast cancer is divided into operable and inoperable stage IIIC. In operable stage IIIC, the cancer:
is found in 10 or more of the lymph nodes under the arm; or
is found in the lymph nodes beneath the collarbone and near the neck on the same side of the body as the breast with cancer; or
is found in lymph nodes within the breast itself and in lymph nodes under the arm. In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone and near the neck on the same side of the body as the breast with cancer.Stage IVIn stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.Recurrent Breast Cancer Recurrent breast cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the breast, in the chest wall, or in other parts of the body.There are different types of treatment for patients with breast cancer.Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Four types of standard treatment are used:1. Surgery Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:
Lumpectomy: A surgical procedure to remove a tumor (lump) and a small amount of normal tissue around it.
Partial mastectomy: A surgical procedure to remove the part of the breast that contains cancer and some normal tissue around it. This procedure is also called a segmental mastectomy. Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy. This procedure is called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after. Lymph node dissection is done through a separate incision.Other types of surgery include the following:
Total mastectomy: A surgical procedure to remove the whole breast that contains cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.
Modified radical mastectomy: A surgical procedure to remove the whole breast that contains cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.
Radical mastectomy: A surgical procedure to remove the breast that contains cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy. Even if the doctor removes all of the cancer that can be seen at the time of surgery, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Treatment given after surgery to increase the chances of a cure is called adjuvant therapy. If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline or silicone gel. The Food and Drug Administration (FDA) has decided that breast implants filled with silicone gel may be used only in clinical trials. Before the decision to get an implant is made, patients can call the FDA’s Center for Devices and Radiologic Health at 1-888-INFO-FDA (1-888-463-6332) for more information. 2. Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.3. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Ductal Carcinoma In Situ (DCIS) Treatment of ductal carcinoma in situ (DCIS) may include the following:
Breast-conserving surgery with or without radiation therapy or hormone therapy.
Total mastectomy with or without hormone therapy.
Clinical trials testing breast-conserving surgery and hormone therapy with or without radiation therapy. Lobular Carcinoma In Situ (LCIS) Treatment of lobular carcinoma in situ (LCIS) may include the following:
Biopsy to diagnose the LCIS followed by regular examinations and regular mammograms to find any changes as early as possible. This is referred to as observation.
Tamoxifen to reduce the risk of developing breast cancer.
Bilateral prophylactic mastectomy. This treatment choice is sometimes used in women who have a high risk of getting breast cancer. Most surgeons believe that this is a more aggressive treatment than is needed.
Clinical trials testing cancer prevention drugs. Treatment Options for Inflammatory Breast Cancer Treatment of inflammatory breast cancer may include the following:
Systemic chemotherapy.
Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.
Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment. Treatment Options for Recurrent Breast Cancer Treatment of recurrent breast cancer (cancer that has come back after treatment) in the breast or chest wall may include the following:
Surgery (radical or modified radical mastectomy), radiation therapy, or both.
Systemic chemotherapy or hormone therapy. In the United States, a woman who lives to be 90 years old has a 1 in 8 risk of being diagnosed with breast cancer. With 215,990 cases expected, breast cancer will be the most frequently diagnosed nonskin malignancy in US women in 2004. In the same year, breast cancer will kill approximately 40,110 women, second only to lung cancer as a cause of cancer mortality in women. Breast cancer also occurs in men, and there will be about 1,450 new cases in 2004. Despite a prior long-term trend of gradually increasing breast cancer incidence, data from the Surveillance, Epidemiology, and End Results (SEER) Program show that from 1989 to 1992 there was a 5% decrease in breast cancer mortality. Diet and Vitamins A low-fat diet might influence breast cancer risk through hormonal mechanisms. Ecologic studies show a positive correlation between international age-adjusted breast cancer mortality rates and the estimated per capita consumption of dietary fat. When case-control studies have been used to evaluate the hypothesis that dietary fat is related to breast cancer risk, the results have been mixed. A pooled analysis of results from 7 cohort studies has addressed these issues and concluded that there is no evidence for an association between total dietary fat intake and breast cancer risk. Fruit and vegetable consumption (or specific fruits or vegetables) may be associated with reduced breast cancer risk. However, a pooled analysis of adult dietary data from 8 cohort studies, which included 351,823 women in whom 7,377 incident cases of breast cancer occurred, provides little support for an association. When examining the dietary data treated as continuous variables (based on grams of intake/day), there was no association. Comparing highest to lowest quartiles of intake, the pooled multivariate RRs of breast cancer were 0.93 (95% CI, 0.86-1.00) for total fruits, 0.96 (95% CI, 0.89-1.04) for total vegetables, and 0.93 (95% CI, 0.86-1.00) for total fruit and vegetables combined. Likewise, there was no statistically significant association between any of the specific fruits and vegetables examined and breast cancer risk. This analysis was subject to limitations common to attempts to combine dietary data across studies that have collected information using different food frequency questionnaires. However, it suggests that if there is any decreased risk of breast cancer associated with consumption of fruits and vegetables, the association is probably weak. Micronutrient intake may also play a role. Case-control studies show an inverse association between dietary beta-carotene intake and breast cancer risk. High intake of foods containing folate, beta-carotene, and vitamins A and C may also reverse the increased risk associated with alcohol use. In the Women’s Health Study, in which 39,876 women were assigned to take beta-carotene or placebo, cancer incidence was unaffected at 2 years.Fenretinide is a vitamin A analogue that has been shown to reduce breast carcinogenesis in preclinical studies. A phase III Italian trial compared the efficacy of a 5-year intervention with fenretinide versus no treatment in 2,972 women, aged 30 to 70 years, with surgically-removed stage I breast cancer or DCIS. At a median observation time of 97 months, there were no statistically significant differences in the occurrence of contralateral breast cancer (P=.642) or ipsilateral breast cancer (P=.177) between the 2 arms. There were no statistically significant differences between the 2 arms in tumors in other organs, incidence of distant metastases, and all-cause mortality.