Breast Cancer Information - Causes, Symptoms And Treatment

Breast cancer is the most common cancer affecting women and is the number two killer (after lung cancer) of women ages 35 to 54. One in nine women will develop breast cancer in her lifetime. It may develop any time after puberty but is most common after age 50 (about 20% of cases occur in women under age 30 and about 70% in women over age 50). In the United States, about 1,500 men are diagnosed With breast cancer each year.

The 5-year survival rate for localized breast cancer has improved from 72% in the 1940s to 96% today because of earlier diagnosis and the variety of treatments available. According to the most recent data, mortality rates continue to decline in White women and, for the first time, are also declining in younger Black women. Lymph node involvement is the most valuable prognostic predictor. With adjuvant therapy, 70% to 75% of women With negative nodes will survive 10 years or more compared With 20% to 25% of women With positive nodes.

Causes of breast cancer

Although the cause of breast cancer isn't known, its high incidence in women implicates estrogen. In addition, certain predisposing factors are clear. For example, women at highest risk include those who have a family history of breast cancer, particularly first-degree relatives (mother, sister, or maternal aunt).

Other women at high risk include those who:

• have long menstrual cycles or began menses early or menopause late
• have never been pregnant
• were first pregnant after age 30
• have had ovarian cancer, particularly at a young age
• were exposed to low-level ionizing radiation
• are obese
• who have taken or are on hormonal contraceptives or hormone replacement therapy (HRT).

Recently, scientists have discovered the BRCA 1 and BRCA 2 genes. Mutations in these genes are thought to cause less than 10% of breast cancer. However, these discoveries have made genetic predisposition testing an option for women at high risk.

Women at lower risk include those who:

• were pregnant before age 20
• have had multiple pregnancies
• are of Native American or Asian descent.

Breast cancer can affect various parts of the breast Structures; however, it occurs more commonly in the left breast than the right and more commonly in the outer upper quadrant. Growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm in size. It spreads by way of the lymphatic system and the bloodstream, through the right side of the heart to the lungs, and eventually to the other breast, the chest wall,liver, bone, and brain. Many refer to the estimated growth rate of breast cancer as "doubling time," or the time it takes the malignant cells to double in number. Survival time for breast cancer is based on tumor size and spread. The number of involved nodes is the single most important factor in predicting survival time.

Breast cancer is classified by histologic appearance and location of the lesion:

• adenocarcinoma - arising from the epithelium
• intraductal- within the ducts (includes Paget's disease)
• infiltrating - occurring in parenchyma of the breast
• inflammatory (rare) - reflecting rapid tumor growth, in which the overlying skin becomes edematous, inflamed, and indurated
• lobular carcinoma in situ - reflecting tumor growth involving lobes of glandular tissue
• medullary or circumscribed -large tumor with rapid growth rate.

These histologic classifications should be coupled with a staging or nodal status classification system for a clearer understanding of the extent of the cancer. The most commonly. used system for staging cancer before and after surgery is the tumor size, nodal involvement, metastatic progress (TNM) staging system.

Signs and symptoms of breast cancer

Warning signals of possible breast cancer include:

• lump or mass in the breast (firm, fixed, non tender, and irregular in shape)
• change in symmetry or size of the breast
• change in skin, such as thickening, scaly skin around the nipple, dimpling, peau d' orange, edema, or ulceration
• change in skin temperature, such as a warm, hot, or pink area (in a non lactating woman past childbearing age) . unusual drainage or discharge, such as greenish black, white or creamy (in a non lactating woman), serous, or bloody (If a breast fed infant rejects one breast, this may suggest possible breast cancer.)
• change in the nipple, such as itching, burning, erosion, or retraction
• pain (usually only when tumor is advanced)
• bone metastasis, pathologic bone fractures, and hypercalcemia
• edema of the arm.

Diagnosis information

In 2003, the American Cancer Society published its most recent guide lines for early breast cancer screening.

Mammography is still the gold standard because it has been consistently proven to reduce deaths from breast cancer. One major change in the guidelines concerns breast self examination (BSE). Although the American Cancer Society once considered BSE as the most reliable method of detecting breast cancer, evidence of its benefits is lacking.

The updated guidelines emphasize educating women, especially high-risk women, about mammography and other screening methods; offering more information to older women; and clarifying the role of clinical breast examinations.

Mammography is indicated for any woman whose physical examination suggests breast cancer. It should be done as a baseline on women between ages 35 and 39; then annually for women age 40 and older. Women with a family history of breast cancer generally should begin breast cancer screening at an earlier age.

The value of manunography remains questionable for women under age 35 (because of the density of the breasts), except those who are strongly suspected of having breast cancer. False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a negative mammogram should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. ultrasonography, such as the T-Scan 2000 that was approved by the Food and Drug Administration in 1999, can distinguish a fluid-filled cyst from a tumor as small as 1 cm and may be used instead of an invasive surgical biopsy. However, this scan is intended to be used alongside conventional diagnosing; not alone.

Bone scan, CT scan, measurement of alkaline phosphatase levels,liver function studies, and liver biopsy can detect distant metastases. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen or progesterone dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)

Breast cancer treatment

Much controversy exists over breast cancer treatments. In choosing therapy, the patient and doctor should take into consideration the stage of the disease, the woman's age and menopausal status, and the disfiguring effects of the surgery. Treatment of breast cancer may include one or any combination of the following:

• surgery
• chemotherapy
• peripheral stem cell therapy
• primary radiation therapy
• estrogen, progesterone, androgen, or antiandrogen aminoglutethimide therapy.

