Diagnosis and Treatment of Breast Cancer
Breast cancer is defined by the development of malignant tumors in the breast glandular tissues. Today, more women than ever before are surviving breast cancer. Breast cancer has affected over two million women. The outlook for women with breast cancer can be positive with early detection and prompt and appropriate treatment.
Nobody knows why some women get breast cancer while others do not. Although the disease can affect younger women, women over the age of 50 account for 75% of all cases. Familial or genetic risk factors, estrogen exposure, demographic factors (age, race, ethnicity, and socioeconomic status), nutrition and lifestyle, and smoking are among the risk factors mentioned.
Breast cancer symptoms are subtle at first, but as the cancer progresses, it can cause changes that women should be aware of. An abnormal lump or swelling in the breast is the most common symptom, but lumps can also appear beside the breast or under the arm. Unexplained breast pain, abnormal nipple discharge, changes in breast texture, or changes in the skin on or around the breast are all possible symptoms.
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Breast Cancer Screening
The dilemma is whether to screen or not to screen. The issue is not only medical, but also economic in nature. Cancer diagnosis, whether initial or recurrence, is the most stressful time for a cancer patient. Sadness (depression), fear (anxiety), confusion, and occasional anger characterize this crisis.
The goal of breast cancer screening for women is to detect cancer at an early stage when surgery and medical treatment can be most effective in reducing mortality. Screening is only beneficial when an earlier diagnosis reduces mortality and morbidity and the risks of the screening test are minimal. Currently, three methods of breast cancer screening are used: X-ray mammography, clinical breast examination, and breast self-examination.
Mammography is by far the most reliable of the three screening methods. However, in women with dense breast tissue, both ultrasound and mammograms may miss tumors that a Magnetic Resonance Imager can detect (MRI). MRI is also more accurate in detecting cancer in women who carry the BRCA1 and BRCA2 breast cancer genes. However, biopsy - a minor surgical procedure in which the lump or part of the lump is removed and examined under a microscope for cancer cells - is the primary means of diagnosis - and many believe the only definitive one. A fine needle aspiration, needle or core biopsy, or surgical biopsy may be performed by a doctor.
Mammography
A mammogram is a type of x-ray of the breast that can detect cancers that a woman or her doctor cannot feel. Breast cancer screening aims to detect the disease at an early stage, when cure is more likely. The amount of radiation required to create a clear mammogram (image) varies according to breast size and density. To avoid unnecessary exposure, the lowest possible dose of radiation is recommended.
A mammogram cannot distinguish between benign and malignant tumors and is thus not completely accurate. However, mammography detects over 90% of all breast cancers, though a negative mammogram does not always indicate the absence of the disease. Mammography and clinical examination are complementary, and if there is a strong suspicion of a palpable lesion, a biopsy is the only way to make a positive diagnosis.
Several large studies have conclusively demonstrated that mammography screening for breast cancer reduces mortality by approximately 30% in women over the age of 50. According to the American Cancer Society, women aged 40 to 49 should have screening mammograms every one to two years. Mammography screening every year is recommended for women over the age of 50.
However, the risks of any screening intervention must be carefully considered alongside the benefits. Radiation exposure, false positives, and over-diagnosis are all risks associated with mammography screening for breast cancer. The risk of radiation-induced breast cancer from mammography screening is thought to be low. The excess risk of breast cancer caused by radiation increases with the woman's age at exposure and the cumulative radiation dose. However, the advantages of mammography continue to outweigh the risks of radiation-induced breast cancer.
Clinical Breast Examination (CBE)
During a clinical breast examination, the doctor looks for lumps or other changes that could indicate breast cancer in the breasts and underarms. The CBE consists of bilateral examination and palpation of the breasts, as well as the axillary and supraclavicular areas. The examination should be performed both upright and supine. The length of time spent by the examiner is one of the best predictors of examination accuracy.
The efficacy of CBE alone in breast cancer screening is unknown. Several large studies have conclusively demonstrated the efficacy of CBE when combined with mammography as a breast cancer screening tool in women over the age of 50. The American Cancer Society recommends that women between the ages of 20 and 39 have CBEs every three years. CBEs should be performed on women over the age of 40 on an annual basis.
Breast Self-Examination (BSE)
A woman conducts a systematic examination using her fingers to feel for changes in her breast shape and fluid discharge from the nipple in order to detect any abnormalities. It should ideally be done once a month. Estimates vary, but 80 to 95% are discovered by the patient as a lump. Intuitively, regular breast self-examination as a complementary screening modality, perhaps in conjunction with mammography, may help detect some cancers at an earlier stage, when the prognosis is better.
