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Breast Cancer
OVERVIEW: Breast cancer is malignant neoplasm of the breast. Breast cancers are classified as noninvasive (in situ) or invasive (infiltrating). Approximately 70% of all breast cancers have a component of invasion.
SIGNS AND SYMPTOMS: • Palpable lump (55%)
• Abnormal mammogram without a palpable mass (35%)
• Change in the color or texture of breast skin
• Dimpling of breast skin
• Nipple retraction
• Breast enlargement
• Lump in the armpit
• Bone pain (rare)
• Discharge
CAUSES: Unknown
SCOPE: • One in eight women in the United States will develop breast cancer within a lifetime.
• 150,000 new cases are diagnosed annually, and 50,000 women die.
MOST OFTEN AFFECTED: Women 30-80 years of age, with a peak at ages 45-65. More common in females, although 1%
occurs in males. About 20% of women have a family history of breast cancer. A breast cancer
gene has been identified that affects about 1 in 400 women.
RISK FACTORS: • Family history of breast cancer
• Early menarche, late menopause, no births, or first full-term pregnancy after age 30
• Women with a history of breast cancer or previous breast biopsies revealing atypical changes
• Other risk factors may include estrogen use, high dietary fat, high alcohol use
DIAGNOSIS PHYSICAL EXAMINATION: • Thorough.
• Other diseases with similar signs and symptoms will be investigated, such as abscess and other benign breast conditions.
• If cancer is identified, the doctor will stage the disease, i.e., determine the extent of involvement.
TESTS AND PROCEDURES: • Several blood tests may be done to assist in diagnosis, particularly those to assess liver function and hormone activity.
• Chest X-ray
• Specialized radiological imaging that may be done includes mammography, ultrasound, bone scan, liver imaging, computed tomography (CT scan).
• Tissue may be obtained by biopsy for analysis in the laboratory.
TREATMENT GENERAL MEASURES: • Persons with breast cancer are usually treated by a team consisting of a medical oncologist, a surgeon, and a radiation oncologist.
• Treatment of breast cancer involves period of hospitalization for surgery and other treatment.
• The decision to treat with hormone therapy or chemotherapy is complex. Premenopausal women tend to respond more to cytotoxic (cell-killing) chemotherapy, and postmenopausal women tend to obtain greater benefit from hormone therapy.
• Treatment of early disease:
• Local control measures
• Modified radical mastectomy or lumpectomy followed by radiation
• The optimal treatment is unclear.
• Treatment of locally advanced breast cancer:
• Combination chemotherapy and radiation therapy prior to mastectomy
• Treatment of metastatic cancer (cancer that has spread to adjacent lymph nodes)
• Measures to provide symptom improvement
• Combinations of chemotherapy, hormone therapy, or radiation therapy
ACTIVITY: Minimal activity restrictions during treatment
DIET: No proven relationship exists between breast cancer and diet.
MEDICATIONS COMMONLY PRESCRIBED DRUGS: • Chemotherapy
• Hormone therapy: tamoxifen, medroxyprogesterone, and aminoglutethimide
• Combination chemotherapy: cyclophosphamide, methotrexate, ftuorouracil, anthracyclines, taxanes
CONTRAINDICATIONS: N/A
PRECAUTIONS: Monitoring for infection is important for patients receiving chemotherapy.
DRUG INTERACTIONS: Drug interactions are common and depend on the combinations used. The oncologist will provide information about drug interactions.
Other Drugs: • Chemotherapy agents: vinblastine, cisplatin, thiotepa, mitomycin, etoposide, and pactitaxel (Taxol)
• Ondansetron (Zofran), dronabinol (Marinol), metoclopramide (Reglan), and others for nausea control.
FOLLOW UP PATIENT MONITORING: • Regular followup physical examinations by the doctor are important to detect relapses.
• Up to 60% of patients with invasive disease will have a relapse within 5 years despite initial therapy.
PREVENTION/AVOIDANCE: • Decreasing dietary fat or alcohol has not been shown to alter breast cancer risk.
• The synthetic anti-estrogen drug tamoxifen may be a useful preventive agent in high-risk women (such as those with a family history).
• The estrogen receptor modulator drug Raloxifene (Evista) may reduce the risk of breast cancer and play a role in prevention in the future
• Perform a monthly breast self-examination to detect lumps, skin, or nipple changes.
• Clinical breast examination (breast examination by a doctor) should be part of the gynecological examination.
• Mammography:
• In women over 50 years of age, mammography screening can reduce breast cancer deaths by 30%.
• All women over 35 years of age should have baseline screening mammogram.
• Mammography should be repeated every 1-2 years between the ages of 40-49 and annually after age 50.
COMPLICATIONS: • Chemotherapy
• Hormone therapy: tamoxifen, medroxyprogesterone, and aminoglutethimide
• Combination chemotherapy: cyclophosphamide, methotrexate, ftuorouracil, anthracyclines, taxanes
WHAT TO EXPECT: • 10-year survival rates:
• Noninvasive: 95%
• Stage I occult: 90%
• Stage II: 40%
• Stage III: 15%
• Stage IV (metastatic): 0%
MISCELLANEOUS OTHER FACTORS: N/A
PEDIATRIC: Breast cancer occurs rarely in children.
GERIATRIC: There is a higher percentage of hormone-positive tumors among the elderly. These cancers are responsive to hormone therapy, and thus disease-free survival may be improved.
OTHERS: N/A
PREGNANCY: Breast cancer occurs infrequently during pregnancy.
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