Breast Cancer

BREAST CANCER The first known reference to breast cancer in medical history is found in Edwin Smith Surgical Papyrus, written during 3000 to 2500 B.C. Smith was an archeologist who discovered cave drawings of diseased breasts. Another Egyptian medical papyrus written about 1500 years later mentioned bulging tumors and prescriptions for healing fatty tumors and abscesses with the knife and by fire. Three thousand years later the famous Roman physician Galen appeared on the scene and captured the imagination of his colleagues with his four-humor theory of health and disease. The human body was governed by the four-humor of black bile, yellow bile, phlegm and blood in a person who was healthy, all four were in perfect balance. Galen's thoughts about cancer were that the disease was caused by an overload of black bile and should be treated by special diets and purges. Eventually, exceptions were made. A breast tumor, for example, was usually removed. Galen who named the disease cancer for the Latin word Crab because most malignant tumors looked so much like this crustacean. In the United States in the 1900 the age-adjusted death rate from Carcinoma of the breast rose from 13.5 deaths per 100,000 females, to 23.5 deaths per 100,000 females in 1930. Since then, it has been remarkably stable. It is evident that the mortality rates for breast carcinoma are strikingly different in different countries. The highest in Western European countries and the United States and Canada, much lower in the Central European countries, and lowest of all in Costa Rica, Mexico and Japan. What is clearly inarguable is the central role of hormonal factors in the genesis of breast cancer. At least three sites of action of hormones that are likely to be important in the eventual development of gross malignancy. First, there is direct evidence that steroidal and non-steroidal estrogens may function as true carcinogens. Hormones clearly can function as promoters of some previously occurring carcinogenic event. There are many examples both in animal models and from epidemiologic studies that suggest that if hormonal stimulation is withdrawn following exposure to a carcinogen, a tumor will not appear. It is likely that hormones play a permissive role in allowing carcinogenic events to occur. Cancer of the breast is a condition in which the breast tissue contains a malignant growth. If left untreated, the tumor will continue to grow and eventually metastasize to other areas of the body. The breasts are organs of milk secretion for the nourishment of the young and are composed mainly of fat, connective tissue and milk secreting ducts. Virtually every type of tissue found in the body is also present in the breast. The disease is apparently influenced by many factors including heredity, childbearing, and according to some authorities, a diet high in fat. Obesity is also linked to an increased risk of breast cancer. Recently, the use of alcohol has been linked to an increase risk of breast cancer. Several studies show that there is a marked increase when female relatives have had breast cancer, including mothers, sisters and grandmothers. The disease is rare in women under the age of 30; the incidence rises sharply in the early 40's; levels off about age 45 and then increases again after age 55. Breast cancer is more common among women of North American or Northern European origin than among women in Asian and African countries due to their high fat diet. Women who have had cancer in one breast have a 10-15 percent chance of developing another cancer in the other breast. A long menstrual history, early onset of menstruation or late menopause increase the risk while early menopause, either natural or artificial, decreases the risk. There is a higher risk- for women whose first full term pregnancy occurred after the age of 30 or have never given birth. The relationship of hormones to breast cancer is still unclear. Studies show a possible link between breast cancer and oral contraceptives. The female sex hormone estrogen has long been known to produce breast cancer in animals. Estrogen therapy has also been shown to cause pre-cancerous changes in breast tissue in humans. Factors which do not seem to increase the risk of breast cancer are injury to the breast, sexual stimulation and breast feeding. The most common sign of breast cancer is a mass which is almost always painless. Bloody nipple discharge, dimpling of the skin, nipple retraction, a change in the contour of the breast, fixation of a mass to the chest wall, swelling and redness of the breast skin and axillary lymph node enlargement. Women over the age of 20 should do a monthly breast exam. Women between the age of 20-40 should be examined by a Doctor every three years and women over 40 should be examined yearly. A baseline mammogram should be obtained between the ages of 35-39. If you are 40-49 you should have a mammogram every two years and then yearly after the age of 50 depending on your risk factors. Diagnosis: The diagnosis of breast cancer involves differentiating benign from malignant changes in the breast and determining the nature and extent of those changes that are malignant. The diagnosis approach to breast cancer, beginning with the history and physical examination and concluding with assigning an appropriate