Approximately four out of every five breast lumps found are cysts or other benign (noncancerous) lesions. If a lump is discovered, it is critical to determine whether it is cancerous or not as soon as possible. Several epidemiologic studies now show that practicing breast self-examination increases survival and that cancers detected by breast self-examination are smaller.
Breast cancer is staged once it has been discovered. The doctor can use staging to determine whether or not the cancer has spread and, if so, to what parts of the body. More tests may be conducted to assist in determining the stage. Knowing the stage of the disease aids the doctor in treatment planning.
The type, stage, and location of the tumor, as well as whether the cancer has remained in the breast or spread to other parts of the body, all influence the treatment options for breast cancer. There are several treatments available, but the ones most commonly chosen by women - either alone or in combination - are surgery, radiation therapy, chemotherapy, and hormone therapy.
Standard cancer treatments are generally designed to surgically remove the cancer; use hormone therapy to prevent cancer cells from getting the hormones they need to survive and grow; use high-energy beams to kill cancer cells and shrink tumors; and use anti-cancer drugs to kill cancer cells.
However, the current consensus holds that cancer is a systemic disease characterized by a complex spectrum of host-tumor relationships, with cancer cells spreading via the bloodstream, and that variations in local or regional therapy are unlikely to affect a patient's survival. Cancer must be attacked systemically, using radiation therapy, chemotherapy, hormone therapy, and immunotherapy.
A lumpectomy combined with radiation therapy is a common available treatment for women with early-stage breast cancer. A lumpectomy is a surgical procedure that preserves a woman's breast. A lumpectomy involves the removal of only the tumor and a small amount of surrounding tissue by the surgeon. The survival rate for a woman who receives this therapy along with radiation is comparable to that of a woman who chooses a radical mastectomy, which is the complete removal of a breast.
If the breast cancer has only spread to other parts of the breast, treatment may include a combination of chemotherapy and surgery. Doctors use chemotherapy to shrink the tumor before removing it surgically. A woman may be able to avoid a mastectomy by shrinking the tumor before surgery.
Chemotherapy and/or hormonal therapy may be used to destroy cancer cells and control the disease if the cancer has spread to other parts of the body, such as the lung or bone. Radiation therapy may also be beneficial in the treatment of tumors in other parts of the body.
Because 30% of breast cancers recur, the National Cancer Institute recommends that all women with breast cancer receive chemotherapy or hormone therapy after surgery, even if there is no evidence of cancer spread. One-third of recurrences can be prevented or delayed with systemic adjuvant therapy.
Breast Cancer Prevention
Breast cancer cannot be completely avoided, but early detection can greatly reduce the risk of developing advanced disease.
There are now several drugs available to treat or prevent breast cancer. Tamoxifen and Raloxifene, for example, work to prevent the development of breast cancer by interfering with the process of tumor initiation and progression. The antiestrogenic effect of these agents appears to inhibit the growth of malignant cells. Chemoprevention is currently the most promising intervention for achieving primary prevention.
Tamoxifen
Tamoxifen is a nonsteroidal antiestrogen that acts as a partial estrogen agonist. It is FDA-approved and is now used for patients with estrogen-receptive cancer as well as high-risk individuals who are still menstruating and producing significant estrogen.
It may increase the risk of stage I endometrial cancer and worsen vaginal dryness and hot flashes when taken orally. Tamoxifen may be less effective as a breast cancer preventive agent in women who have a strong family history of the disease.
Raloxifene
Raloxifene hydrochloride is a selective estrogen receptor modulator (SERM) that prevents estrogen from acting in the breast and endometrium. At 40 months of follow-up, the incidence of estrogen receptor positive invasive breast cancer was reduced by 76% in women treated with either dose of raloxifene. Raloxifene has been linked to an increased risk of thromboembolic disease but not an increased risk of endometrial cancer.
In addition, recent research has linked a low incidence of breast cancer to a variety of environmental factors, particularly diet. Soy (found in foods such as tofu, tempeh, soy milk, and vegetarian meat substitutes) has been promoted as a cancer-preventive food, but there is no clear evidence to support this claim. Consuming more fruits and vegetables, eating less red meat (perhaps substituting soy protein), and avoiding cholesterol (olive oil contains none) may all aid in the prevention of breast cancer.
A chemical found in broccoli, cabbage, and other cruciferous vegetables that is now available as a dietary supplement may help prevent estrogen-related breast cancers. Another possible preventive measure is to take standard doses of anti-inflammatory drugs like ibuprofen and aspirin twice a week or more.
Finally, a recent study found that exercise helps survivors live longer lives. The precise mechanism is unknown, but physical activity is thought to lower hormone levels, insulin resistance, and weight gain, all of which are risk factors for breast cancer.
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