Breast Cancer Eva Caballero School of Health Professions Abstract Breast cancer is a disease in which malignant cells (cancer) form in the tissues of the breast (Hail, 2011). It is considered a heterogeneous disease – differing by individual, age group, and even kinds of cells within the tumors themselves (Hail, 2011). There are several types of breast carcinomas including Ductal Carcinoma In Situ, Invasive Lobular Carcinoma, and Male Breast Cancer (Yi-Bin & David, 2011). Some methods used to diagnose breast carcinoma are mammograms, MRI’s, and biopsies (NCI, 2010).
A staging system is standardized way for the cancer care team to summarize information about how far a cancer has spread (ACS, 2012). The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system (ACS, 2012). Each stage has different prognoses with varying survival rates as well (Marissa, 2011). There are also many ways to prevent breast cancer including maintain a healthy weight, avoiding the alcohol consumption, and by getting an annual mammogram (Reynolds, 2010).
A genetic mutation that raises the risk of breast cancer is found in up to 60 percent of U. S. women, making it the first truly common breast cancer susceptibility gene (Metcalf & Metcalf, 2008). Other breast diseases besides breast cancer are breast fat necrosis and fibrocystic breast disease (Sacks, 2011; Silverman, 1994). These diseases do not necessarily lead to breast cancer and can be treated (Sacks, 2011; Silverman, 1994).
Keywords: – breast cancer, ducts, lobules, tumor, invasive (infiltrating carcinoma), noninvasive (noninfiltrating carcinoma), Ductal Carcinoma In Situ (DCIS), Invasive Lobular Carcinoma (ILC), intraductal carcinoma, nonfunctioning breast tissue, estrogen, lymph nodes, mammogram, MRI (magnetic resonance imaging), core biopsy, somatic mutations, fine needle aspiration biopsy, stereotactic biopsy, FGFR2, BRCA1, BRCA2, CDH1, PTEN, STK11, AR, ATM, BARD1, BRIP1, CHEK2, DIRAS3, ERBB2, NBN, PALB2, RAD50, metastasis, fat necrosis, fibrocystic breast disease Breast Cancer
Cells are the building blocks of living things and cancer grows out of normal cells in the body (Dugdale, 2010). Cancer is the uncontrolled growth of abnormal cells in the body (Dugdale, 2010). Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer doesn’t allow normal blood function by abnormal cell division in the blood stream (Peter, 2011). Normal cells in the body follow an orderly process of growth, division, and death, this is called apoptosis, and when this process breaks down, cancer begins to form (Peter, 2011).
Cancer has been around since prehistoric times, and breast cancer is one of the earliest forms to have been mentioned (Eisenpreis, 1999). In the United States, breast cancer death rates are higher than those for any other cancer, besides lung cancer (breastcancer. org, 2012). Today, about 1 in 8 women (12%) will develop breast cancer in her lifetime (Martin, 2012). Breast cancer is a cancer that starts in the tissues of the breast (Yi-Bin & David, 2011). In rare cases, breast cancer can start in other areas of the breast (Yi-Bin & David, 2011). Breast cancer can be invasive or noninvasive (Yi-Bin & David, 2011).
Invasive meaning it has spread from the milk duct (lobule) to the other tissues in the breast (Eisenpreis, 1999). Noninvasive means that it has not yet invaded other breast tissue (Yi-Bin & David, 2011). Types of Breast Cancer Breast cancer can begin in different areas of the breast – the ducts, the lobules, or sometimes, the tissue in between (breastcancer. org, 2012). There are several different types of breast cancer, including breast cancer in men (breastcancer. org, 2012). Some include Ductal Carcinoma In Situ, Invasive Lobular Carcinoma, and Male Breast Cancer (breastcancer. rg, 2012). Ductal carcinoma in situ (DCIS), or intraductal carcinoma, is a noninvasive breast cancer in the lining of the milk ducts that has not yet invaded nearby tissues of the breast (Yi-Bin & David, 2011). It may progress to invasive cancer if it is left untreated (Yi-Bin & David, 2011). DCIS is the earliest form of breast cancer and is usually found during a mammogram done as part of breast cancer screening (Mayo Clinic Staff, 2011). Because of the increased use of mammograms, the rate at which DCIS is diagnosed has increased dramatically in recent years (Mayo Clinic Staff, 011). When a woman has DCIS, she is at higher risk for the cancer coming back or also at higher risk for developing a new breast cancer than a person who has never had breast cancer before (breastcancer. org, 2012). Experts believe that 20 to 50% of women with DCIS will later develop an invasive breast cancer within 10 years of the DCIS diagnosis (Hoffman, 2010). The risk of lymph node involvement with ductal carcinoma in situ is only 1% to 2% so the lymph nodes under the arm do not need to be removed, as may be the case with other types of breast cancer (Hoffman, 2010).
