Breast Cancer

BREAST CANCER

Overview

Breasts prepare milk for the baby. They extend from the collar bone to the armpit at the side. There are large muscles behind the breasts attached to the ribs and to the shoulder joint bones.

The breast consists of milk glands supported by tissue and fat. Milk is made in the milk glands and milk sacks and conveyed through the ducts to the nipple. These glands are divided in about 20 segments radiating from the nipple.

The breast changes in shape and texture during monthly periods, pregnancy, and age and with weight changes. A large majority (about 90%) of all breast cancers begin in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancers that begin in the lobules are called lobular carcinoma. Lobular carcinoma has a higher chance of occurring in the opposite breast either at the time of diagnosisor in the future.

 

If the disease has spread outside of the duct or lobule and into the surrounding tissue, 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, depends on whether it is originated as ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).
 

Other, less frequently occurring cancers of the breast include medullar, mucinous, tubular, or papillary breast cancer. Inflammatory breast cancer, is a faster-growing type of cancer that accounts for about 5% of all breast cancers. It may be misdiagnosed as a breast infection because there is often swelling of the breast and redness of the breast skin. Paget's disease is a type of in situ cancer that can begin in the ducts of the nipple. 

Breast cancer cells may spread to other sites in the body by migrating through the blood vessels and/or lymph vessels. The lymph nodes can be located under the arm (axillary), in the neck (cervical), or just above the collarbone (supraclavicular). The most common sites of distant metastasis are the bones, lungs, and liver. The cancer can also recur locally in the skin or tissues of the chest.

When cancer begins, it is a single, genetically abnormal cell. As this one cell divides, it eventually becomes a tumor (a mass of cells) and develops a blood supply to nourish its continued growth. At some point, cells may break off from the primary mass and move through the blood supply or nearby lymph system to other parts of the body this process is called metastasis.

In some cases breast cancers may be diagnosed and treated before metastasis occurs. In other cancers may have already metastasized by the time they are diagnosed, if the diagnosis is no early enough. Generally, as the tumor grows in size, the chances of metastasis increases. The larger the size of primary tumor the greater the chances of metastasis. 

Symptoms

Although widespread use of screening mammography has increased the number of breast cancers found before they cause any symptoms, some breast cancers are not found by mammography, either because the test was not done or because even under ideal conditions mammography cannot find every breast cancer.

The most common sign of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but some cancers are tender, soft, and rounded.

Other signs of breast cancer include a generalized swelling of part of a breast, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. Sometimes a breast

cancer can spread to underarm lymph nodes even before the original tumor in the breast tissue is large enough to be detected.

Risk factors

Natural Risk factors

(1) Gender – Women have more breast cells than men hence the chances of them developing breast cancer are higher than men. These cells in women are constantly exposed to the growth promoting effects of female hormones, men can develop breast cancer, but it happens very rarely.

(2) Age – A person’s risk of developing breast cancer increases with age. About 80% of patients with breast cancer are above 50 when diagnosed.

(3) Genetic risk factors – Genetic factors have been found responsible for developing breast cancer.

(4) Family history of breast cancer – Breast cancer risk is higher among women whose close relatives have been found to be having breast cancer.

(5) Race – Race factor is known to affect breast cancer development in women.

(6) Previous abnormal biopsy – Women whose earlier breast biopsies were detected with any of the changes, have a higher risk of breast cancer.

- Fibro adenoma

- Hyperplasia without atypia.

- Sclerosing adenosis.

- Solitary Papiloma.

(7) Previous breast radiation – Women who had radiation in the chest are for treatments of another cancer are at a significantly higher risk of developing breast cancer.

(8) Menstrual period – Women who started menstruating at an early age, before age 12, or who went through menopause at a late age (55 or above) have a slightly higher risk of developing breast cancer.

Life style related risk factors

(1) Not having children – Women who did not have any children or who gave birth to a child at a very late ag have a higher risk of developing breast cancer.

(2) Oral contraceptive use – Oral contraceptives are found to be suspect in affecting breast cancer growth in women. Women should take proper medical guidance before using them.

(3) Hormone replacement thrapy – Long term use of hormone replacement therapy after menopause, particularly estrogens and progesterone combined may increase the risk of breast cancer.

(4) Breast feeding and pregnancy – Breast feeding can lower the risk of breast cancer.

(5) Alcohol and tobacco use – Use of alcohol and tobacco, like in all types of cancers greatly increases the chances of breast cancer.

(6) Breast implants – Or tight undergarments greatly increases the risk of breast cancers. 

Breast self examination

 (i) Lie down and place your right arm behind your head. The exam is done while lying down. This is because when lying down the breast tissue spreads evenly over the chest wall and it is as thin as possible making it much easier to feel all the breast tissue.

(ii) Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping small circular motions of the finger pads to feel the breast tissue.

(iii) Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin, medium pressure to feel a little deeper, and firm pressure to feel the tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. Use each pressure to feel the breast tissue before moving on to the next spot.

(iv) Move around the breast in an up and down pattern starting at an imaginary line drawn straight down from the underarm and moving across the breast to the middle of the chest bone. Be sure to check the entire breast area going down until you feel only

ribs and up to the neck or collar bone (clavicle).

(v)T he up and down pattern is the most effective pattern for covering the entire breast, without missing any breast tissue.

(vi) Repeat the exam on the left breast, using the finger pads of the right hand. While standing in front of a mirror with the hands pressing firmly down on your hips, look at the breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin.

(vii) Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it difficult to examine. This procedure for doing breast self-exam is different than in previous procedure. 

Diagnosis

(1) Mammography

(2) Breast ultrasound

(3) Ductogram

(4) Magnetic resonance imaging

(5) Nipple discharge examination

(6) Biopsy

(7) CT scan

Staging

(a) Stage I – The tumor is smaller than 2cms and has not spread outside the breast.

(b) Stage II – The tumor is larger than 2cms, but not larger than 5 cms and to nearby lymph nodes.

(c) Stage III - The tumor is any size, has spread to 10 or more nodes in the axilla or

to internal mammary lymph nodes, which are enlarged because of the cancer.

All of these are on the same side as the breast cancer. The cancer hasn't spread to distant sites.

(d) Stage IV – The cancer regardless of size has spread to distant organs such as bone, liver, or lung, or to lymph nodes away from the breast.