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I was diagnosed with breast cancer at the age of 24. I wasn’t sure if my boyfriend at the time would want to stay with me, with all the surgery, radiation, chemo that I would be going through, not to mention the losing of half my breast. Before my surgery, we attended his company picnic and won a free couple’s getaway package at a local hotel. We decided to take the weekend a week before my surgery. I was looking forward to it, since I was really nervous about surgery, and couldn’t wait to get away. As we were getting dressed for our free dinner at a great place, he proposed. Completely surprised me! Life after that was a whirlwind. There was surgery, chemo, and radiation, and all that goes with cancer treatment. Yet there was also wedding planning! It was wonderful to have something to distract me, and wonderful to have such a caring person to stand by me.
We planned on our wedding the next fall. We didn’t realize at the time that our wedding date was the exact day, a year later, that I started chemo! What better way to celebrate? Things were coming together. The only thing I got to miss out on was getting my hair styled. I had to wear a wig for my wedding, which I think turned out well, but wasn’t what I pictured as a little girl. Marrying my prince charming was, though.
It is so great to have a person like that in my life. I can’t imagine going through this on my own, and having a boyfriend stick around through it. I believe if it weren’t for him, and of course for God, that I wouldn’t have gotten through it.
September 9th, 2006
I have been working as a Nurse in a nursing home for the last 2 years. One of my patient daughter was diagnosed with rectal cancer at age 42. The cancer was so advanced by the time when it was diagnosed, such that she had to get a colostomy.
The cancer formed a fistula to the vagina and so the bowel content could be seen coming out of the vagina. This is my most horrifying thing I have ever seen in my carrer.
She has been on hospice care for over 6 months but she is still hanging in there. The most disturbing thing is that her family want her to die, to stop the pain she goes through. The pain is both physical and psychological, due to colostomy and folet catheter.
Thats my story
September 6th, 2006
About two weeks ago, I met an amazing woman when I was making a home visit to a terminally ill patient. I normally make such visits in my mission to touch the hearts of the sick and hurting people.
In the home, I met a lady by the name Nicole. She was taking care of the sick person I had gone to visit for a wage. I could tell she had a passion on doing that.
After visiting the terminally sick patien, who happens to be Nicole Grand father, Nicole offered me a cup of cofee and we sat down for a chat. When I was about to finish my cup, I realized that Nicole had not even sipped her cofee once. I couldn’t help to think that Nicole, 28 YO, was admiring me 
but I kept on assuming hoping that the right moment would arise and say what she had in her mind.
Nicole started her story and told me that she has been divorced twice by the same man. She has a 6 years old who suffers from ADHD… and so she continued with a long story. I noticed her etes were becoming red as we continued talking. “My former husband divorced me because I have cervical cancer”… she said. “I am the last born in our family and all of us have cervical cancer”.
In my thoughts, I realized that I had come there in that house for a very special reason… to reach the sich, hurting and desperate. I couldn’t do much to help her situation but I had something to give. I had my ears to listen to her as she vent out her pain of living with cancer.
Nicole feels rejected because of her cervical cancer. She is scheduled for a hysterectomy (surgical removal of uterus) this november but she has no one to take care of her during her recovery. She has parents who lives in another state and her operation is scheduled in Dallas.
I realized I had something even bigger to give Nicole. I have some hours I can volunteer and teach her about preparing for the surgery. She had mild anemia and so I thought that should be the first thing I will talk with her.
Nicole has become my close friend. My fiance’ and I will be there for Nicole even after surgery to help keep up with recovery and her ADHD 6 years old.
My story is actually longer than this.. it could be 10 pages long but I have tried to cut it short to avoid boring readers.
Thoughts for the day
Live to give. You may not have material things to give but someone needs your hug. Someone needs your ears. Infact, these are more valuable than material gifts to someone in pain.
Quote of the day: “You have not lived your day until you do something for someone who cannot pay you back”
:-) :-O
September 5th, 2006
Breast Cancer
Types of Breast Cancer
There are several types of breast cancer. The aggressiveness of the cancer and the likelihood that the cancerous cells will spread (metastasize) to other parts of the body depends on the type of cancer involved.
Breast Cancers
Common Breast Cancers
The most common types of breast cancer are: Ductal carcinoma in situ (DCIS). A cancer that is contained, and thus does not yet have the ability to spread beyond the immediate area, is said to be in situ . Ductal cancer in situ (DCIS) is confined to the ducts of the milk-producing glands and has not invaded the surrounding tissues of the breast, although, if neglected, it might eventually do so. For the time being, however, it doesn’t have access to the blood vessels or lymphatic channels that exist in the fatty tissue outside the glands, and it cannot spread to other organs in the body. DCIS is a breast cancer at its earliest stage (Stage 0), still confined to the ducts. Nearly 100% of women with cancer at this stage can be cured. In screening centers, 20–30% of the new breast cancers diagnosed are DCIS and 70–80% are invasive. On a mammogram, DCIS in the majority of patients looks like a cluster of calcifications (tiny white spots or little grains of sand) without a mass. In about 15% of patients, there’s also a lump, and in the remaining 10% of women, a mass is found without calcifications. Invasive (infiltrating) ductal carcinoma (IDC). This is the most common form of breast cancer —70–80% of invasive breast carcinomas are IDC. This cancer begins in a duct, breaks through the duct wall, and invades the fatty tissue of the breast. From there it can spread to other parts of the body via the lymphatic channels or bloodstream. Invasive (infiltrating) lobular carcinoma. Between 10–15% of invasive breast cancers are this type. The cancer cells have grown through the wall of the lobule and can spread to other parts of the body by way of the lymphatic channels or bloodstream.
Breast Cancers
Less Common Breast Cancers
There are several less common forms of breast cancer. Medullary carcinoma. This invasive cancer is the pink color of brain tissue (the medulla) and has a relatively well defined, distinct boundary between tumor and normal breast tissue. About 6% of all breast cancers are of this type, and its prognosis is better than for invasive lobular or invasive ductal carcinomas. It can exhibit different degrees of aggressiveness. Tubular carcinoma. This accounts for 1–2% of breast cancers, and its cells look like little tubes (hence the name). It is an invasive cancer but it spreads beyond the breast only infrequently, and therefore has a better prognosis than invasive ductal or lobular carcinomas. Colloid or mucinous carcinoma. Also rare, this is an infiltrating ductal cancer that is formed by mucus-producing cancer cells. Papillary carcinoma. Extremely rare, the cells of this particular breast cancer stick out like little papules, or finger-like projections. This form of cancer can be either invasive or noninvasive. Inflammatory breast cancer. This advanced form of breast cancer starts with breast swelling and skin that looks red and feels warm. Usually there’s not a distinct lump, and the first impression is that of infection. Infections either get better or worse, so if the inflammation doesn’t clear up or gets worse after 10 days to two weeks of antibiotics, you should see a breast surgeon, who will probably order a mammogram and then perform a biopsy of the skin. This is an unusual type of breast cancer, and it’s an aggressive one. The skin is red because cancer cells are congesting the lymphatic channels, thus blocking fluid drainage from the lymph vessels of the skin.