In seven out of 10 cases, breast-conserving lumpectomies – instead of mastectomies – were an effective treatment option (Hoffman, 2010). This will depend upon the size of your tumor and the extent of its spread throughout your breast and the surrounding lymph nodes (Hoffman, 2010). While DCIS isn’t life-threatening, it does require treatment to prevent the condition from becoming invasive (Mayo Clinic Staff 2011). Most recurrences happen within 5 to 10 years after the first diagnosis and the chances of that happening are under 30 percent (breastcancer. rg, 2012). Invasive Lobular Carcinoma is an invasive type of breast cancer that begins in the milk-producing glands (lobules) of the breast (Mayo Clinic Staff, 2011). When a person has ILC, this means that the cancer cells have broken out of lobule where they started and they now have the potential to spread to other areas or tissues of the body (Mayo Clinic Staff, 2011). This type of cancer is more difficult to see on imaging because of the way it grows with spreading branches (Hopkins, 2012).
The treatments for invasive lobular carcinoma fall into two broad categories: Local and Systemic Treatment. Local treatments treat the tumor and the areas surrounding it, such as the chest and lymph nodes (breastcancer. org, 2012). Systemic treatments travel throughout the body to destroy any type of cancer cells that may have left the original tumor and traveled to other tissues to reduce the risk of the cancer coming back (breastcancer. org, 2012). ILC cells can proceed to infiltrate fatty tissue and create a web-like mass (Stephan, 2008).
This web of cancer cells may feel like a thickened area of breast tissue, and may not cause concern or pain at first (Stephan, 2008). Unfortunately, if it is left undetected, ILC can develop into a mass that is about ? inch ( 2 centimeters) to about 2 inches (5 centimeters) or bigger in size, before causing more noticeable symptoms (Stephan, 2008). Breast cancer in men is a very rare disease (Attebery, Adams ; Weiss, 2011). But the truth is that boys and girls, men and women all have breast tissue (Attebery, Adams ; Weiss, 2011).
Men have a small amount of nonfunctioning breasts tissue (breast tissue that cannot produce milk) that is concentrated in the area directly behind the nipple on the wall of the chest (Attebery, Adams ; Weiss, 2011). A type of breast cancer that has spread outside of the duct and into the surrounding tissue is called invasive or infiltrating carcinoma (ASC, 2012). Some symptoms that may occur in males developing breast cancer include lumps, changes to the nipple or breast skin, or discharge of fluid from the nipple (National Cancer Institute, 2011).
Men who have an altered gene related to breast cancer have an increased risk of developing breast cancer (National Cancer Institute, 2012). The major problem is that breast cancer in men is more often than not diagnosed later than breast cancer in women because men are less likely to be suspicious of an abnormality in that area (Wax, 2012). Also, their small amount of breast tissue is harder to feel, making it more difficult to catch these cancers early, and allowing tumors to spread more quickly to the surrounding tissues (Wax, 2012).
Breast cancer in men is detected the same way as breast cancer is detected in women – through self-examination, clinical examination, or mammography (x-ray of the breast) (ASC, 2012). Methods for Diagnosis Breast cancer is sometimes found after symptoms appear, but many women with early breast cancer have no symptoms (American Cancer Society, 2011). This is why getting the recommended screening tests before any symptoms develop is so important (American Cancer Society, 2011). Three types of methods used for diagnosis are mammograms, MRI’s, and biopsies (NCI, 2010).
A mammogram is a low-dose x-ray picture of the breast and can be used to check for breast cancer in women who don’t have any signs or symptoms of the disease. (NCI, 2010) The results are recorded on x-ray film or directly into a computer for a doctor called a radiologist to examine (Webmd, 2010). There are different types of mammograms including Screening mammograms and Diagnositc mammograms (Webmd, 2010). Mammograms detect tiny bits of calcium that develop in dead cancer cells (Hoffman, 2010). As more and more cancer cells age and die, theses calcifications grow nd on the mammogram, they appear as a shadowy area (Hoffman, 2010). Current guidelines from the American College Radiology, the American Cancer Society, and the Society for Breast Imaging recommend that women receive annual mammograms starting at age 40, even if they have no symptoms or family history of breast cancer (ACR, 2010). For every 1,000 women who have screening mammogram: 100 are recalled to get more mammography or ultrasound images, 20 are recommended for needle biopsy and 5 are diagnosed with breast cancer (ACR, 2010).
