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Introduction to Breast Cancer Authors: OncoLink Editorial Team Affiliations: University of Pennsylvania Cancer Center Posted Date: 6/94 (est.) Last Revision Date: Monday, 29-Mar-1999 10:20:14 EST Copyright © 1994, The Trustees of the University of Pennsylvania Incidence The American Cancer Society estimates that in the United States in 1996, over 150,000 women will be diagnosed with breast cancer and nearly 40,000 will die from this disease. In the United States, breast cancer accounts for 29% of all cancers in women; one woman out of eight will develop breast cancer sometime during her life. Although earlier detection results in higher cure rates, breast cancer remains the leading cause of cancer death of adult women under 54 years of age and the second most common cause after age 54. Among women of all ages, breast cancer is second only to lung cancer as the leading cause of cancer deaths in women. Less than 1% of all breast cancer cases occur in men. The course of disease and its clinical management are very similar to that in women. Screening and Detection With modern technology, breast cancer can often be detected at a very early stage of development when the chance for cure is highest. The key to cure is early detection and prompt treatment. Physical examination, mammography, and breast self-examination comprise an early detection approach. Women over age 20 should practice the breast self-examination (BSE) monthly. BSE is best done one week after menstruation starts, or on the same day each month for the post-menopausal woman. A pamphlet illustrating the BSE technique is available from the American Cancer Society (How to Do Breast Self-Examination. No. 2674, Atlanta, ACS) and your doctor's office. Asymptomatic women should have their breasts examined by a trained health professional every three years from ages 20-40 and annually thereafter. Symptoms or physical findings to be reported to a physician are: a breast or axillary (armpit) lump or thickening nipple scaling, retraction, thickening, or discharge skin dimpling or erythema (reddening) edema (swelling) ulceration distended veins in an irregular pattern breast pain Mammography is a special x-ray technique used to examine the breast. The American Cancer Society recommends that asymptomatic women have mammograms every 1-2 years between the ages 40-49 and annually thereafter. Women with a family history of breast cancer may require more frequent mammography. The typical radiation exposure is very low, approximately 0.02 cGy/exposure. The risk from this exposure to the breast after age 35 is considered negligible. The major advantage of mammography is that breast cancer can often be found before it can be palpated (felt). Nevertheless, women need to know that BSE and physical examination by a trained professional continue to be important, because mammography does not detect about 10% of breast cancers found on physical examination. Risk Factors All women are at risk of breast cancer. Women at a higher risk for developing breast cancer are those with a strong family history of breast cancer, a personal history of breast cancer, early menarche or late menopause, or a first full-pregnancy after age 30. The risk of developing breast cancer also increases with increasing age. Long-term estrogen therapy, a high fat diet, and alcohol use have been reported as possible risk factors, but the extent of their relationship to the onset of breast cancer remains unclear. Diagnosis The diagnosis of breast cancer can only be made by pathological examination of breast tissue. A lump in the breast usually warrants biopsy even when the mammogram is described as being normal. Breast tissue may be obtained by needle aspiration biopsy or surgical biopsy. Needle aspiration is used by some physicians to help differentiate between cysts and solid tumors. Cysts frequently disappear after aspiration and the removal of fluid. Cytological or pathological examinations of material removed in the aspiration can be used to identify the cancer. Ultrasound may help determine whether the lump is solid or cystic. Surgical biopsy is generally performed under general or local anesthesia in an ambulatory surgical center. Excisional biopsy , the most commonly performed procedure, is used when lumps are small. In these cases, the entire tumor and a margin of normal tissue is excised. If the tumor is large, incisional biopsy may be done to remove a small amount of tissue for pathological examination. Tissue obtained from surgical biopsy can be evaluated by frozen section, which permits a diagnosis within 30 minutes and may be followed by definitive surgery; but most surgeons wait for a permanent section, which take about 24-48 hours. The latter approach is allows the patient time to discuss treatment options with the physician and is the more common approach today. Breast cancer