January 25th, 2006
Definition
Male breast cancer is a malignant tumor that forms in a man’s breast.
Description
Breast cancer is rare in men, but can be serious and fatal. Many people believe
that only women can get breast cancer, but men have breast tissue that also
can develop cancer. When men and women are born, they have a small amount of
breast tissue with a few tubular passages called ducts located under the nipple
and the area around the nipple (areola). By puberty, female sex hormones cause
breast ducts to grow and milk glands to form at the ends of the ducts. But male
hormones eventually prevent further breast tissue growth. Although male breast
tissue still contains some ducts, it will have only a few –or no– lobules.
Near the breasts of men and women are axillary lymph nodes. These are underarm
small structures shaped like beans that collect cells from lymphatic vessels.
Lymphatic vessels carry lymph, a clear fluid that contains fluid from tissues,
cells from the immune system, and various waste products throughout the body.
The axillary lymph nodes are important to breast cancer patients, as they play
a role in the spread and staging of breast cancer.
Breast cancer is much more common in women, mostly because women have many
more breast cells that can undergo cancerous changes and because women are exposed
to the effects of female hormones.
Infiltrating ductal carcinoma is the most common type of breast cancer in men.
It is a type of adenocarcinoma, or a type of cancer that occurs in glandular
tissue. Infiltrating ductal carcinoma starts in a breast duct and spreads beyond
the cells lining the ducts to other tissues in the breast. Once the cancer begins
spreading into the breast, it can spread to other parts of the body. This distant
spread is called metastasis. When breast cancer metastasizes to other areas
of the body, it can cause serious, life-threatening consequences. For example,
breast cancer might spread to the liver or lungs. About 80% to 90% of all male
breast cancers are infiltrating ductal carcinomas.
Ductal carcinoma in situ (DCIS) is not common; it accounts for about 10% of
all male breast cancers. It also is an adenocarcinoma. In situ cancers remain
in the immediate area where they began, so DCIS remains confined to the breast
ducts and does not spread to the fatty tissues of the breast. This means it
is likely found early. DCIS also may be called intraductal carcinoma.
Other types of breast cancer are very rare in men. Adenocarcinomas that are
lobular (forming in the milk glands or lobules) only occur in about 2% of male
breast cancer cases because men normally do not have milk gland tissues. Inflammatory
breast cancer, a serious form of breast cancer in which the breast looks red
and swollen and feels warm, also occurs rarely. Paget’s disease of the nipple,
a type of breast cancer that grows from the ducts beneath the nipple onto the
nipple’s surface, only accounts for about 1% of female breast cancers. However,
slightly more men have this form of breast cancer than women. Sometimes, Paget’s
disease is associated with another form of breast cancer.
Although not a form of cancer, but a benign condition, gynecomastia is important
to mention. It is the most common of all male breast disorders and can be associated
with male breast cancer in a rare condition called Klilnefelter’s syndrome.
Gynecomastia most often occurs in teenage boys when their hormones change during
puberty. Older men also may experience the condition when their hormone balance
changes as they age. Gynecomastia is an increase in the amount of breast tissue,
or breast tissue enlargement. If a man has Klinefelter’s syndrome, he can develop
gynecomastia and increased risk of breast cancer.
Demographics
Breast cancer in men is rare, accounting for less than 1% of all breast cancers.
Still, about 1,450 American men were diagnosed with the disease and 470 men
died from it in 2004. Although studies show the number of breast cancer cases
in women has decreased in the United States and Europe since the 1960s, the
number of breast cancer cases in men have not decreased, but remained stable
or slightly increased.
The rate of increase in cases begins and steadily rises at age 50 for men.
However, the average age for male breast cancer is between 60 and 70 years old,
with a median age of 67 years. Men often are diagnosed at a later stage than
women.
Causes and symptoms
Scientists do not know what causes most cases of male breast cancer. However,
excellent progress is being made in genetic research and in understanding how
genes instruct cells to grow, divide, and die. For example, researchers have
now mapped all of the genes in the human body. Genes are part of the body’s
DNA, which is the chemical that instructs the cells. When DNA or genes carry
defects (mutations), they activate changes in the cells, such as rapid cell
division, that lead to cancer. Some genes, called tumor suppression genes, cause
cells to die. Scientists have identified some genetic mutations that are risk
factors for breast cancer. In other cases, environmental, or outside, factors
are thought to increase a man’s risk for breast cancer.
Mutations of at least two versions of a tumor suppressor gene (BRCA1 and BRCA2)
have been identified as causes of breast cancer in women. In men, the BRCA2
mutation is considered responsible for about 15% of breast cancers. Men can
inherit genes from either parent. Studies have shown that BRCA1 also may increase
a man’s risk for breast cancer, but its role is less certain. These mutations
have been shown to increase other cancers in men, including prostate cancer.
Klinefelter’s syndrome is a rare genetic cause of breast cancer in men. It results
from inheriting an additional X chromosome.
Several other factors also may cause male breast cancer. Some conditions, such
as the liver disease cirrhosis, can cause an imbalance in a man’s hormones,
producing high levels of the female hormone estrogen, which can lead to breast
cancer. Exposure to some substances such as high amounts of radiation may contribute
to male breast cancer. A 2004 report studied why a cluster of breast cancer
cases occurred among a small group of men who worked in the basement office
of a multi-story office building. The study linked their breast cancer to exposure
to high magnetic fields from a nearby electrical switchgear room in their work
space.
Many men do not realize they can develop breast cancer; they ignore the symptoms.
The most common symptom is a mass, or lump in the chest area, particularly around
the nipple. The lump will be firm, not tender or painful. Other signs that may
warn of male breast cancer include:
Skin dimpling or puckering
Changes in the nipple, such as drawing inward (retraction)
Nipple discharge of any kind
Redness or scaling of the nipple or breast skin
Abnormal swelling (or lump) of the breast, nipple, or chest muscle
Prolonged rash or irritation of the nipple, which may indicate Paget’s disease
Diagnosis
Physicians follow the same steps for diagnosing breast cancer in men as in women,
except that routine screening of breast cancer is not done in men. Once symptoms
are noticed, however, physicians will proceed in the same way. The physician
will conduct a thorough medical history and examination, including questions
that may identify risk factors for breast cancer, such as male or female relatives
with the disease. The medical history also helps gather details on possible
symptoms for breast cancer.