A mammography unit is a rectangular box that houses the tube in which x-rays are produced (Radiological Society of North America, 2011). Once it is carefully aimed at the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an image on photographic film or a special digital image recording plate (Radiological Society of North America, 2011). A brief medical history and a history of specific problems related to the breast, such as pain or a palpable lump (one that is felt), is obtained prior to the mammogram (Stoppler, 2011).
All jewelry and clothing in the chest and breast area are removed prior to the mammogram (Stoppler, 2011). The patient’s breasts are then placed on a firm flat panel and a gentle, but firm pressure is applied to the breast with another panel, resulting in compression of the breast between the two panels (Stoppler, 2011). The compression of the breast is necessary to obtain quality mammograms and spreads the breast tissue out so that the x-ray image displays the inner breast tissue with good resolution (Stoppler, 2011).
Dense bone absorbs much of the radiation while soft tissue, such as muscle, fat and organs, allow more of the x-rays to pass through them (Radiological Society of North America, 2011). As a result, bones appear white on the x-ray, soft tissue shows up in shades of gray and air appears black (Radiological Society of North America, 2011). The results of the mammogram can be given to the patient either by the radiologist at the completion of the mammogram or by the patient’s doctor who ordered the mammogram (Stoppler, 2011). An abnormal mammogram does not mean you have cancer (Stoppler, 2011).
In some cases, it may just be an area of thicker or denser breast tissue, a cyst, or a benign lump such as a fibro adenoma (Stoppler, 2011). Unlike mammography which uses low dose x-rays to produce an image of the breast, MRI (Magnetic Resonance Imaging) uses powerful magnetic fields and radio waves to create images of the breast (Imaginis, 2012). The MRI system has the ability to switch magnetic fields and radio waves to achieve views in any plane and from any orientation while x-ray mammography requires re-orientation of the breast and mammography system for each view desired (Imaginis, 2012).
MRI is a huge magnet and the woman gets put in the middle of the magnet; the magnetic field is turned on and then turned off again (Eisenpreis, 1999). The way the magnetized cells return to normal gives an image (Eisenpreis, 1999). The MRI finds lumps better than it tells whether or not they are cancerous (Eisenpreis, 1999). However, MRI can be good at showing how big a cancer is, once it has been found on the mammogram (Eisenpreis, 1999).
A breast biopsy removes a sample of breast tissue that is looked at under a microscope to check for breast cancer and is usually done to check a lump found during a breast examination or a suspicious area found on a mammogram, ultrasound, or magnetic resonance imaging (MRI) (Marshall, 2009). During a fine-needle aspiration biopsy, the doctor inserts a thin needle into a lump and removes a sample of cells or fluid (Marshall, 2009). Nowadays, doctors might have decided to do something called stereotactic biopsy, where a patient lies on a table, with her breasts hanging down (Eisenpreis, 1999).
A mammogram is taken to show where the lump is and a device holding a needle quickly shoots in and removes a few cells from the lesion (Eisenpreis, 1999). There is also something called a core biopsy that uses a larger needle to take out a piece of tissue, instead of just cells (Eisenpreis, 1999). A doctor numbs your skin with a shot of numbing medicine where the biopsy needle will be inserted and once the area is numb, a small cut is made in the skin from where the needle with a special tip is inserted into breast tissue (Marshall, 2009).
Three to twelve samples will be taken to acquire the most accurate results (Marshall, 2009). Classifications and Associated Prognoses The stages of breast cancer are usually expressed as a number on a scale of 0 through IV – with stage 0 describing non-invasive cancers that remain within their original location and stage IV describing invasive cancers that have spread outside the breast to other parts of the body (Marisa, 2011). Cancer stage is based on four characteristics; the size of the cancer, hether the cancer is invasive or non-invasive, whether the cancer is in the lymph nodes, whether the cancer has spread to other parts of the body beyond the breast (Marisa, 2011). Sometimes doctors use the term “locally advanced” or regionally advanced” to refer to large tumors that involve the breast skin, underlying chest structures, changes to the breast’s shape, and lymph node enlargement that is visible or that the doctor can feel during an exam (Marisa, 2011).
The three ways that cancer spreads in the body are: Through tissue where cancer invades surrounding normal tissue, through the lymph system where the cancer invades the lymph system and travels through the lymph vessels to other places in the body, and through the blood, where cancer invades the veins and capillaries and travels through the blood to other places in the body (NCI, 2009). When cancer cells break away from the primary (original) tumor and travel through the lymph nodes or blood to other places in the body, another (secondary) tumor may form (NCI, 2009).