tissue should also be assayed for estrogen and progesterone receptors. These hormone receptor assays aid in predicting whether certain hormones influence the growth of the cancer. Women with positive hormone receptor assays are more like to respond to hormone therapy and also have a better overall prognosis. Staging and Types of Breast Cancer Staging is a method of grouping patients by the extent of disease to determine the choice of treatment, predict prognosis, and compare the results of different treatment approaches. The more advanced the disease, the poorer the prognosis. The staging system recommended by the American Joint Committee on Cancer is shown below. Breast Cancer Stage Grouping Tumor Nodes Metastasis Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T3 N1,N2 M0 Stage IIIB T4 Any N M0 Any T N3 M0 Stage IV Any T Any N M1 Definition of TMN (Primary Tumor (T)) Definitions for classifying the primary tumor (T) are the same for clinical and for pathological classification. The telescoping method of classification can be applied. If the measurement is made by physicial examination, the examiner will use the major headings (T1, T2, or T3). If other measurements, such as mammographic or pathologic are used, the telescoped subsets of T1 can be used. TX - primary tumor cannot be assessed T0 - no evidence of primary tumor Tis - carcinoma in situ, intraductal carinoma, lobular carcinoma in situ, or Paget's disease of the nipple with no tumor. T1 - Tumor is 2cm or less in the greatest dimension. T1a - 0.5cm or less in the greatest dimension. T1b - More than 0.5cm, but not more than 1cm in the greatest dimension. T1c - More than 1cm but not more than 2cm in the greatest dimension. T2 - Tumor is more than 2cm but not more than 5cm in the greatest dimension. T3 - Tumor is more than 5cm in the greatest dimension. T4 - Tumor of any size with direct extension to the chest wall or skin. T4a - Extension to the chest wall. T4b - Edema (including peau d'orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast. T4c - Both T4a and T4b. T4d - Inflammatory carcinoma. Regional Lymph Nodes (N) NX - Regional lymph nodes cannot be assessed (e.g. previously removed). N0 - No regional lymph node metastasis. N1 - Metastasis to movable ipsilateral axillary lymph node(s). N2 - Metastasis to ipsilateral axillary lymph node(s) fixed to one another or to other structures. N3 - Metastasis to ipsilateral internal mammary lymph node(s). Distant Metastasis (M) MX - Presence of distant metastasis cannot be assessed. M0 - No distant metastasis. M1 - Distant metastasis (include metastasis to ipsilateral supraclavicular lymph node(s)). The lymphatic spread of breast cancer. (Reprinted with permission of the publisher.) The most common route of spread of breast cancer is to the axillary lymph nodes. About 30-40% of breast cancer patients already have positive (disease-affected) axillary nodes when the tumor is palpable. The more axillary nodes that are involved, the greater the risk of micrometastases (clinically undetectable tumor cells) elsewhere and relapse or recurrence. The common sites of breast cancer recurrence are local recurrence at the original site in the breast or distant spread to bone, liver, lung, and brain. Some complications of metastatic disease include spinal cord compression, pathological bone fractures, pleural effusion, and bronchial obstruction. Breast cancers are dividing according to the cell type, with types varying with incidence, patterns of growth and metastases, and survival. Infiltrating ductal carcinoma is the most common type of breast cancer, accounting for about 70% of the tumors. The rare inflammatory breast cancers (1-4% of breast cancer cases) are associated with the poorest prognosis. Carcinoma in situ (CIS) is a non-invasive cancer that has an excellent prognosis and can often be detected by mammography when nothing significant is palpable. Treatment Treatment recommendations differ depending on the type and stage of disease at the time of diagnosis. Today, women have treatment options. Several states, such as California, Pennsylvania, and Florida have laws that require a women be informed of such options. Stage I or II disease is generally treated by breast conservation surgery and irradiation, or modified radical mastectomy with or without breast reconstruction. Mastectomy and irradiation are local treatments and obviously will not affect cancer cells that have already metastasized. Adjuvant chemotherapy may also be given to patients with early-stage disease who are at a higher risk for developing metastatic disease. Many, but not all patients with breast cancer should receive adjuvant chemotherapy. Patients with locally advanced breast cancers (Stage III) have a poorer prognosis. Good local control may be achieved with a combination of surgery, chemotherapy, and irradiation. Chemotherapy should be considered because patients