The physician also performs a clinical breast examination. This helps locate
and study a lump or suspicious area. The physician will feel (palpate) a mass
to get an idea of its size, texture, likely location and relation to surrounding
skin, muscles and tissues. At this point, the physician already will begin to
look for signs that the cancer may have spread to other organs and to the lymph
nodes. The physician will palpate lymph nodes and the liver, for instance, to
see if they are enlarged.
The next step in diagnosis usually is a diagnostic mammogram. Mammography is
an x ray of the breast. Mammograms are performed by radiologic technologists
who take special training in the procedure. Mammograms are evaluated by radiologists,
physicians who receive medical training specifically in interpreting x rays.
If the initial mammogram shows suspicious findings, the radiologist may order
magnification views to more closely look at the suspicious area. Mammograms
can accurately show the tissue in the breast, even more so in men than women,
because men do not have dense breasts or benign cysts in their breasts that
interfere with the diagnosis.
The radiologist also might recommend an ultrasound to follow up on suspicious
findings. Ultrasound often is used to image the breasts. Also known as sonography,
the technique uses high-frequency sound waves to take pictures of organs and
functions in the body. Sound wave echoes can be converted by computer to an
image and displayed on a computer screen. Ultrasound does not use radiation.
A technologist will perform the ultrasound; it will be evaluated by the radiologist.
Biopsies, which involve removing a sample of tissue, are the only definite
way to tell if a mass is cancerous. At one time, surgical biopsies were the
only option, requiring removal of all or a large portion of the lump in a more
complicated procedure. Today, fine-needle aspiration biopsy and core biopsies
can be performed. In fine-needle aspiration biopsy, a thin needle is inserted
to withdraw fluid from the mass. The physician may use ultrasound or other imaging
guidance to locate the mass if necessary. The fluid is tested in a laboratory
under a special microscope to determine if it is cancerous.
A core biopsy is similar, but involves removing a small cylinder of tissue
from the mass through a slightly larger needle. Core biopsy may require local
anesthesia. These biopsy techniques usually can be performed in a physician
office or outpatient facility. The cells in biopsy samples help physicians determine
if the lump is cancerous and the type of breast cancer. A tissue sample also
may be used for assigning a grade to the cancer and to test for certain proteins
and receptors that aid in treatment and prognosis decisions.
If there is discharge from the nipple, the fluid also may be collected and
analyzed in a laboratory to see if cancer cells are present in the fluid.
Diagnosis of breast cancer spread may require additional tests. For example,
a computed tomography (CT) scan may be ordered to check organs such as the liver
or kidney for possible metastasized cancer. A chest x ray can initially check
for cancer spread to the lungs. Bone scans are nuclear medicine procedures that
look for areas of diseased bone. Magnetic resonance imaging (MRI) has been increasingly
used in recent years as a follow-up study to mammograms when findings are not
clear. However, for metastatic breast cancer, they are more likely to be ordered
to check for cancer in the brain and spinal cord. Positron emission tomography
(PET) scans also have become more common in recent years.
Treatment team
The treatment team for male breast cancer normally consists of a primary care
physician, a medical oncologist (cancer specialist) and if radiation therapy
is used, a radiation oncologist. Many other staff also are involved. For instance,
special oncology nurses help guide patients through their care and recovery.
Radiation therapists are specially trained technologists who deliver the radiation
therapy treatments prescribed by the radiation oncologist.
Clinical staging, treatments, and prognosis
A technique called sentinel lymph node biopsy may be the first step in staging.
The sentinel node is the first one the cancer cells are likely to reach, so
it is the first one checked for cancerous cells. Using a radioactive substance
and blue dye injected into the area around the tumor, physicians can track the
path of the cells and stage the cancer. The technique has been used for many
years on women with breast cancer; research in 2004 showed it worked well for
predicting lymph node status in men as well.
Staging
Cancer staging systems help physicians compare treatments and research and identify
patients for clinical trials. Most of all, they help physicians determine treatment
and prognosis for individual patients by describing how severe a patient’s cancer
is in relation to the primary tumor. The most common system used for cancer
is the American Join Committee on Cancer (AJCC) TNM system, which bases staging
largely on the spread of the cancer. T stands for tumor and describes the tumor’s
size and spread locally, or within the breast and to nearby organs. The letter
N stands for lymph nodes and describes the cancer’s possible spread to and within
the lymph node system. In some descriptions below, the cancer may have been
found by sentinel node biopsy as microscopic disease in nodes that are in the
breasts (rather than the armpits). For simplification, these findings have been
grouped with the axillary lymph nodes. M stands for metastasis to note if the
cancer has spread to distant organs. Further letters and numbers may follow
these three letters to describe number of lymph nodes involved, approximate
tumor sizes, or other information. The following is a summary of breast cancer
stages:
Stage 0: Tis, N0, M0: Ductal carcinoma in situ (DCIS). This is the earliest
and least invasive form of breast cancer; the cancer cells are located within
a duct and have not invaded surrounding fatty tissue.
Stage I: T1, N0, M0: The tumor is less than 1 in. in diameter (2 cm or less)
and has not spread to lymph nodes or distant organs.
Stage IIA: T0, N1, M0/T2, NO, MO: No tumor is found or the tumor is smaller
than 2 cm and cancer is found in one to three axillary lymph nodes (even if
no tumor is found), or the tumor is between 2 and 5 cm in diameter but has not
spread to the axillary lymph nodes. The cancer has not spread to distant organs.
Stage IIIB: T2, N1, M0/T3, NO, MO: The tumor is between 2 and 5 cm in diameter
and has spread to one to three axillary lymph nodes or the tumor is larger than
5 cm, has not grown into the chest wall or spread to the lymph nodes or distant
organs.
Stage IIIA: T0-2, N2, M0/T3, N1, MO: The tumor is smaller than 5 cm in diameter
and has spread to four to nine axillary lymph nodes or the tumor is larger than
5 cm and has spread to one to nine axillary lymph nodes. The cancer has not
spread to distant organs.
Stage IIIB: T4, N0-2, M0: The tumor has grown into the chest wall or the skin
and may have spread to no lymph nodes or as many as nine lymph nodes. Cancer
has not spread to distant sites.
Stage IIIC: T0-4, N3, MO: The tumor is any size, has spread to 10 or more axillary
lymph nodes or to one or more lymph nodes under or above the collarbone (clavicle)
on the same side as the breast tumor. The cancer has not spread to distant organs.
Inflammatory breast cancer: Classified as stage III, unless it has spread to
distant organs or lymph nodes not near the breast (which would classify it as
Stage IV).
Stage IV: T0-4, N0-3, M1: Regardless of the tumor’s size, the cancer has spread
to distant organs, such as the liver, bones, or lung, or to lymph nodes far
from the breast.
Treatment
If the axillary lymph nodes were identified as containing cancer at the time
of the sentinel lymph node biopsy, they will be removed in an axillary dissection.
