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Diagnosis and Treatment of Breast Cancer
Breast cancer is characterized by the growth of malignant tumors in the glandular tissues of the breast. Today, more women are surviving breast cancer than ever before. More than two million women are breast cancer survivors. With early detection and prompt and appropriate treatment, the outlook for women with breast cancer can be positive.
No one knows why some women develop breast cancer and others do not. Although the disease can affect younger women, 75% of all breast cancers occur in women aged 50 or older. Some of the noted risk factors include family or genetics, exposure to estrogen, demographic factors (age, race, ethnicity, and socioeconomic status), diet and lifestyle, and smoking.
Symptoms of breast cancer are hardly noticeable when it first develops, but as the cancer grows, it can cause changes that women should watch out for. The most common symptom is an abnormal lump or swelling in the breast, but lumps can also appear next to the breast or under the arm. Other symptoms may include unexplained breast pain, abnormal nipple discharge, changes in breast texture, or changes in the skin on or around the breast.
Breast Cancer Screening
To screen or not to screen – that is the dilemma. The problem is not only medical, but also a matter of economics. Cancer diagnosis, whether initial or recurrence, is the period of greatest acute stress for a cancer patient. This crisis is defined by sadness (depression), anxiety (anxiety), confusion, and occasionally anger.
The purpose of screening women for breast cancer is to detect cancer in its earliest stages when surgery and medical treatment can be most effective in reducing mortality. Screening is only beneficial if an earlier diagnosis results in a reduction in mortality and morbidity and if the risks of the screening test are low. There are currently three methods of screening for breast cancer: X-ray mammography, clinical breast examination and breast self-examination.
Of the three screening methods, mammography is by far the most reliable. However, in women with very dense breast tissue, both ultrasound and mammograms can miss tumors, which can, however, be detected by a Magnetic Resonance Imager (MRI). MRI is also more accurate at detecting cancer in women who carry the breast cancer genes BRCA1 and BRCA2. The main means of diagnosis – and many believe the only definitive – is biopsy – a small surgical procedure in which the lump or part of the lump is removed and examined under a microscope for cancer cells. A doctor may perform fine needle aspiration, a needle or core biopsy, or a surgical biopsy.
A mammogram is a special X-ray of the breast that can often detect cancers that are too small for a woman or her doctor to feel. Screening aims to detect breast cancer at a very early stage when cure is more likely. The amount of radiation needed to produce a clear mammogram (photo) varies with breast size and density. To avoid unnecessary exposure, it is highly desirable to use the lowest possible dose of radiation.
A mammogram cannot distinguish between a benign or malignant tumor and is therefore not 100% accurate. However, mammography detects more than 90% of all breast cancers, although a negative mammogram does not necessarily indicate its absence. Mammography and clinical examination are complementary and if there is a strong suspicion of a palpable lesion, the only way to make a positive diagnosis is to take a biopsy.
The results of several large studies have convincingly shown that screening for breast cancer by mammography reduces mortality by approximately 30% in women older than 50 years. The American Cancer Society states that women ages 40 to 49 should get screening mammograms every one to two years. Annual mammographic screening is recommended for women age 50 and older.
However, the risks of any screening intervention must be evaluated as closely as the benefits. The risks associated with mammography screening for breast cancer include radiation exposure, false positives, and overdiagnosis. The risk of radiation-induced breast cancer from screening mammography is estimated to be minimal. The excess risk for breast cancer caused by radiation increases with a younger age of the woman at exposure and increasing cumulative radiation dose. However, the benefits of mammography still significantly outweigh the risk of radiation-induced breast cancer.
Clinical Breast Examination (CBE)
During a clinical breast examination, the doctor checks the breasts and armpits for lumps or other changes that could be a sign of breast cancer. The CBE involves bilateral inspection and palpation of the breasts and the axillary and supraclavicular areas. Examination should be carried out in both the upright and supine positions. One of the best predictors of research accuracy is the length of time the researcher spends.
The effectiveness of CBE alone in breast cancer screening is uncertain. The results of several large studies have convincingly demonstrated the effectiveness of CBE in combination with mammography as screening for breast cancer in women older than 50 years. The American Cancer Society recommends that women should have CBEs every three years from ages 20 to 39. Annual CBEs should be performed on women age 40 and older.
Breast self-examination (BSE)
A systematic examination by a woman in which she uses her fingers to feel for changes in her breast shape and liquid discharge from the nipple to detect any abnormalities. It is ideally carried out every month. Estimates vary, but 80 to 95% are first discovered as a lump by the patient. Intuitively, it follows that regular breast self-examination as a complementary screening modality may together with mammography help to detect some cancers at an earlier stage, when the prognosis is more favorable.