This process is called metastasis (NCI, 2009). The stage of the breast cancer can help the patient and the doctor understand the prognosis (the most likely outcome of the disease) and make decisions about treatment, along with all the other results in the pathology report (Marisa, 2011). A staging system is standardized way for the cancer care team to summarize information about how far a cancer has spread (ACS, 2012). The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system (ACS, 2012).
The TNM staging system classifies cancers based on their T, N, and M stages (ACS, 2012). The letter “T” followed by a number 0 to 4 describes the tumor’s size and spread to the skin or to the chest wall under the breast (ACS, 2012). The letter “N” followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected. The letter “M” followed by a 0 or 1 indicates whether the cancer has spread to distant organ (ACS, 2012). There are typically five stages (0 to 4) with sub-stages that indicate the prognosis for breast cancer (Lippman, 2005).
Stage 0 where the carcinoma is insitu and no lymph nodes are affected had 99 percent 5 year survival rate (ACS, 2012). Stage IA also has a high rate, 92 percent, in which the tumor is equal to 2 centimeters (ACS, 2012). In stage IB, the tumor is 2 centimeters with micro metastases in 1 to 3 axillary lymph nodes but the cancer has not spread to distant sites (ACR, 2012). In stage IIA, the cancer cells have moved to the ipsilateral nodes and the 5 year survival rate lowers to 82 percent (Lippman, 2012). In stage IIB, the cancer cells have spread to movable ipsilateral nodes and the tumor is over 5 centimeters (Lippman, 2012).
The 5 year survival rate lowers to 65 percent (ACS, 2012). In stage IIIA, there is no evidence of a primary tumor and no distant spreading (ACS, 2012). The 5 year survival rate lowers to 47 percent (Lippman, 2005). The tumor could be between 2 and 5 centimeters but there is still no distant spreading at this point (ACS, 2012). In stage IIIB the tumor has extended to the chest wall but there is still no distant metastases (Lippman, 2005). The 5 year survival rate lowers again to a 44 percent (Lippman, 2005). In stage IV the cancer can be any size (any T) and may or may not have spread to nearby lymph nodes (any N) (ACS, 2012).
It has spread to distant organs or to lymph nodes far from the breast (M1) (ACS, 2012). The most common sites of spread are the bone, liver, brain, or lung (ACS, 2012). The survival rate lowers to 14 percent (Lippman, 2005). Prevention Methods Three ways to prevent breast cancer are by maintaining a healthy weight, avoiding alcohol consumption, and getting an annual mammogram (Reynolds, 2010). Mammogram screening, early diagnosis and better treatments have all contributed to the reduction in breast cancer cases by around 2 percent a year and the improved survival rate in the U. S. (Reynolds, 2010).
Experts say now the focus needs to shift on improving personal lifestyle habits to prevent the disease even more (Reynolds, 2010). Early detection of breast cancer with screening mammography means that treatment can be started earlier in the course of the disease, possibly before it has spread (NCI, 2010). A medical team found an 11 percent lower risk of breast cancer in those women consuming the more healthful diet, including more whole grains, fruits and vegetables and less fatty, processed foods (Reynolds, 2010). They also found that those consuming large amounts of alcohol had a 21 percent increased risk (Reynolds, 2010).
Drinking alcohol during adolescence has been linked to an increased risk of breast cancer, especially for girls with a family history of the disease (Reynolds, 2010). Exercise also plays a role in the reduction of breast cancer risk (Reynolds, 2010). In one study from the Women’s Health Initiative, as little as 1. 25 to 2. 5 hours per week of brisk walking reduced a woman’s risk by 18 percent (Reynolds, 2010). Walking 10 hours a week reduce the risk more (Reynolds, 2010). Diet and exercise can lead to weight reduction, another positive lifestyle change that can influence breast cancer disease risk (Reynolds, 2010).
Many breast cancers are fueled by estrogen, a hormone produced in fat tissue (Reynolds, 2010). Experts suspect that more fat tissue equals more estrogen resulting in more cases of breast cancer that could possibly be avoided (Reynolds, 2010). Genetic ; Hereditary Influence According to researchers, the mutations in the gene, which is called FGFR2, raise the risk of breast cancer by 20 to 60 percent. (Metcalf ; Metcalf, 2008). A genetic mutation that raises the risk of breast cancer is found in up to 60 percent of U. S. omen, making it the first truly common breast cancer susceptibility gene (Metcalf ; Metcalf, 2008). Women with faulty copies of the genes BRCA1 or BRCA2 have 50 percent to 85 percent chance of getting breast cancer in their lifetimes, but they are rare genes and only account for 5 percent to possibly 10 percent of breast cancer cases (Metcalf ; Metcalf, 2008). Only 7% of all breast cancers are hereditary (Hirshaut ; Pressman, 2008). Of these hereditary cancers, 45% is caused by BRCA1 while 35% is caused by BRCA2 (Hirshaut ; Pressman, 2008). (Hirshaut ; Pressman, 2008).
