Breast cancer

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Breast cancer

breast cancer - SPOC

Anatomy

The breasts of an adult woman are milk-producing glands on the front of the chest wall. They rest on the pectoralis major and are supported by and attached to the front of the chest wall on either side of the sternum by ligaments. Each breast contains 15-20 lobes arranged in a circular fashion. The fat that covers the lobes gives the breast its size and shape. Each lobe comprises many lobules, at the end of which are glands that produce milk in response to hormones. Most of the benign and malignant pathology arising in the duct and lobular network. Specifically, most breast cancer is thought to originate in the terminal ductal lobular unit.

Pathophysiology

As described earlier, breast contains ducts, lobules and fat cells in between. Cells in the breast are supposed to grow differentiate and function in a particular manner, that is influenced by hormones and adequate blood supply from chest wall muscles. Imbalance in hormones and muscular spasm leads and external toxin accumulation from diet formation of high risk cells in breast. These high cells can get diverted to cyst formation, fibroadenoma, and if there is mutation, turns into malignancy. Pregnancy and breast feeding is known to decrease high risk cell formation. High risk cells can get promoted to cancer cell formation due to many reasons like vitamin D deficiency, obesity, estrogen supplements, exposure to carcinogenic pesticides, and radiation. Some individuals inherit defects in the DNA and genes like the BRCA1, BRCA2 and P53 among others. Those with a family history of ovarian or breast cancer thus are at an increased risk of breast cancer. The immune system normally seeks out cancer cells and cells with damaged DNA and destroys them. Breast cancer may be a result of failure of such an effective immune defense and surveillance. There are several signaling systems of growth factors and other mediators that interact between stromal cells and epithelial cells. Disrupting these may lead to breast cancer as well.

Risk factors

Getting older

The risk for breast cancer increases with age; most breast cancers are diagnosed after age 50.

Genetic mutations

Inherited changes (mutations) to certain genes, such as brca1 and brca2. Women who have inherited these genetic changes are at higher risk of breast and ovarian cancer.

Reproductive history

Early menstrual periods before age 12 and starting menopause after age 55 expose women to hormones longer, raising their risk of getting breast cancer.

Having dense breasts

Dense breasts have more connective tissue than fatty tissue, which can sometimes make it hard to see tumors on a mammogram. Women with dense breasts are more likely to get breast cancer.

Personal history of breast cancer or certain non-cancerous breast diseases

Women who have had breast cancer are more likely to get breast cancer a second time. Some non-cancerous breast diseases such as atypical hyperplasia or lobular carcinoma in situ are associated with a higher risk of getting breast cancer.

Family history of breast cancer

A woman’s risk for breast cancer is higher if she has a mother, sister, or daughter (first-degree relative) or multiple family members on either her mother’s or father’s side of the family who have had breast cancer. Having a first-degree male relative with breast cancer also raises a woman’s risk.

Previous treatment using radiation therapy

omen who had radiation therapy to the chest or breasts before age 30 have a higher risk of getting breast cancer later in life.

Risk factors you can change

Not being physically active

Women who are not physically active have a higher risk of getting breast cancer.

Being overweight or obese after menopause

Older women who are overweight or obese have a higher risk of getting breast cancer than those at a normal weight.

Taking hormones

Some forms of hormone replacement therapy (those that include both estrogen and progesterone) taken during menopause can raise risk for breast cancer when taken for more than five years. Certain oral contraceptives (birth control pills) also have been found to raise breast cancer risk.

Reproductive history

Having the first pregnancy after age 30, not breastfeeding, and never having a full-term pregnancy can raise breast cancer risk.

Drinking alcohol

Studies show that a woman’s risk for breast cancer increases with the more alcohol she drinks.

Research suggests that other factors such as smoking, being exposed to chemicals that can cause cancer, and changes in other hormones due to night shift working also may increase breast cancer risk.

PRECANCEROUS LESIONS

A few recognized precancerous breast lesions are fibrocystic disease of breast, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, atypical columnar cell hyperplasia or flat epithelial atypia (FEA), lobular carcinoma in situ, papillary lesions, and proliferative radial scar. Fibrocystic disease with any cyst of significant size should be followed up with tissue biopsy to rule out malignant change. All patients with fibrocystic disease should be on regular follow up for any abnormal malignant changes.

TREATMENT OPTIONS

Treatment depends solely on the stage of cancer at diagnosis and is individualized based on tumor characteristics

Surgical treatment options

Removal of cancer in the breast

Lumpectomy or partial mastectomy, generally followed by radiation therapy if the cancer is invasive. Radiation therapy may or may not be used if it is ductal in situ carcinoma. A mastectomy may also be recommended, with or without immediate reconstruction.

Lymph node evaluation

Sentinel lymph node biopsy and/or axillary lymph node dissection.

Systemic THERAPIES

Chemotherapy, Hormonal therapy Targeted therapy and Immunotherapy

A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy based on the stage and the tumor biology. 

Preventive measures

Lifestyle modifications

Regular exercise and eating a healthy, balanced diet are recommended for all women, as they can help prevent many health conditions, including heart diseasediabetes and many forms of cancer.

Studies have looked at the link between breast cancer and diet, and although there are no definite conclusions, there are benefits for women who:

· Maintain a healthy weight

· Exercise regularly

· Have a low intake of saturated fat, balanced antioxidant rich diet

· Do not drink/limit alcohol

Screening

Self breast examination

once a month

Clinical breast examination ( CBE )

by a doctor

Mammogram

a type of x ray of the breast to detect small breast lumps which are not felt by clinical examination. It is painless, non invasive test

Ultrasound breast

useful in the guidance of biopsies and  therapeutic procedures.

MRI breast

highly sensitive, preferred screening method for women at high risk and in younger women

Screening recommendations

Women with average risk

  • Between 40–75 years – annual CBE + annual mammography.
  • Breast self-examination(BSE), start at 20 yrs – monthly.
  • Clinical breast examination (CBE) 3 yearly, 20-  40 years.

Women with high risk ( > 20% )

  • CBE 6 monthly, start at 25 years.
  • MRI annually, start at 25 years.
  • Mammography annually, start at 30 years (6  monthly interval from MRI)

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