Surgery involves either mastectomy or lumpectomy. A lumpectomy may be done on an outpatient basis and may be the only surgery needed, especially if the tumor is small and there is no evidence of axillary node involvement. In many cases, radiation therapy is combined with this surgery. A two-stage procedure in which the surgeon removes the lump and confirms that it's malignant and then discusses treatment options with the patient is desirable because it allows the patient to participate in her treatment plan. Sometimes, if the tumor is diagnosed as clinically malignant, such planning can be done before surgery.

In lumpectomy and dissection of the axillary lymph nodes, the tumor and the axillary lymph nodes are removed, leaving the breast intact. Modified radical mastectomy removes the breast and the axillary lymph nodes. Radical mastectomy, the performance of which has declined, removes the breast. pectoralis major and minor, and the axillary lymph nodes. Postmastectomy reconstructive surgery can create a breast mound if the patient desires it and doesn't have evidence of advanced disease.

Chemotherapy, involving various cytotoxic drug combinations, is used as either adjuvant or primary therapy, depending on several factors, including TNM staging and estrogen receptor status. The most commonly used antineoplastic drugs are cyclophosphamide (Cytoxan), fluorouracil (S-FU, Adrucil), methotrexate (Trexall), doxorubicin (Adriamycin, Rubex), vincristine (Oncovin), paclitaxel (Taxol), and prednisone (Deltasone). A common drug combination used in both premenopausal and postmenopausal women is cyclophosphamide, methotrexate, and fluorouracil (CMF).

Tamoxifen, an estrogen antagonist, is the adjuvant treatment of choice for postmenopausal patients with positive estrogen receptor status. Tamoxifen has also been found to reduce the risk of breast cancer in women at high risk.

Peripheral stem cell therapy may be used for advanced breast cancer by replacing stem cells that were destroyed by high doses of chemotherapy. These healthy transplanted stem cells help to produce blood cells after chemotherapy.

Primary radiation therapy before or after tumor removal is effective for small tumors in early stages with no evidence of distant metastasis; it's also used to prevent or treat local recurrence. Pre surgical radiation to the breast in inflammatory breast cancer helps make tumors more surgically manageable.

Estrogen, progesterone, androgen, or antiandrogen aminoglutethimide therapy may also be given to postmenopausal women with advanced breast cancer.

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SPECIAL NEEDS

Unfortunately, many older women don't receive regular, mammograms, even when recommended by health care professionals because they fear radiation, discovering cancer, or discomfort during the procedure; they can't afford the costs of the mammogram; or they're embarrassed about exposing their breasts.

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Special considerations

To provide good care for a breast cancer patient, begin with a history; assess the patient's feelings about her illness, and determine what she knows about it and what she expects. Preoperatively, make sure you know what kind of surgery is scheduled so you can prepare her properly. If a mastectomy is scheduled, in addition to the usual preoperative preparation (for example, skin preparations and not allowing the patient anything by mouth), provide the following information:

• Teach her how to deep breathe and cough to prevent pulmonary complications and how to rotate her ankles.
• to help prevent thromboembolism.
• Tell her she can ease her pain by lying on the affected side or by placing a hand or pillow on the indsion. Preoperatively, show her where the incision will be. Inform her that she'll receive pain medication and that she need not fear addiction. Remember, adequate pain relief encourages coughing and turning and promotes general well being. Positioning a small pillow anteriorly under the patient's arm provides comfort.
• Encourage her to get out of bed as soon as possible (even as soon as the anesthesia wears off or the first evening after surgery).
• Explain that. after mastectomy, an incisional drain or suction device (Hemovac) will be used to remove accumulated serous or sanguineous fluid and to keep the tension off the suture line, promoting healing.

After the procedure:

• Inspect the dressing anteriorly and posteriorly, promptly reporting bleeding.
• Measure and record the amount and color of drainage. Expect drainage to be bloody during the first 4 hours and then to become serous.
• Check circulatory status (blood pressure, pulse, respirations, and bleeding).
• Monitor intake and output for at least 48 hours after general anesthesia
• Prevent lymphedema of the arm, which may be an early complication of any breast cancer treatment that involves lymph node manipulation. Instruct her to exercise her hand and arm regularly and to avoid activities that might cause infection or impairment in this hand or arm, which in. creases the chance of developing lymphedema.
• Tell the patient not to let anyone draw blood, start an IV., give an injection, or take a blood pressure reading on the affected side because these activities will also increase the chances of developing lymphedema.
• Inspect the incision. Encourage the patient and her partner to look at her incision as soon as feasible, perhaps when the first dressing is removed.
• Advise the patient to ask her physician about reconstructive surgery or to call the local or state medical society for the names of plastic reconstructive surgeons who regularly perform surgery to create breast mounds. In many cases, reconstructive surgery may be planned prior to the mastectomy. Also, both surgeries may be performed at the same time.
• Instruct the patient about breast prostheses. The American Cancer Society's Reach to Recovery group can provide instruction. emotional support, counseling, and a list of area stores that sell prostheses.
• Give psychological and emotional support. Most patients fear cancer and possible disfigurement and worry about loss of sexual function. Explain that breast surgery doesn't interfere with sexual function and that the patient may resume sexual activity as soon as she desires after surgery.
• Also explain to the patient that she may experience "phantom breast syndrome" (a phenomenon in which a tingling or a pins-and-needles sensation is felt in the area of the amputated breast tissue) or depression following mastectomy. listen to the patient's concerns, offer support. and refer her to an appropriate organization such as the American Cancer Society's Reach to Recovery, which offers caring and sharing groups to help breast cancer patients in the hospital and at home.
• Explain to the patient the importance of regular (monthly) breast self examinations and routine follow-up.