Sometimes, this is done at the time of the biopsy.
For Stage I, surgery often is the only treatment needed for men. Women often
have lumpectomies, which remove as little surrounding breast tissue as possible,
to preserve some of their breast shape. For men, this is less of a concern,
and mastectomy, or surgical removal of the breast, is performed in 80% of all
male breast cancers. Men with Stage I tumors larger than 1 cm may receive additional
(adjuvant) chemotherapy.
Men with Stage II breast cancer also usually receive a mastectomy. If they
have cancer in the lymph nodes, they probably will receive adjuvant therapy.
Those with estrogen receptor-positive tumors may receive hormone therapy with
tamoxifen. The treatment team may recommend adjuvant radiation therapy if the
cancer has spread to nearby lymph nodes and/or to the skin.
Stage III breast cancer requires mastectomy followed by adjuvant therapy with
tamoxifen when hormones are involved. Most patients with Stage III disease also
will require chemotherapy and radiation therapy to the chest wall.
Men with Stage IV breast cancer will require systemic therapy, or chemotherapy
and perhaps hormonal therapy that works throughout the body to fight the cancer
in the breast, as well as the cancer cells that have spread. Patients also may
receive immunotherapy to help patients fight infection following chemotherapy.
Radiation and surgery also may be used to relieve symptoms of the primary cancer
and areas where the cancer may have spread. The treatment team also may have
to diagnose specific treatments for the metastatic cancers, depending on their
sites.
If male breast cancer recurs in the breast or chest wall, it can be treated
with surgical removal and followed by radiation therapy. An exception is recurrence
in the same area, where additional radiation therapy can damage normal tissue.
Recurrence of the cancer in distant sites is treated the same as metasteses
found at the time of diagnosis.
Prognosis
Prognosis for male breast cancer varies, depending on stage. Generally, prognosis
is poorer for men than for women, because men tend to show up for diagnosis
when their breast cancer has reached a later stage. The average five-year survival
rate for Stage I cancers is 96%. For Stage II, it is 84%. Stage III cancers
carry an average five-year survival rate of 52%, and by Stage IV, the rate drops
to 24%.
Alternative and complementary therapies
Many alternative and complementary therapies can help cancer patients relax
and deal with pain, though none to date have been shown to treat or prevent
male breast cancer. For example, traditional Chinese medicine offers therapies
that stress the importance of balancing energy forces. Many studies also show
that guided imagery, prayer, meditation, laughter, and a positive approach to
cancer can help promote healing. Early studies have shown that soy and flaxseed
may have some preventive properties for breast cancer. However, these trials
have been conducted in women. When looking for these therapies, cancer support
groups suggest asking for credible referrals and working with the medical treatment
team to coordinate alternative and complementary care.
cancer treatment
Coping with cancer treatment
It is difficult for some men to accept and cope with a breast cancer diagnosis,
since it is a relatively rare and unexpected disease among men. It is important
that men work closely with their treatment team to talk about the their concerns
and to carefully follow all instructions for care. Support groups and family
support are critical in coping with a breast cancer diagnosis.
Eating a nutritious diet, stopping use of tobacco, and limiting use of alcohol,
can help in recovery from breast cancer. Beginning a regular exercise program
when the treatment team recommends also helps.
Clinical trials
Research currently is underway to test various chemotherapy combinations for
male breast cancer at different stages. A clinical trial also is underway to
investigate a vaccine for treating patients with metastatic breast cancer. The
National Institutes of Health list clinical trials by disease type, including
those for which they are recruiting patients. Choosing to participate in a clinical
trial is a decision that involves the patient, family, and treatment team.
Prevention
Some forms of male breast cancer cannot be prevented. But detecting the cancer
at an early stage can prevent serious complications, such as spread to distant
organs. Men who have a history of breast cancer in their family should pay particular
attention to the symptoms of breast cancer and seek immediate medical evaluation.
Physicians may be able to test the blood of men with family history for presence
of the BRCA2 gene so they may more carefully watch for early signs of breast
cancer. Avoiding exposure to radiation also may help present some male breast
cancers.
Special concerns
Men should remember that there are important difference between male and female
breast cancers. Some experts say that specific guidelines and instructions for
men with breast cancer are noticeably lacking, so men should not be afraid to
ask questions or to push a physician for more information when he suspects he
might have a suspicious lump or finding in his breast.
January 25th, 2006
Definition of Breast Cancer
Breast cancer is caused by the development of malignant cells in the breast. The malignant cells often originate in the lining of the milk glands or ducts of the breast (ductal epithelium). Cancer cells are characterized by uncontrolled division leading to abnormal growth and the ability of these cells to invade normal tissue locally or to spread throughout the body, in a process called metastasis.
Description of Breast Cancer
Breast cancer often arises in the milk-producing glands of the breast tissue. Groups of glands in normal breast tissue are called lobules. The products of these glands are secreted into a ductal system that leads to the nipple. Depending on where in the glandular or ductal unit of the breast the cancer arises, it will develop certain characteristics that are used to sub-classify breast cancer into types. The pathologist will denote the subtype at the time of evaluation with the microscope. Ductal carcinoma begins in the ducts, and lobular carcinoma has a pattern involving the lobules or glands. The more important classification is related to the evaluated tumor’s capability to invade, as this characteristic defines the disease as a true cancer. The stage before invasive cancer is called in situ , meaning that the early malignancy has not yet become capable of invasion. Thus, ductal carcinoma in situ is considered a minimal breast cancer.
How breast cancer spreads
The primary tumor begins in the breast itself but once it becomes invasive, it may progress beyond the breast to the regional lymph nodes or travel (metastasize) to other organ systems in the body and become systemic in nature. Lymph is the clear, protein-rich fluid that bathes the cells throughout the body. Lymph will work its way back to the bloodstream via small channels known as lymphatics. Along the way, the lymph is filtered through cellular stations known as nodes, thus they are called lymph nodes. Nearly all organs in the body have a primary lymph node group filtering the tissue fluid, or lymph, that comes from that organ. In the breast, the primary lymph nodes are under the armpit, or axilla. Classically, the primary tumor begins in the breast and the first place to which it is likely to spread is the regional lymph nodes. Cancer, as it invades in its place of origin, may also work its way into blood vessels. If cancer gets into the blood vessels, the blood vessels provide yet another route for the cancer to spread to other organs of the body.
Breast cancer follows this classic progression though it often becomes systemic or widespread early in the course of the disease. By the time one can feel a lump in the breast it is often 0.4 inches, or one centimeter, in size and contains roughly a million cells. It is estimated that a tumor of this size may take one to five years to develop. During that time, the cancer may metastasize.
