Breast cancer is the most common type of cancer diagnosed m American women (30 percent of all cancers in women are of the breast). Over the past five decades, the number of cases have increased steadily. Today, about 1 in 8 women m the United States will develop breast cancer. Men can also get breast cancer, but it is rare. Less than 1 percent of all breast cancer occurs in men.
Breast cancer is the leading cause of cancer death in women aged 35-54 years. Fortunately, overall mortality is not up. In addition, more localized cancers have been diagnosed over time. These statistics indicate that screening for breast cancer, including mammography, has probably played a role in detecting more cancers at an earlier stage, thus impacting overall mortality.
Although a specific cause for breast cancer has not been identified, there are certain risk factors that increase the likelihood that a woman will develop the disease. The more risk factors a woman has, the greater her chances of getting the disease. However, It is important to keep mind that having many risk factors does not mean a woman will definitely get breast cancer. Conversely, having only a few or no risk factors does not mean that a woman will not get it.
RISK FACTORS
The number one risk factor of the development of breast cancer is the female sex. Women develop breast cancer on the order of 100:1 compared to men. The risk factors are age (The chances of getting breast cancer increases with age. Most breast cancers still occur in women over 50 about 77 - 80 percent of cases.); family history (Women whose mother, sister, or aunt have had breast cancer, particularly at a younger age or bilaterally have a greater risk); BRCA1 and BRCA2 genes (Families with this mutation tend to have a high incidence of such cancers, often at a young age. The risk estimates are as high as 80 percent by age 80); longer reproductive span (Women who have an earlier menarche (before 12 years) and/or a later menopause (after 60 years), or have had no children, or have had a first child after age 30, thereby increasing the length of their reproductive years, are at a greater risk.); obesity; prior biopsies; previous breast cancer; hormonal therapy; and radiation. (High doses of radiation to certain areas of the body, i.e., neck, chest, can also increase the risk of breast cancer. Today, however, this is a rare occurrence with better equipment and the wealth of knowledge gained from previous patients regarding technique. Procedures such as chest X-rays and mammograms use low does of radiation and are therefore associated with very low risks of breast cancer.)
SCREENING AND DIAGNOSIS
Early detection is the key to significantly improve the outcome of breast cancer. The goal is to find cancers at their earliest stage, hopefully before it has a chance to move outside the breast. This improves the chances that treatment will be successful and that the patient can be cured. Survival rates increase when the cancer is found and treated early.
The most sensitive and specific method of early detection is mammography. Mammograms are low-dose X-rays used to find abnormalities that are too small to be seen or felt. the American Cancer Society recommends that women over 40 have an annual mammogram. However, every woman should decide with her doctor how often and when to begin surveillance based on her personal risk.
A lump or other changes in the breast on physical examination or an abnormal area on a mammogram do not always imply cancer is present. However, any abnormality should be thoroughly investigated.
Through a "biopsy" procedure, the abnormality can be partially or completely removed and examined.
There are several types of biopsies, including a fine needle aspiration and a core biopsy, usually reserved for palpable abnormalities, the stereotactic biopsy predominately used for micro calcifications found on mammogram, and the traditional open surgical biopsy having both diagnosis and potentially therapeutic benefits.
TYPES OF BREAST CANCER
There are a variety of types of breast cancer. Each type grows at a different rate and responds differently to the , treatments currently available.
About 15-20 percent of cancers are very early cancers called carcinoma in situ. These cancers are found in the milk glands and ducts and have not spread into the fatty tissue. There are two types: LCIS and DCIS Lobular carcinoma in situ (LCIS) is considered a risk factor for the development of future breast cancer, rather than a true breast cancer. Ductal carcinoma in situ (DCIS) is a true breast cancer that has' almost a 100 percent cure rate. Women with LCIS found on biopsy should have aggressive follow-up with frequent physical examinations, regular mammograms, and a high risk evaluation.
Cancers that have spread beyond the ducts and glands into the fatty tissue are determend invasive or infiltrating carcinomas. From the fatty tissue these cells can unfortunately spread to other parts of the body.
TREATMENT
Breast cancer treatment can take on a variety of forms, depending on the grade and stage of the cancer, as well as the overall health and wishes of the patient. Therapy needs to be appropriate and adjusted for each woman.
At a minimum, early cancers are removed completely by local excision (lumpectomy) with the margins free of tumor. This is the basis for what has come to be termed "breast conservation surgery" (BCS). This surgery is appropriate when the tumor burden is small and the cancer has not spread beyond the breast. Depending on the pathology, sampling of the axilliary lymph nodes may be warranted to determine if lymph node metastases are present. Fortunately, the necessity to evaluate lymph nodes in breast cancer patients has resulted in the application of a technique first developed for melanoma patients called sentinel lymph node biopsy. Radiation therapy usually follows BCS to sterilize any remaining tumor cells at the lumpectomy site and within the other breast tissue. Radiation treatments are usually given five days per week for 5- 6 weeks by a radiation oncologist.
More extensive cancers may require a procedure known as a modified radical mastectomy (MRM). This is removal of the entire breast and axilliary lymph nodes.
Depending on the size and type of cancer present, the status of the lymph nodes, and the overall health of the patient, systemic therapy" may be advised. This therapy can be in the form of chemotherapy and/or hormonal therapy (depending on the tumor's hormone status).
PREVENTION
Issues of prevention are growing more and more important. Factors to change that have a potential for prevention are diet, exercise, reduction in obesity, reduction or elimination of the use of post menopausal estrogens, and possibly, a shift toward childbirth at an earlier age.
Tamoxifen, the hormonal agent used in the treatment of hormone sensitive breast cancers, has been studied and shown to decrease the chance of recurrence in the treated breast, as well as decrease the development of breast cancer in the opposite breast by 1/3.
The decision to use Tamoxifen should be based on a consideration of the potential benefit and risk. The higher the risk of breast cancer, the more likely that the benefits outweigh the risk.
A second agent has now been demonstrated to be effective in breast cancer risk reduction. Originally approved for the prevention of osteoporosis in postmenopausal females, Evista (Raloxifene), appears to have all the benefits of Tamoxifen with less deleterious side effects. Most people assume that the most foolproof way to prevent breast cancer is to remove the breasts. If you don't have breasts, the reasoning goes, you won't get breast cancer. Contrary to popular belief, however, it doesn't completely eliminate the risk of breast cancer. No mastectomy can be guaranteed to get out all of the breast tissue, even in the most experienced of hands, and thus the risk remains.
FINAL THOUGHT
According to the American Cancer Society, breast cancer will strike more than 200,000 times this year and claim 40,000 lives. It is therefore incumbent upon all of us to get involved. Involved in our own person health, as well as, involved in the efforts to eradicate this disease. Whether it is through national organizations like The Susan G. Komen Breast Cancer Foundation (800) 462-9273; www.breastcancerinfo.com) or the American Cancer Society (800) 227-2345; www.cancer.org) (local chapter, (718) 987-8872), we must continue to raise awareness and funds for breast cancer research and trails.
October is breast cancer awareness month. Women, men, family, and friends, from all over will walk to remember those lost, celebrate those who survive, and remind all of us of our commitment to find a cure.