stage to the cancer and making treatment recommendations. The history and physical examinations, by defining the breast changes, will indicate the additional studies to be performed to further characterize the abnormalities. These studies may be non-invasive or invasive and may be directed at the breast or at distant organs and tissue. Non-invasive studies evaluating the breast include mammography, (X-ray study of the breast). Baseline mammography should be performed between the age of 35 and 40, than annually or biannually between ages 40 and 49, and annually after age 50. Galactography, (ductal orifice is cannulated at the nipple and contrast material injected). Ultra-sonography, thermography and computerized tomography. These studies differ in their sensitivity for detecting certain lesions but, in general, may identify malignant changes. Invasive procedures are almost always necessary to establish the diagnosis of the breast abnormality, and are performed after non-invasive procedures are completed. Available invasive procedures include, needle aspiration, cytologic analysis, used extensively to diagnose solid breast mass. Percutaneous needle biopsies, and open incisional or incisional biopsies. Selection of a particular procedure will depend upon the nature of the lesion. If a malignancy (the extent to which the malignancy involves the breast tissue locally and the extent to which it has spread to regional lymph nodes and to distant organs and tissues) is confirmed, the possibility of spread to distant organs and tissues can be evaluated by a second group of non-invasive studies. Breast cancer patient may be staged on the basis of clinical or pathologic information or both. Needle aspiration: Removal of fluid or tissue from a mass by using a needle. Solid masses can be aspirated for cytologic study. If positive, this can provide a rapid way of establishing malignancy. A negative result does not rule out cancer. Biopsy: Removal of tissue for histologic examination. After initial exam other studies such as blood tests, x-rays and scans are done to determine if the disease has spread. Invasive ductal carcinoma represents 70 to 80 percent of all malignant mammary carcinomas. They present with a stony hard tumor that commonly metastasizes to the axiliary lymph nodes. Due to this, their prognosis is the poorest of ductal carcinomas. Tublar carcinoma is an uncommon form of breast cancer constituting only 2 percent of all breast carcinomas. The neoplasm resembles normal breast ducts and produces a firm to hard tumor with ill-defined or stellar margins. The prognosis is favorable due to its slow growth pattern. Medullary carcinoma constitutes 5 to 10 percent of all mammary carcinomas. These are complex constellation tumors that give the appearance of being large and solid. They often produce axillary node metastases giving a less than favorable prognosis. Patients with medullary carcinoma tend to be younger than those with other types of breast cancer and is uncommon in elderly patients. Infiltrating lobular carcinoma are most often located in the upper outer quadrant of the breast and tend to have ill defined margins. Subtle thickening of the breast tissue or minute, distince, firm modules that feel like grains of sand may be the only evidence of a tumor. Skin retraction and fixation are signs of advance local disease that accompany large tumors. Diagnosis by mammography is difficult because of the lack of definite margins and a tendency to grow in a multiple foci throughout the breast coupled with the lack of calcifications. Mucinous carcinomas are another form of ductal cancer which are slow growing and slow to metastasize. They account for about three percent of all mammary carcinomas and the prognosis tends to be good. Inflammatory breast cancer presents with prominent skin edema, redness and warmth, with the skin having the texture of an orange peel. The prognosis is poor even if the disease is apparently localized. Pagets Disease of the Nipple: Pagets disease of the breast typically begins as slowly progressive reddening and thickening of the nipple. With erosion of the surface epithelium there may be oozing of serum. Pagets disease of the nipple is associated with an underlying malignancy of the breast, most often a nonpalpable indraductal carcinoma. Secretory Carcinoma, also known as juvenile carcinoma is characterized by its abundant intracellular and extracelluar matrix. The prognosis is excellent. Adenoid Cystic Carcinoma: This very rare, slowly growing variant of ductal carcinoma accounts for less than I percent of all breast cancers. The prognosis is good in comparison with other breast cancers and with similarly appearing tumors in other anatomic locations. Cystosarcoma Phyllodes: This tumor is a large, solitary, palpable breast mass, frequently with a history of recent rapid growth. The tumor takes its name from the gross appearance of the specimen (Greek phyllon, leaf) in which leaflike lobulations of tumor project into long epithelium-lined clifts and cystic cavities. Pathologic Variables and Prognosis in Breast Cancer: Pathologic finds and correlation with clinical outcome, are factors which include (1) Invasiveness; (2) Tumor size; (3) Axillary nodal status; (4) Nipple and skin involvement; (5) Histologic type, and (6) Kinetic