When primary breast cancer spreads, it may first go to the regional lymph nodes under the armpit, the axillary nodes. If this occurs, regional metastasis exists. If it proceeds elsewhere either by lymphatic or blood-borne spread, the patient develops systemic metastasis that may involve a number of other organs in the body. Common sites of systemic involvement for breast cancer are the lung, bones, liver, and the skin and soft tissue. As it turns out, the presence of, and the actual number of, regional lymph nodes containing cancer remains the single best indicator of whether or not the cancer has become widely metastatic. Because tests to discover metastasis in other organs may not be sensitive enough to reveal minute deposits, the evaluation of the axilla for regional metastasis becomes very important in making treatment decisions for this disease.
If breast cancer spreads to other major organs of the body, its presence will compromise the function of those organs. Death can result from compromise of these vital organs’ functions.
Demographics of Breast Cancer
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 2002, 200,000 new cases of breast cancer were diagnosed. About 45,000 women die of breast cancer each year, accounting for 16% of deaths caused by cancer in women. However, deaths from breast cancer are declining in recent years, a reflection of earlier diagnosis from screening mammograms and improving therapies.
Causes and symptoms of Breast Cancer
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. While physicians have long known a small increased risk for breast cancer was linked to use of HRT, a landmark study released in 2003 proved the risk was greater than thought. The Women’s Health Initiative found that even relatively short-term use of estrogen plus progestin is associated with increased risk of breast cancer, diagnosis at a more advanced stage of the disease, and a higher number of abnormal mammograms. The longer a woman used HRT, the more her risk increased.
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 genes BRCA-1 and BRCA-2. In 2003, scientists discovered a third gene called EMSY. 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 of Breast Cancer
The diagnosis of breast cancer is accomplished through biopsy of a 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. The patient may not have noticed a symptom or abnormality, and a lump was detected by a screening 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. Mammography has been helpful in detecting breast cancer that cannot be identified 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 a mammogram is recommended. The American Cancer Society (ACS) has made recommendations for the use of mammography on a screening basis. In 2003, the ACS updated its guidelines concerning screening mammograms. The most notable change was that women should begin annual screening at age 40 instead of age 50. (in the past, the ACS, recommended beginning mammograms at age 40, but only ever one or two years instead of annually.) Women at higher risk for breast cancer should benefit from beginning screenings at earlier ages and at more frequent intervals.
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 it is discovered, the better the long-term outcome (prognosis) becomes.
When a patient has physical signs or symptoms
A 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.
The presence of a breast lump is a common sign of breast cancer. 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) scans have only rare in the evaluation of breast lesions. Magnetic resonance imaging (MRI) has been used more often in recent years to follow up on suspicious findings from mammograms or for certain patients.
Clinical staging, treatments, and prognosis
Staging of Breast Cancer
Once diagnosis is established, before treatment is rendered, more tests are done to determine if the cancer has spread beyond the breast. These tests include a chest x ray and blood count with liver function tests. Along with the liver function measured by the blood sample, the level of alkaline phosphatase, an enzyme from bone, is also determined. A radionuclear bone scan may be ordered. This test looks at the places in the body to which breast cancer usually metastasizes. A CT scan may also be ordered. The physician will do a careful examination of the axilla to assess likelihood of regional metastasis but unfortunately this exam is not very accurate. Since the axillary node status is the best reflection of possible widespread disease, some or all of these nodes may be removed at the time of surgical treatment. However, recent studies show great success with sentinel lymph node biopsy. This technique removes the sentinel lymph node, or that lymph node that receives fluid drainage first from the area where the cancer is located. If this node is free of cancer, staging can be assigned accordingly. This method saves women the discomfort and side effects associated with removing additional lymph nodes in her armpit.
Using the results of these studies, clinical stage is defined for the patient. This helps define treatment protocol and prognosis. After surgical treatment, the final, or pathologic, stage is defined as the true axillary lymph node status is known. Detailed staging criteria are available from the American Joint Commission on Cancer Manual and are generalized here:
Stage 1–The cancer is no larger than 2 cm (0.8 in) and no cancer cells are found in the lymph nodes.
Stage 2–The cancer is between 2 cm and 5 cm, and the cancer has spread to the lymph nodes.
Stage 3A–Tumor is larger than 5 cm (2 in) or is smaller than 5 cm, but has spread to the lymph nodes, which have grown into each other.
Stage 3B–Cancer has spread to tissues near the breast, (local invasion), or to lymph nodes inside the chest wall, along the breastbone.
Stage 4–Cancer has spread to skin and lymph nodes beyond the axilla or to other organs of the body.
Treatment of Breast Cancer
Surgery, radiation, and chemotherapy are all utilized in the treatment of breast cancer. Depending on the stage, they will be used in different combinations or sequences to effect an appropriate strategy for the type and stage of the disease being treated.
Surgery
Historically, surgical removal of the entire breast and axillary contents along with the muscles down to the chest wall was performed as the lone therapy, (radical mastectomy). In the last 25 years, as it has been appreciated that breast cancer often spreads early, surgery remains a primary option but other therapies have risen in importance.
Today, surgical treatment is best thought of as a combination of removal of the primary tumor and staging of the axillary lymph nodes. A modified radical mastectomy involves removing the whole breast along with the entire axillary contents but not the muscles of the chest wall.
If the tumor is less than 4 cm (1.5 in) in size and located so that it can be removed without destroying the reasonable cosmetic appearance of the residual breast, just the primary tumor and a rim of normal tissue will be removed. The axillary nodes will still be removed for staging purposes, usually through a separate incision. Because of the risk of recurrence in the remaining breast tissue, radiation is used to lessen the chance of local recurrence. This type of primary therapy is known as lumpectomy, (or segmental mastectomy), and axillary dissection.
Sentinel lymph node biopsy, a technique for identifying which nodes in the axilla drain the tumor, has been developed to provide selective sampling and further lessen the degree of surgical trauma the patient experiences.
When patients are selected appropriately based on the preoperative clinical stage, all of these surgical approaches have been shown to produce similar results. In planning primary surgical therapy, it is imperative that the operation be tailored to fit the clinical circumstance of the patient.
The pathologic stage is determined after surgical treatment absolutely defines the local parameters. In addition to stage, there are other tests that are very necessary to aid in decisions regarding treatment. Handling of the surgical specimen is thus very important. The tissue needs to be analyzed for the presence or absence of hormone receptors and a receptor called HER-2. The presence of these receptors will influence additional therapies. Microscopic evaluation may also include the assessment of lymphatic or blood vessel invasion as these predict a worse outcome. The DNA of the tumor cells is quantitatively analyzed to help decide the biologic aggressiveness of the tumor. These parameters will be utilized collectively along with the axillary lymph node status to define the anticipated aggressiveness of the cancer. This assessment, along with the age and general condition of the patient, will be considered when planning the adjuvant therapies. Adjuvant therapies are treatments utilized after the primary treatment to help ensure that no microscopic disease exists and to help prolong patients’ survival time.