Variations of the BRCA1, BRCA2, CDH1, PTEN, STK11, and TP53 genes increase the risk of developing breast cancer (Chen, 2007). The AR, ATM, BARD1, BRIP1, CHEK2, DIRAS3, ERBB2, NBN, PALB2, RAD50, and RAD51 genes are associated with breast cancer (Chen, 2007). Cancers occur when a buildup of genetic mutations in critical genes – those that control cell growth and division or the repair of damaged DNA – allow cells to grow and divide uncontrollably to form a tumor (Honrado, Osorio, Palacios ; Benitez, 2006). These changes, which are called somatic mutations, are not inherited (Honrado, Osorio, Palacios ; Benitez, 2006).
Less commonly, gene mutations inherited from a parent increase the risk of developing cancer (Honrado, Osorio, Palacios ; Benitez, 2006). In people with these inherited genetic changes, additional somatic mutations in other genes must occur for cancer to develop (Honrado, Osorio, Palacios ; Benitez, 2006). Additional factors that may influence a person’s risk of developing breast cancer include gender, age, ethnic background, a history of previous breast cancer, certain changes in breast tissue, and hormonal factors (Thompson ; Easton, 2004).
A history of breast cancer in closely related family members is also an important risk factor, particularly if the cancer occurred at an early age (Thompson ; Easton, 2004). Women who have inherited certain mutations in these genes have a high risk of developing breast cancer, ovarian cancer, and several other types of cancer during their lifetimes (Thompson ; Easton, 2004). Inherited changes in several other genes, including CDH1, PTEN, STK11, and TP53, have been found to increase the risk of developing breast cancer (Thompson ; Easton, 2004).
In hereditary breast cancer, the way that cancer risk is inherited depends on the gene involved (Walsh ; King, 2007). For example, mutations in the BRCA1 and BRCA2 genes are inherited in an autosomal dominant patter, which means one copy of the altered gene in each cell is sufficient to increase a person’s chance of developing cancer (Walsh ; King, 2007). In other cases, the inheritance of breast cancer risk is unclear (Walsh ; King, 2007). It is important to emphasize that people inherit an increased risk of cancer, not the disease itself (Walsh ; King, 2007).
Not all people who inherit mutations in these genes will develop cancer (Walsh ; King, 2007). Other Breast Diseases Two other diseases found in the breast other than breast carcinoma are breast fat necrosis and fibrocystic breast disease (Sacks, 2011; Silverman, 1994). Fybrocystic breast disease is a commonly used phrase to describe painful, lumpy breasts (Sacks 2011). Hormones made in the ovaries can make a woman’s breasts feel swollen, lumpy, or painful before during menstruation each month (Sacks 2011). Fibrocysitc changes in the breast with the menstrual cycle affect over half of women (Sacks, 2011).
Symptoms are usually worse right before the menstrual period, and then improve after the period starts (Sacks, 2011). Symptoms can include pain in both breasts, breasts that feel swollen and heavy, pain or discomfort under the arms, and thick or lumpy breasts (Sacks, 2011). This disease can be treated with medication like acetaminophen or ibuprofen (Sacks, 2011). Breast Fat necrosis is a benign condition that can occur in your breast (Silverman. 1994). It consists of fatty tissue that has been bruised, injured, or has died (Silverman, 1994).
Once fatty tissue has been injured or has died, it can gradually change into scar tissue or may collect as liquid within an oil cyst (Silverman, 1994). Fat necrosis does not lead to the development of breast cancer, but it may sometimes cause breast pain (Silverman, 1994). An area of fat necrosis in your breast may feel like a fairly hard lump, or like a section of thick skin (Silverman, 1994). The person may see some drainage from the nipple that is nearest to the bruised region (Silverman, 1994). The nipple may sometimes even pull inward a little bit or the breast skin may dimple above the lump of fat necrosis (Silverman, 1994).
Each case of fat necrosis is unique, so treatments will vary but if the fat necrosis has occurred recently, using warm compresses may help it subside (Silverman, 1994). When fat necrosis causes pain, the person can use ibuprofen and aspirin, but if that doesn’t help, ask your doctor if a prescription medication may be used (Silverman, 1994). About 39,520 women in the U. S. were expected to die in 2011 from breast cancer, though death rates have been decreasing since 1990 — especially in women under 50 (“Learn about cancer,” 2011).
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