with stage III disease are at risk for developing distant metastases. Treatment approaches for patients with locally recurrent or metastatic disease vary depending on the site and extent of disease. In many cases, local and systemic therapy are combined. Because patients with metastatic disease rarely exhibit a lasting response to standard treatments, researcher are evaluating the use of high-dose chemotherapy regimens followed by autologous bone marrow transplant (or stem cell replacement). Surgery Breast conservation surgery consists of excision of the tumor and a partial (lower) axillary lymph node dissection. The terms "lumpectomy," "segmental resection", "tylectomy", and "partial mastectomy" are frequently used to describe the local surgery. Surgery is always followed by radiation therapy. Recent studies of patients with small tumors up to 5 cm (about 2 inches) in size and no evidence of multifocal disease or extensive intraductal cancer show no difference in survival between breast conservation surgery followed by radiation therapy and modified radical mastectomy. Modified radical mastectomy is a removal of the entire breast plus an axillary node dissection. The disadvantages of a modified radical mastectomy are cosmetic deformity and the potential for psychosocial problems affecting body image and self-concept. Breast conservation surgery may be performed as an outpatient procedure or may require an overnight stay. Patients are generally hospitalized for 2-5 days following a modified radical mastectomy. The trend towards shorter hospital stays for these procedures means that many patients will be discharged with a surgical drain in place. The potential consequences and implications of primary therapy for breast cancer are summarized as follows: Potential Consequences and Implications of Primary Therapy for Breast Cancer Modified Radical Mastectomy loss of body part altered body image prosthesis (required) reconstructive surgery (optional) chest wall tightness skinflap necrosis Partial Mastectomy, Axillary Node Dissection & Irradiation breast fibrosis hyperpigmentation rib fractures breast edema changes in the skin sensitivity myositis prolonged duration of primary therapy Common Symptoms of Both Procedures sensory loss hand and arm care post-op complications seroma hematoma wound infection lymphedema arm weakness pain psychological distress imparied arm mobility fatigue adjuvant chemotherapy Ball Squeezing Back Scratcher Hand Wall Climbing Arm and shoulder exercises commonly prescribed for patients following breast cancer surgery. (Reprinted with permission of the publisher. Impaired shoulder mobility may occur if exercises are not begun soon after surgery. Exercises help reduce lymphedema and prevent limitation of joint motion. Patients start with limited exercises of the lower arm, such as squeezing a rubber ball. These begin as soon as the surgeon decides that the wound is healing adequately, often within 24 hours of surgery. Should exercises may begin seven days after surgery or when surgical drains are removed. The specific exercises the surgeon orders may vary with the surgical procedure. Other operative complications include seromas, hematomas, nerve injury, and lymphedema. A seroma is the accumulation of serous or serosanguinous fluid in the dead space of the axillary fossa or chest wall. Seromas can delay healing and foster infection. Hematomas occur when blood accumulates in the interstital space and can be aspirated when liquified or be reabsorbed over time without intervention. Nerve injury may occur despite surgical efforts to avoid trauma. Patients may complain of sensations of pain, tingling, numbness, heaviness, or increased skin sensitivity on the arm or chest. These sensations change over time and usually disappear during or after one year. Less often, muscle atrophy may occur secondary to nerve injury and result in decreased arm or shoulder function. The trend toward less radical surgery has reduced the incidence of lymphedema of the arm. Transient arm swelling lasting a few weeks after surgery is not unusual. Patients should report arm numbness, paresthesias, heaviness, and pain. Management of lymphedema includes arm elevation at night, mild exercise, and an elastic support sleeve. If necessary, a pneumatic compression sleeve or pump can be used. Measures to prevent infection in the affected arm is also important. After a mastectomy, a temporary breast prosthesis can be worn for a cosmetic appearance. In 4-6 weeks, the woman can be fitted for a permanent prosthesis. Today's prostheses come in a variety of shapes, sizes, and colors. A good fit is important to self-image, posture, balance and clothing fit. Reconstruction has become an option for more women due to improved surgical techniques. Reconstruction restores symmetry, obviates the need for prostheses, and improves the patient's self-image. It is important for a