Radiation of Breast Cancer
Like surgical therapy, radiation therapy is a local modality–it only treats the exposed tissue. Radiation is usually given post-operatively after surgical wounds have healed. The pathologic stage of the primary tumor is now known and this aids in treatment planning. The extent of the local surgery also influences the planning. Radiation may not be needed at all after modified radical mastectomy for stage I disease, but is almost always utilized when breast-preserving surgery is performed. If the tumor was extensive or if multiple nodes were involved, the field of tissue exposed will vary accordingly. Radiation is utilized as an adjunct to surgical therapy and is considered an important modality in gaining local control of the tumor. The use of radiation therapy does not affect decisions for adjuvant treatment. In the past, radiation was used as an alternative to surgery on occasion. However, now that breast-preserving surgical protocols have been developed, primary radiation treatment of the tumor is no longer performed. Radiation also has an important role in the treatment of the patient with disseminated disease, particularly if it involves the skeleton. Radiation therapy can affect pain control and prevention of fracture in this circumstance.
Drug therapy of Breast Cancer
Many breast cancers, particularly those originating in post-menopausal women, are responsive to hormones. These cancers have receptors on their cells for estrogen and progesterone. Part of primary tumor assessment after removal of the tumor is the evaluation for the presence of these estrogen and progesterone receptors. If they are present on the cancer cells, altering the hormone status of the patient will inhibit tumor growth and have a positive impact on survival. The drug tamoxifen binds up these receptors on the cancer cells so that the hormones can’t have an effect and, in so doing, inhibits tumor growth. If the patient has these receptors present, tamoxifen is commonly prescribed for five years as an adjunct to primary treatment. Adjuvant hormonal therapy with tamoxifen has few side effects but they have to be kept in mind, particularly the need for yearly evaluation of the uterus.
In late 2003, cancer experts were beginning to recommend a new group of drugs called aromatase inhibitors (Arimidex, common name anastrozole, or more recently Femara and Novartis, common name letrozole) as an alternative to tamoxifen. New guidelines also recommend letrozole following five years of tamoxifen therapy. These drugs fight breast cancer differently, but early research shows they fight it as effectively and with fewer side effects.
Shortly after the modified radical mastectomy replaced the radical mastectomy as primary surgical treatment, it was appreciated that survival after local treatment in stage II breast cancer was improved by the addition of chemotherapy. Adjuvant chemotherapy for an interval of four to six months is now standard treatment for patients with stage II disease. The addition of systemic therapy to local treatment in patients who have no evidence of disease is performed on the basis that some patients have metastases that are not currently demonstrable because they are microscopic. By treating the whole patient early, before widespread disease is diagnosed, the adjuvant treatment improves survival rates from roughly 60% for stage II to about 75% at five years after treatment. The standard regimen of CMF, or cytoxan, methotrexate, and fluorouracil, is given for six months and is well tolerated. The regimen of cytoxan, adriamycin (doxorubicin), and fluorouracil, (CAF), is a bit more toxic but only requires four months. (Adriamycin and cytoxin may also be used alone, without the fluorouracil.) The two methods are about equivalent in results. Adjuvant hormonal therapy may be added to the adjuvant chemotherapy as they work through different routes.
As one would expect, the encouraging results from adjuvant therapy in stage II disease have led to the study of similar therapy in stage I disease. The results are not as dramatic, but they are real. Currently, stage I disease is divided into categories a, b, and c on the basis of tumor size. Stage Ia is less than a centimeter in diameter. Adjuvant hormonal or chemotherapy is now commonly recommended for stage Ib and Ic patients. The toxicity of the treatment must be weighed individually for the patient as patients with stage I disease have a survivorship of over 80% without adjuvant chemotherapy.
If patients are diagnosed with stage IV disease or, in spite of treatment, progress to a state of widespread disease, systemic chemotherapy is utilized in a more aggressive fashion. In addition to the adriamycin-containing regimens, docetaxel and paclitaxel) have been found to be effective in inducing remission.
On the basis of certain prognostic factors, some patients with stage II or III disease can be predicted to do poorly. If their performance status allows, they may be considered for treatment with highly aggressive chemotherapy. The toxicity is such that bone marrow failure will result. To get around this anticipated side effect of the aggressive therapy, either the patients will be transplanted with their own stem cells, (the cells that will give rise to new marrow), or an allogeneic bone marrow transplantation will be required. This therapy can be a high-risk procedure for patients. It is given with known risk to patients predicted to do poorly and then only if it is felt they can tolerate it. Most patients who receive this therapy receive it as part of a clinical trial.
For patients who are diagnosed with advanced local disease, surgery may be preceded with chemotherapy and radiation therapy. The disease locally regresses allowing traditional surgical treatment to those who could not receive it otherwise. Chemotherapy and sometimes radiation therapy will continue after the surgery. The regimens of this type are referred to as neo-adjuvant therapy. This has been proven to be effective in stage III disease. Neo-adjuvant therapy is now being studied in patients with large tumors that are stage II in an effort to be able to offer breast preservation to these patients.
A drug known as Herceptin (trastuzumab), a monoclonal antibody, is now being used in the treatment of those with systemic disease. The product of the Human Epidermal Growth Factor 2 gene, (HER-2) is overexpressed in 25%-30% of breast cancers. Herceptin binds to the HER-2 receptors on the cancer, resulting in the arrest of growth of these cells.
Prognosis Breast Cancer
The prognosis for breast cancer depends on the type and stage of cancer. Over 80% of stage I patients are cured by current therapies. Stage II patients survive overall about 70% of the time; those with more extensive lymph nodal involvement do worse than those with disease confined to the breast. About 40% of stage III patients survive five years, and about 20% of stage IV patients do so.
cancer treatment
Coping with cancer treatment
Surgery for breast cancer is physically well-tolerated by the patient, especially those undergoing minimal surgery in the axilla. Most patients can return to a normal lifestyle within a month or so after surgery. Exercises can help the patient regain strength and flexibility. Arm, shoulder, and chest exercises help, and complete recovery of activity is to be expected.
About 5%-7% of patients undergoing complete axillary lymph node resection as part of their therapy may develop clinically significant lymphedema, or swelling in the arm on the side of involvement. If present, elevation and massage may be needed intermittently. Though usually not serious, on occasion this complication may interfere with complete physical recovery. The incidence of lymphedema is less with less axillary surgery. This is the reason for the enthusiasm for sentinel node biopsy as the surgical staging procedure in the axilla.
It is common after breast cancer treatment to be depressed or moody, to cry, lose appetite, or feel unworthy or less interested in sex. The breast is involved with a woman’s identity and loss of it may be disturbing. For some, counseling or a support group can help. Many women have found a support group of breast cancer survivors to be an invaluable help during this stage. Involvement with volunteers from the local chapter of the Reach to Recovery program may be very helpful.