analysis of cell division. Invasiveness: Non-invasive (in situ) carcinomas almost never metastasize. Non-infiltrating lesions are cured by mastectomy; local excision alone is followed by recurrence in 25 to 75 percent of cases. However, distinguishing between recurrence and multifocality and multicentricity is not easy, which makes interpretation of such statistic very difficult. Tumor Size: Once the cancer ruptures through the basement membrane and infiltrates the stroma, size becomes an important indicator of prognosis, since size directly correlates with the likelihood of mestastasis. Axillary Nodal Status: The presence of axillary modal metastasis reduces the overall survival rate. Increasing numbers of positive axillary nodes are associated with a progressively greater incidence of treatment failure. Histologic Type: Invasive breast cancers can also be divided into favorable and unfavorable types, depending upon histologic types include tubular carcinoma, mucinous (colloid) carcinoma, adenoid cystic carcinoma, secretary (juvenile) carcinoma and perhaps medullary carcinoma. Unfavorable types include inflammatory carcinoma and undifferentiated carcinoma. Kinetic Analysis of Cell Division: Kinetic Analysis of triliated thymidine uptake by replicating breast cancer cells, has also been used as an independent objective indicator of prognosis. Treatments depending upon the stage of disease, the type of cancer, the age, physical status and preference of the patient and judgment of the physician. a combination of approaches are available. Stage I and Stage II breast cancers are usually treated by mastectomy with axillary dissection (removal of axillary lymph nodes or conservative surgery), lumpectomy, partial mastectomy, quadrantectomy, or segmental mastectomy. A simple lumpectomy with an axillary lymph node dissection takes about one hour and requires several days of hospitalization. Radiation therapy on an outpatient basis will require several weeks time to complete. Mastectomies can take two to four hours and several days in the hospital. Stage III is locally advanced breast cancer without apparent metastasis to distant organs. A combination of surgery, chemotherapy and possible radiation therapy might provide the most effective control. The complications of surgery and radiation are usually minimal and largely involves limitation of shoulder motion, edema, or stiffness of the chest wall. Side effects of chemotherapy are specific to the drug used. Advanced breast cancer, edema of the skin of limited extent (involving less than one third of the skin over the breast), skin ulceration and solid fixation of the tumor to the chest wall, even when it has spread to distant organs can be treated palliatively with radion therapy and chemotherapy. Chemotherapy in advanced breast cancer can offer a high remission rate. Drugs commonly used are Adriamycin, Cytoxan, Methotrexate, 5-FU, Prednisone and Vincristine. Chemotherapy can kill cancer cells allowing the normal tissues to heal. This therapy is used in conjunction with a mastectomy or with breast conserving surgery and irradiation. Temporary side effects include nausea, vomiting, hair loss, low blood cell counts, low platelet count, interruption of the menstrual cycle and fatigue. Radiation therapy is a high energy x-ray beam aimed at the breast and sometimes at nearby areas that still contain some lymph nodes such as under the arm, above the collarbone and along the breast bone. The goal of radiation therapy is to destroy any cancer cells that may still remain in the breast or surrounding lymph node areas. There may be some changes in the breast due to the radiation therapy. The skin around the treated area may begin to look reddened, irritated, tanned or sunburned. As the redness goes away you will notice a slight darkening of the skin. Radiation therapy is also used to ease discomfort from a painful bone mass or brain metastases. Prognosis: The five year survival rate for localized breast cancer is 90 percent. If the breast cancer is not invasive, the survival rate approaches 100 percent. If the cancer has spread regionally, however, the survival rate is 68 percent. For persons with distant metastases, the survival rate is 18 percent. After treatment there are options a women can use, breast forms or prosthesis, which are made of a variety of substances such as silicone, foam rubber, silastic, viscous fluid or glycerin. Fitted individually and worn in brassiere pockets, they can give the form, weight and appearance of a normal bustline. Reconstructive plastic surgery may effectively restore the form of the breast and adjacent tissue lost at surgery. Implants of breast prostheses or surgical transfer of body tissue may be used. Rehabilitation: There are a number of Reach To Recovery programs offered for women who have had breast cancer. It is designed to help women meet the physical, emotional and cosmetic need related to their disease and/or treatment. It also provides information and support to loved ones and friends. The success of cancer treatment depends not only on early detection and effective treatment, but also on a careful, consistent, regular visits to the treating physician and monthly self examination are essential to achieve a symptom free life. 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