woman to discuss the option of breast reconstruction with her surgeon before a mastectomy, since the surgeon may want to consult a plastic surgeon about the location of the mastectomy incisions or to perform the reconstruction at the time of the mastectomy. Reconstruction can be done right after the mastectomy or any time after healing has occured. Implant reconstruction is a common method, requiring 1-3 days of hospitalization. Implants are commonly placed under the pectoralis muscle. The surgery creates a new breast mound. Nipple/areola reconstruction is an additional option. Other procedures using tissue and skin from the lower abdomen, back or buttocks may be used to reconstruct the breast. Radiation Therapy Since clinically undetectable breast cancer cells may be left following local excision of the cancer, radiation therapy is given for local tumor control. After mastectomy, women with large tumors or evidence of tumor cells in the margins of the excised tissue may also benefit from radiation to reduce the chance of local recurrence. Chest wall recurrence following mastectomy can be treated with radiation therapy. Radiation therapy can also be used preoperatively to shrink large breast tumors and make them more easily resectable. Palliative radiation therapy is commonly used to relieve the pain of bone metastasis and for the symptomatic management of metastases to other sites, such as the brain. Fatigue, skin reactions, changes in sensation, color and texture of the skin, and breast swelling are common during and immediately following a course of radiation therapy to the breast. Chemotherapy and Hormone Therapy Chemotherapy, hormone therapy, or a combination of the two can be used to palliate the effects of metastatic disease. Recommendations for adjuvant chemotherapy and/or adjuvant hormone therapy are usually based on the number of positive axillary nodes, menopausal status, size of the primary tumor, and the estrogen receptor assay. The chemotherapeutic drugs most commonly used are alkylating agents, antimetabolites, antitumor antibiotics, and vinca alkaloids. Hormone manipulation is achieved primarily through hormone blockers and infrequently by surgical removal of sex hormone-producing glands (oophorectomy, adrenalectomy, or hypophysectomy). Tamoxifen, an anti-estrogen, is the most widely used hormonal agent. Side effects vary with specific drugs and may include fatigue, weight gain, nausea, vomiting, alopecia, disturbances in appetite and taste, neuropathies, diarrhea, bone marrow suppression, and menopausal symptoms. Hair loss and weight gain or loss can affect a patient's body image. Premenopausal women commonly experience premature menopause, with symptoms of decreased vaginal lubrication, hot flashes, irregular menses, and amenorrhea. Patients with distant metastases require systemic treatment with cytotoxic chemotherapy or hormonal manipulation. At this stage, the goal of the therapy is to provide the best quality of life. Psychosocial Considerations The period following the discovery of a breast tumor is very stressful for the patient. The breast may represent femininity, sexuality, love, nurturance, and maternal feelings for a woman. Often, it is an important part of her self-image. Feelings of anxiety, anger and depression are common. The woman may view the possible loss of a breast as a personal assault. The woman is also dealing with the fact that she has cancer and the threat of the diagnosis on her mortality. Women undergoing a mastectomy may have feelings of mutilation, a decrease in self-image, and problems in sexual and family relationships. These feelings also have an impact on the spouse or significant other and the family. Feelings of despair, helplessness, shock, guilt, and personal vulnerability are common. Key sources of support at this time are physicians, nurses, family, friends, and a nearby breast cancer support group. The American Cancer Society's "Reach to Recovery" program arranges for visits to the patient from women living successfully agfter treatment for breast cancer. After training, these survivors offer support and provide advice on the various aspects of living with a mastectomy. Other patient education and support groups, such as "I Can Cope", "CanSurmount" and others mentioned on OncoLink and elsewhere on the Internet can be useful. Unfortunately, metastases may be present at the time of diagnosis, but more commonly occur after an apparent disease-free interval. The recurrence of breast cancer produces a significant emotional reaction that may include anxiety, depression, and disorganization as the patient and family are once again confronted with issues of new treatment decisions and possible death. Because prolonged survival can be achieved in many cases of recurrence, patients require periodic follow up after the first definitive treatment.

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