Breast Cancer
Courtesy of Dr. Georgette

• symptoms and signs
• laboratory findings
• about the disease
• prevention
• treatment
• prognosis
  a.  staging
  b.  TNM
  c.  5-year survival by stage

Symptoms and signs. breast development in males; breast lump or breast mass noted upon breast self exam which is usually painless, firm to hard, with irregular borders; breast pain; lump or mass in the armpit; a change in the size or shape of the breast with/without breast discomfort and/or breast enlargement on one side only; abnormal nipple discharge, e.g., bloody or clear-to-yellow fluid may look like pus purulent; change in the color or feel of the skin of the breast, nipple, or areola, e.g., dimpled, puckered, or scaly, retraction, "orange peel" appearance, redness; accentuated veins on breast surface; change in appearance or sensation of the nipple, e.g., retraction, enlargement, itching; bone pain weight loss swelling of arm; skin ulceration in the later stages of the disease.

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Laboratory findings. mammography may identify a breast mass; needle aspiration or needle biopsy of the mass and ultrasonography to determine consistency, i.e., fluid-filled or solid; biopsy, either removal of a portion or the entire mass for evaluation for evaluation and staging.

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About the disease. Breast cancer, a.k.a. carcinoma of the breast, is a malignant form of cancer that develops in breast tissue, with the most common type starting at the lining of the ducts, i.e., ductal carcinoma. Lobular carcinoma in situ (LCIS) is not a true cancer, although this condition increases a woman's risk of developing cancer later. Ductal carcinoma in situ (DCIS) is breast cancer at its earliest stage (stage 0); women with cancer at this stage can be cured. Infiltrating (invasive) lobular carcinoma (ILC), which constitutes 10% and 15% of breast cancers, starts in the milk glands (lobules), breaks through the wall of the gland and invades the fatty tissue of the breast. Infiltrating (or invasive) ductal carcinoma (IDC) is the most common type of breast cancer, accounting for nearly 80% of cases; it starts in the milk passage or duct, breaks through the wall of the duct, and invades the fatty tissue of the breast. Breast cancer is more common in women, although it can also develop in men. The cause is still unknown for most types of breast cancer. Recent studies have identified genes BRC1 and BRC2 in a familial type of breast cancer. Predisposing factors to breast cancer include obesity, early menarche (start of menstruation before age 12) and/or late menopause (after age 55), and delayed or absent child bearing, family history of breast cancer, past medical history of breast cancer, presence of other cancers, e.g., ovarian, uterine, colon, and radiation exposure. Other risk factors include age after 30, with the average age of women diagnosed being 60 years, and post-menopausal estrogen therapy and oral contraceptive use, although recent data could not confirm risk from estrogen replacement therapy. In general, the rate of breast cancer is higer in more affluent countries as compared to underdeveloped countries. Japan, however, has a low incidence of cases. Alcohol intake and diet which is very high in fat seem to place women at considerable risk.

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Prevention. primary prevention may be difficult as most of the risk factors are uncontrollable; early detection by routine breast self-exam beginning around age 20 and screening mammography after age 40; some scientists believe that a low-fat diet, eating well-balanced meals with plenty of fruits and vegetables, and maintaining ideal weight can lower risk; drink alcohol in moderation as the risk appears to go up with the amount of alcohol consumed

Treatment. dependent on the aggressiveness and extent of the disease

Stage 0: two types of stage 0 breast cancer, ductal carcinoma in situ (DCIS), and lobular carcinoma in situ (LCIS), treated quite differently; most women with LCIS may not need treatment because the condition is not a true cancer; monitor the patient closely focusing on signs of developing cancer, especially those exhibiting risk factors; high-risk population may opt for bilateral mastectomy; treatment choice for DCIS include lumpectomy, usually coupled with radiation therapy, and mastectomy, depending on mammography and biopsy results.

Stage I: lumpectomy with removal of axillary lymph nodes; another option is modified radical mastectomy

Stage II: consider radiation therapy after mastectomy if the tumor is large or has spread to many lymph nodes; adjuncts include hormone therapy, chemotherapy, or both.

Stage III: divided into two parts: IIIA and IIIB; combination of surgery (lumpectomy or a modified radical mastectomy), chemotherapy, radiation, and hormone therapy is often used; chemotherapy (with or without hormonal therapy) is administered pre- and post-surgery.

Stage IV: systemic therapy the primary treatment, using chemotherapy, hormonal therapy, or both; radiation and/or surgery may also be used for symptomatic relief

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Prognosis. dependent on the clinical stage of the cancer; staging of cancer as formulated by the American Joint Committee on Cancer is, as follows:

I. tumor less than 2 cm in diameter, nodes not involved, no distant metastasis

II. tumor less than 5 cm in diameter, nodes not fixed, no distant metastasis

III. tumor greater than 5 cm in diameter, invading the skin, or attached to the chest wall, or supraclavicular nodes noted, with no distant metastasis

IV. tumor with distant metastasis

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The TNM system for staging developed by the same Committee gives three important pieces of information:

• T refers to the size of the Tumor. A number from 0 to 4 after the T describes the tumor's size and spread. A higher number means a larger tumor and/or more spread.

• N, followed by a number from 0 to 3, indicates whether the cancer has spread to lymph Nodes near the breast and, if so, whether the affected nodes are fixed (stuck) to other structures under the arm.

• M, followed by a 0 or 1, shows whether the cancer has spread (Metastasized) to other organs of the body

common sites of metastasis include the lungs, liver, and bones; local recurrence rate is 25% in those with similar treatment found to have nodal involvement.; local recurrence rate is about 5% after total mastectomy and axillary dissection without nodal involvement; 5-year relative survival rate (although some patients might live more than 5 years after diagnosis) according to stage, as follows:

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Copyright 2000