Breast Cancer Health Article

Demographics

Every woman is at risk for breast cancer. If she lives to be 85, there is a one out of nine chance that she will develop the condition sometime during her life. As a woman ages, her risk of developing breast cancer rises dramatically regardless of her family history. The breast cancer risk of a 25-year-old woman is only one out of 19, 608; by age 45, it is one in 93. In fact, less than 5% of cases are discovered before age 35 and the majority of all breast cancers are found in women over age 50.

In 1999, there were 180, 000 new cases of breast cancer diagnosed. About 45, 000 women die of breast cancer each year, accounting for 16% of deaths caused by cancer in women. For the first time ever, mortality rates decreased an average of 1.7% per year from 1995 through 1999, a reflection of earlier diagnosis and improving therapies.

Causes and symptoms

There are a number of risk factors for the development of breast cancer, including:

• family history of breast cancer in mother or sister
• early onset of menstruation and late menopause
• reproductive history: women who had no children or have children after age 30 and women who have never breastfed have increased risk
• history of abnormal breast biopsies

Though these are recognized risk factors, it is important to note that more than 70% of women who get breast cancer have no known risk factors. Having several risk factors may boost a woman's chances of developing breast cancer, but the interplay of predisposing factors is complex. In addition to those accepted factors listed above, some studies suggest that high-fat diets, obesity, or the use of alcohol may contribute to the risk profile. Another factor that may contribute to a woman's risk profile is hormone replacement therapy (HRT).

HRT provides significant relief of menopausal symptoms, prevention of osteoporosis, and possibly protection from cardiovascular disease and stroke. However, studies show that there is a small increased risk of developing breast cancer with HRT use. Thus, the use of hormone replacement therapy should be based on personal risk factors.

Of all the risk factors listed above, family history is the most important. In The Biological Basis of Cancer, the authors estimate that probably about half of all familial breast cancer cases (families in which there is a high breast cancer frequency) have mutations affecting the tumor suppressor gene BRCA-1. Another gene (BRCA-2) also appears to confer inherited vulnerability to early-onset breast cancers. However, breast cancer due to heredity is only a small proportion of breast cancer cases; only 5%-10% of all breast cancer cases will be women who inherited a susceptibility through their genes. Nevertheless, when the family history is strong for development of breast cancer, a woman's risk is increased.

Not all lumps detected in the breast are cancerous. Fibrocystic changes in the breast are extremely common. Also known as fibrocystic condition of the breast, fibrocystic changes are a leading cause of non-cancerous lumps in the breast. Fibrocystic changes also cause symptoms of pain, swelling, or discharge and may become evident to the patient or physician as a lump that is either solid or filled with fluid. Complete diagnostic evaluation of any significant breast abnormality is mandatory because though women commonly develop fibrocystic changes, breast cancer is common also, and the signs and symptoms of fibrocystic changes overlap with those of breast cancer.

Diagnosis

The diagnosis of breast cancer is accomplished by the biopsy of any suspicious lump or mammographic abnormality that has been identified. (A biopsy is the removal of tissue for examination by a pathologist. A mammogram is a low-dose, 2-view, x-ray examination of the breast.) The patient may be prompted to visit her doctor upon finding a lump in a breast, or she may have noticed skin dimpling, nipple retraction, or discharge from the nipple. Or, the patient may not have noticed anything abnormal, and a lump is detected by the mammogram.

When a patient has no signs or symptoms

Screening involves the evaluation of women who have no symptoms or signs of a breast problem, so when the screening mammogram leads to the evaluation, the patient has no symptoms and may not have any abnormality on examination of the breast. Mammography has been very helpful in detecting breast cancer that one cannot identify on physical examination. However, 10%-13% of breast cancer does not show up on mammography, and a similar number of patients with breast cancer have an abnormal mammogram and a normal physical examination. These figures emphasize the need for examination as part of the screening process.

Screening

It is recommended that women get into the habit of doing monthly breast self examinations to detect any lump at an early stage. If an uncertainty or a lump is found, evaluation by an experienced physician and mammography is recommended. The American Cancer Society (ACS) has made recommendations for the use of mammography on a screening basis. There has been controversy about the timing and appropriate frequency of mammography when used as a screening tool, but the ACS recommendations are as follows: Women should get annual mammograms after age 40. Those with a significant family history (one or more first-degree relatives who have been treated for breast cancer), should start annual mammograms 10 years younger than the youngest relative was when she was diagnosed, but not earlier than 35.