Approximately four out of every five breast lumps discovered in this way turn out to be a cyst or other benign (noncancerous) lesion. However, if a lump is found, it is essential to determine as soon as possible whether it is cancerous or not. There are now several epidemiological studies that indicate that survival is increased in women who practice breast self-examination and that cancers detected by breast self-examination tend to be smaller.
Once breast cancer is found, it is staged. Through staging, the doctor can tell whether the cancer has spread and, if so, to which parts of the body. More tests may be performed to determine the stage. Knowing the stage of the disease helps the doctor to plan treatment.
The choice of treatment for breast cancer depends on a woman’s age and general health, as well as the type, stage and location of the tumor, and whether the cancer has stayed in the breast or spread to other parts of the body There are a number of treatments, but the ones most often chosen by women – alone or in combination – are surgery, radiation therapy, chemotherapy and hormone therapy.
Standard cancer treatments are generally designed to surgically remove the cancer; stopping cancer cells from getting the hormones they need to survive and grow through hormone therapy; use high-energy beams to kill cancer cells and shrink tumors through radiation therapy and use anti-cancer drugs to kill cancer cells through chemotherapy.
However, the current view holds that cancer is a systemic disease involving a complex spectrum of host-tumor relationships, with cancer cells spreading via the bloodstream, and therefore variations in local or regional therapy are unlikely to affect a patient’s survival . Rather, the cancer must be attacked systemically, through the use of radiotherapy, chemotherapy, hormone therapy and immunotherapy.
For women with early-stage breast cancer, one common treatment available is a lumpectomy combined with radiation therapy. A lumpectomy is surgery that preserves a woman’s breast. In a lumpectomy, the surgeon only removes the tumor and a small amount of the surrounding tissue. The survival rate for a woman who has this therapy plus radiation is similar to that for a woman who chooses a radical mastectomy, which is the complete removal of a breast.
If the breast cancer has spread locally – just to other parts of the breast – treatment may include a combination of chemotherapy and surgery. Doctors first shrink the tumor with chemotherapy and then remove it through surgery. By shrinking the tumor before surgery, a woman can avoid a mastectomy and keep her breast.
If the cancer has spread to other parts of the body, such as the lung or bone, chemotherapy and/or hormonal therapy can be used to destroy cancer cells and control the disease. Radiation therapy can also be useful to control tumors in other parts of the body.
Because 30% of breast cancers return, the National Cancer Institute urges all women with breast cancer to have chemotherapy or hormone therapy after surgery, even if there is no evidence that the cancer has spread. Such systemic adjuvant therapy, as it is called, can prevent or delay about one third of recurrences.
Prevention of breast cancer
Breast cancer cannot be completely prevented, but the risk of developing advanced disease can be greatly reduced by early detection.
Several drugs are now available to treat or prevent breast cancer. Chemopreventive agents such as Tamoxifen and Raloxifene act to prevent the development of breast cancer by interrupting the process of initiation and promotion of tumors. The antiestrogenic effect of these agents also seems to lead to growth inhibition of malignant cells. Chemoprevention is the most promising intervention for achieving primary prevention at this time.
Tamoxifen is a nonsteroidal antiestrogen with a partial estrogen agonist effect. It is FDA-approved, and is now used for estrogen-receptive cancer patients as well as for high-risk individuals who still menstruate and produce a lot of estrogen.
Given by mouth, it may increase the risk of stage I endometrial cancer and may also increase vaginal dryness and hot flashes. Tamoxifen may be less effective as a preventive agent in women with a strong family history of breast cancer.
Raloxifene hydrochloride is a selective estrogen receptor modulator (SERM) that blocks the action of estrogen in the breast and endometrial tissue. The incidence of estrogen receptor-positive invasive breast cancer was reduced by 76% among women treated with both doses of raloxifene at 40 months of follow-up. The side effects of raloxifene include an increased risk of thromboembolic disease, but not an increased risk of endometrial cancer.
Also, there are recent studies that link low incidence of breast cancer with various environmental factors, especially diet. One food that is suggested to be cancer preventive is soy (found in foods such as tofu, tempeh, soy milk and vegetarian meat substitutes), but there is no clear evidence for this assumption. Consuming more fruits and vegetables, eating less red meat (perhaps replacing soy protein) and avoiding cholesterol (olives have none) can also help prevent breast cancer.
A chemical (indole-3-carbinol or I-3-C) found in broccoli, cabbage and other cruciferous vegetables that is now available as a dietary supplement may help prevent estrogen-related breast cancer. Another possible preventive measure is regular use of standard doses of anti-inflammatory drugs such as ibuprofen and aspirin two or more times a week.
Finally, a recent study showed that exercise helps prolong life for survivors. The exact mechanism is not known, but it is suspected that physical activity lowers hormone levels, reduces insulin resistance and reduces weight gain, all factors in breast cancer.
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