Nearly all patients undergo some form of adjuvant therapy for breast cancer. The magnitude of the toxicity of these adjuvant therapies is usually small and many patients receiving chemotherapy on this basis are capable of normal activity during this time. Certainly, those who progress to advanced disease are treated with more toxic chemotherapeutic regimens in an attempt to induce remission.
Clinical trials in Breast Cancer
The use of tamoxifen and other agents that alter the hormone status of the patient are under study. The National Surgical Adjuvant Breast and Bowel Project (NSABP) with support from the National Cancer Institute began a study in 1992 (called the Breast Cancer Prevention Trial, or BCPT). It researched the use of tamoxifen as a breast cancer preventive for high-risk women. The results yielded from the study showed that tamoxifen significantly reduced breast cancer risk, and the U.S. Food and Drug Administration approved the use of tamoxifen to reduce breast cancer risk for high-risk patients in 1998. Another NSABP study, known as STAR, has sought to understand if another drug, raloxifene, is as effective as tamoxifen in reducing breast cancer risk in high-risk patients. A number of clinical trials continue on the prevention and treatment of breast cancer. Numerous breast cancer organizations and the National Cancer Institute can provide information on participating in clinical trials.
Immune therapies have not been helpful to date though there are vaccines being developed against proteins such as that produced by HER-2 that may be beneficial in the future.
High-dose chemotherapy with bone marrow rescue remains controversial. Factors can be identified that predict certain patients will develop metastatic disease. This treatment has been offered to this select group of patients but the toxicity is such that defining a clear indication for this treatment remains under study.
Prevention of Breast Cancer
While most breast cancer can’t be prevented, it can be diagnosed from a mammogram at an early stage when it is most treatable. The results of awareness and routine screening have allowed earlier diagnosis, which results in a better prognosis for those discovered.
Special concerns of Breast Cancer
Though breast-preserving therapy is being done more frequently than in years past, modified radical mastectomy remains an option when selecting therapy for the primary tumor. This option may allow treatment without radiation in earlier stage patients, or may be necessary if the presentation of the tumor does not allow breast preservation. Loss of the breast is disfiguring and many patients so treated desire reconstruction of the breast. Breast reconstruction is performed either at the time of initial surgery (immediate) or it may be delayed. Alternatives include placement of implants or the rotation of muscle flaps from the abdomen or back. Most agree that breast preservation gives superior results to any form of reconstruction. When the breast is removed as part of primary therapy, these reconstructions are available and produce reasonable results. In 2003, research showed that young women who choose breast-conserving surgery are at higher risk for local recurrence and should receive indefinite follow-up care from their physicians.
January 25th, 2006
Breast Cancer Causes
About 50% of women who develop breast cancer have no risk factors other than age and sex.
- Sex is the biggest risk because breast cancer occurs mostly in women.
- Age is another critical factor. Breast cancer may occur at any age, though the risk of breast cancer increases with age.
- The average woman at age 30 years has 1 chance in 280 of developing breast cancer in the next 10 years. This chance increases to 1 in 70 for a woman aged 40 years, and to 1 in 40 at age 50 years. A 60-year-old woman has a 1 in 30 chance of developing breast cancer in the next 10 years.
Genetic causes
Family history has long been known to be a risk factor for breast cancer. The risk is highest if the affected relative developed breast cancer at a young age or if she is a close relative such as a mother, sister, daughter, or aunt.
There is great interest in genes linked to breast cancer.
- BRCA1 is an abnormal gene that, when inherited, markedly increases the risk of breast cancer to a lifetime risk of almost 85%. Women with this abnormal gene also have an increased likelihood of developing ovarian cancer. Women who have the BRCA1 gene tend to develop breast cancer at an early age.
- A second abnormal gene, BRCA2, increases the risk of developing breast cancer but not ovarian cancer.
- Testing for these genes is expensive and frequently not covered by insurance. In addition, women who test positive may have trouble getting or keeping health insurance.
- The issues around testing are complicated, and women who are interested in testing should discuss this with their health care providers.
Hormonal causes
Hormonal influences play a role in the development of breast cancer.
Women who start their periods at an early age or experience a late menopause have a higher risk of developing breast cancer.
Conversely, being older at your first menstrual period and early menopause tend to protect one from breast cancer.
Having a child before age 30 years may provide some protection, and having no children may increase your risk for developing breast cancer.
Oral contraceptives have not been shown to increase or decrease a woman’s the lifetime risk of breast cancer.
A large study conducted by the Women’s Health Initiative showed an increased risk of breast cancer in postmenopausal women who were on a combination of estrogen and progesterone for several years. Therefore, women who are considering hormone therapy for menopausal symptoms need to discuss the risk versus the benefit with their health care providers.
Dietary causes
Breast cancer seems to occur more frequently in countries with high dietary intake of fat.
This link is thought to be an environmental influence rather than genetic. For example, Japanese women, at low risk for breast cancer while in Japan, increase their risk of developing breast cancer after coming to the United States.
Several studies comparing groups of women with high- and low-fat diets, however, have failed to show a difference in breast cancer rates.
Benign breast disease
Fibrocystic breast changes are very common.
Fibrocystic breasts are lumpy with some thickened tissue and are frequently associated with breast discomfort, especially right before your menstrual period.
This condition does not lead to breast cancer.
However, certain types of benign breast changes, such as those diagnosed on biopsy as proliferative or hyperplastic, do predispose women to the later development of breast cancer.
Environmental causes
Radiation treatment seems to increase the likelihood of developing breast cancer but only after a long delay. For example, women who received radiation therapy to the upper body for treatment of Hodgkin disease before age 15 years have a significantly higher rate of breast cancer than the general population.
October 31st, 2005
Mesothelioma Treatments
Three traditional kinds of treatment exist for patients with malignant mesothelioma: surgery which removes the cancerous masses from the body, chemotherapy, which uses a variety of potent drugs to kill the cancer, and radiation therapy, which uses high doses of x-rays to kill the cancer cells. Oftentimes, doctors use two or more of these treatment courses together to maximize the likelihood of success.
Mesothelioma Surgery
Several types of surgery exist for treating mesothelioma. A pleurectomy/decortication removes part of the chest or abdominal lining and the surrounding tissue. Doctors most often use the pleurectomy as a palliative procedure to relieve pain and prevent pleural effusion, or the build-up of fluid between the lungs and the chest cavity. While a surgeon can remove a good deal of the tumor through pleurectomy, the procedure often leaves mesothelioma along the diaphragm and lungs. A more aggressive surgery, known as pneumonectomy, removes an entire lung in order to remove the mesothelioma. In extrapleural pneumonectomy the surgeon removes the affected lung along with the lining and diaphragm on the affected side and the lining around the heart.