Because of the greater awareness of breast cancer in recent years, screening evaluations by examinations and mammography are performed much more frequently than in the past. The result is that the number of breast cancers diagnosed increased, but the disease is being diagnosed at an earlier stage than previously. The earlier the stage of disease at the time of presentation, the better the long-term outcome after treatment, or prognosis, becomes.

When a patient has physical signs or symptoms

A very common finding that leads to diagnosis is the presence of a lump within the breast. Skin dimpling, nipple retraction, or discharge from the nipple are less frequent initial findings prompting biopsy. Though bloody nipple discharge is distressing, it is most often caused by benign disease. Skin dimpling or nipple retraction in the presence of an underlying breast mass on examination is a more advanced finding. Actual skin involvement, with edema or ulceration of the skin, are late findings.

A very common presenting sign is the presence of a breast lump. If the lump is suspicious and the patient has not had a mammogram by this point, a study should be done on both breasts prior to anything else so that the original characteristics of the lesion can be studied. The opposite breast should also be evaluated mammographically to determine if other problems exist that were undetected by physical examination.

Whether an abnormal screening mammogram or one of the signs mentioned above followed by a mammogram prompted suspicion, the diagnosis is established by obtaining tissue by biopsy of the area. There are different types of biopsy, each utilized with its own indication depending on the presentation of the patient. If signs of widespread metastasis are already present, biopsy of the metastasis itself may establish diagnosis.

Biopsy

Depending on the situation, different types of biopsy may be performed. The types include incisional and excisional biopsies. In an incisional biopsy, the physician takes a sample of tissue, and in excisional biopsy, the mass is removed. Fine needle aspiration biopsy and core needle biopsy are kinds of incisional biopsies.

FINE NEEDLE ASPIRATION BIOPSY.

In a fine needle aspiration biopsy, a fine-gauge needle may be passed into the lesion and cells from the area suctioned into the needle can be quickly prepared for microscopic evaluation (cytology). (The patient experiencing nipple discharge can have a sample taken of the discharge for cytological evaluation, also.) Fine needle aspiration is a simple procedure that can be done under local anesthesia, and will tell if the lesion is a fluid-filled cyst or whether it is solid. The sample obtained will yield much diagnostic information. Fine needle aspiration biopsy is an excellent technique when the lump is palpable and the physician can easily hit the target with the needle. If the lesion is a simple cyst, the fluid will be evacuated and the mass will disappear. If it is solid, the diagnosis may be obtained. Care must be taken, however, because if the mass is solid and the specimen is non-malignant, a complete removal of the lesion may be appropriate to be sure.

CORE NEEDLE BIOPSY.

Core needle biopsies are also obtained simply under local anesthesia. The larger piece of tissue obtained with its preserved architecture may be helpful in confirming the diagnosis short of open surgical removal. An open surgical incisional biopsy is rarely needed for diagnosis because of the needle techniques. If there remains question as to diagnosis, a complete open surgical biopsy may be required.

EXCISIONAL BIOPSY.

When performed, the excisional, (complete removal) biopsy is a minimal outpatient procedure often done under local anesthesia.

NON-PALPABLE LESIONS.

As screening increases, non-palpable lesions demonstrated only by mammography are becoming more common. The use of x rays and computers to guide the needle for biopsy or to place markers for the surgeon performing the excisional biopsy are commonly employed. Some benign lesions can be fully removed by multiple directed core biopsies. These techniques are very appealing because they are minimally invasive; however, the physician needs to be careful to obtain a good sample.

Other tests

If a lesion is not palpable and has simple cystic characteristics on mammography, ultrasound may be utilized both to determine that it is a cyst and to guide its evacuation. Ultrasound may also be used in some cases to guide fine needle or core biopsies of the breast.

Computed tomography (CT scan, CAT scans), and magnetic resonance imaging (MRI) have only a very occasional use in the evaluation of breast lesions.