Chemotherapy
Chemotherapy uses drugs to kill meso cancer cells. Doctors may administer chemotherapy by pill or through a needle into a vein or muscle. Doctors can administer chemotherapeutic agents either systemically (through the blood stream) or intrapleurally (in the pleural cavity). When administered intrapleurally, the chemotherapy treatment is localized at the site of the tumor. The drugs used for chemotherapy are generally very toxic and are usually accompanied by serious side effects including nausea, vomiting, anorexia, hair loss, and exhaustion. Side effects vary depending on the particular drugs used for the chemotherapy.
Single-agent therapy utilizes only one drug in the chemotherapy regimen to treat the cancer. Several agents have demonstrated modest success in effectively treating mesothelioma. Doxorubicin, probably the most extensively studied agent, has a response rate in the 15 percent range, as do detorubicin, pirarubicin, and epirubicin. Other agents, such as carboplatin, mitomucin, cyclophosphamide, and ifosdamide have similar response rates ranging from 10 to 20 percent. Researchers have studies cisplatin in a number of trials and discovered an approximately 14 percent response rate. One small study of very high dose-intensity cisplatin demonstrated a 36 percent response rate, but the high responsiveness lasted only 2 to 8 months.
Because single-agent chemotherapy regimes have failed to show great effectiveness (response rates less than 20 percent), researchers have examined several combination regimens for treatment of patients with mesothelioma. Combinations including doxorubicin, cisplatine, mitoxantrone, and bleomycin have been reported to realize response rates of up to 44 percent. Such high response rates have not been consistent, and overall combination therapy yields response rates similar to singe-agent therapy.
A new agent, gemcitabine, in combination with cisplatin has showed promising results in a study conducted by Australian researchers. In their research, which included mesothelioma patients in Stages III and IV, the combination therapy reaped a 47 percent response rate with a response duration of 25 weeks. The researchers reported a one-year survival rate of 41 percent with this treatment.
Pemetrexed, a multitargeted antifolate (MTA) has shown promising results when combined with cisplatin. In addition, researchers are currently conducting promising studies of oxaliplatin/raltitrexed and cisplatin/irinotecan combinations. Other new agents researchers are now studying include bevacizumab and onconase both of which are considered novel drug treatment options.
With each new therapy development, doctors have another therapy tool with which to treat patients. The increase in options allows doctors and patients to more carefully tailor a chemotherapy regime that addresses the specific needs of the patient, including the stage of the mesothelioma and the patient’s age.
More on Mesothelioma chemo treatments:
Radiation therapy
In radiation therapy doctors use high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy).
Doctors sometimes use radiation therapy as the main treatment for mesothelioma for patients who might not be well enough to have surgery. Doctors also use radiation in combination with surgery, or as a way to ease symptoms such as shortness of breath, pain, bleeding, or trouble with swallowing.
There can be side effects from radiation. The skin in the area treated may look sunburned and then become darker. Most of these will go away after a short while.
Palliative Therapies
If fluid collects in the chest or abdomen, a doctor may drain the fluid out of a patient’s body by putting in a needle into the chest or abdomen and using gentle suction to remove the fluid. The removal of fluid from the chest is called pleurodesis. Thoracentesis is the removal of fluid for testing. The removal of fluid from the abdomen is called paracentesis. After these procedures, a doctor may also put drugs through a tube into the chest to prevent additional fluid from accumulating.
August 31st, 2005
N.B This topic will make you understand why it is important to do monthly breast exam. The earlier the cancer is detected, the better the prognosis.
Breast cancer staging
To stage cancer, the American Joint Committee on Cancer, first places the cancer in a letter category using the tumor, nodes, metastasis (TNM) classification system. The stage of a breast cancer describes its size and the extent to which it has spread. The staging system ranges from stage 0 to stage IV according to tumor size, lymph nodes involved, and distant metastasis.
T indicates tumor size. The letter T is followed by a number from 0 to 4, which describes the size of the tumor and whether it has spread to the skin or chest wall under the breast. Higher T numbers indicate a larger tumor and/or more extensive spread to tissues surrounding the breast.
TX: The tumor cannot be assessed.
T0: No evidence of a tumor is present.
Tis: The cancer may be LCIS, DCIS, or Paget disease.
T1: The tumor is 2 cm or smaller in diameter.
T2: The tumor is 2-5 cm in diameter.
T3: The tumor is more than 5 cm in diameter.
T4: The tumor is any size, and it has attached itself to the chest wall and spread to the pectoral (chest) lymph nodes.
N indicates palpable nodes. The letter N is followed by a number from 0 to 3, which indicates whether the cancer has spread to lymph nodes near the breast and, if so, whether the affected nodes are fixed to other structures under the arm.
NX: Lymph nodes cannot be assessed (eg, lymph nodes were previously removed).
N0: Cancer has not spread to lymph nodes.
N1: Cancer has spread to the movable ipsilateral axillary lymph nodes (underarm lymph nodes on the same side as the breast cancer).
N2: Cancer has spread to ipsilateral lymph nodes (on the same side of the body as the breast cancer), fixed to one another or to other structures under the arm.
N3: Cancer has spread to the ipsilateral mammary lymph nodes or the ipsilateral supraclavicular lymph nodes (on the same side of the body as the breast cancer).
M indicates metastasis. The letter M is followed by a 0 or 1, which indicates whether the cancer has metastasized (spread) to distant organs (eg, lungs or bones) or to lymph nodes that are not next to the breast, such as those above the collarbone.
MX: Metastasis cannot be assessed.
M0: No distant metastasis to other organs is present.
M1: Distant metastasis to other organs has occurred.
August 26th, 2005
Classification
Breast cancer is a heterogeneous (origination from self) disease in terms of its clinical course, gross and microscopic pathology, and imaging characteristics.
Several histologic classifications exist. One example is the World Health Organization (WHO) classification, which divides breast cancers into noninvasive type, (in situ), invasive type, and Paget disease of the nipple.
In situ carcinoma is characterized by growth within the ducts without penetration of the basement membrane. In situ carcinoma is subdivided into ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).
Invasive carcinoma denotes neoplastic penetration of the basement membrane of a duct containing DCIS and extension of neoplastic cell aggregates into the mammary stroma. It is further subdivided into these types:
- ductal, which accounts for about 75% of all invasive breast cancers.
- medullary
- mucinous, or colloid
- papillary
- tubular
- adenoid cystic carcinoma
- carcinoma with metaplasia.
Paget disease of the nipple is a type of breast cancer that starts in the breast ducts and spreads to the skin of the nipple and then to the areola. It is rare, accounting for only 1% of all breast cancers. Paget disease may be associated with in situ carcinoma or with infiltrating breast carcinoma. If no lump can be felt in the breast tissue, and if the biopsy shows DCIS but no invasive cancer, the prognosis is excellent.
August 26th, 2005
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