AN OVERVIEW OF BREAST CANCER

(Harry Kochat, BioNumerik Pharmaceuticals)

What Is Cancer?

Cancer is not just one disease but rather a group of diseases. All forms of cancer cause cells in the body to change and grow out of control. Most types of cancer cells form a lump or mass called a tumor. Cells from the tumor can break away and travel to other parts of the body. There they can continue to grow. This spreading process is called metastasis. Some cancers, such as blood cancers, do not form a tumor.

Not all tumors are cancer. A tumor that is not cancer is called benign. Benign tumors do not grow and spread the way cancer does. They are usually not a threat to life. Another word for cancerous is malignant. So a cancerous tumor is called malignant.

What Is Breast Cancer?

Most kinds of cancer are named after the part of the body where the cancer first starts. Breast cancer begins in the breast tissue. Men can also get breast cancer, although this is rare.

Inside the breasts are glands that produce and release milk after a woman has a baby. The breast itself is made up of milk-secreting glands, ducts, and fatty, connective, and lymphatic tissue. The glands that make the milk are called lobules and the tubes that connect them to the nipple are called ducts.

There are several types of breast tumors. Many are benign; that is, they are not cancers. They do not spread outside of the breast and they are not a threat to life. A tumor that hasn't spread beyond the area where it began is called in situ. It is confined to the ducts or lobules.

Here are some terms that describe the most important types of breast cancer:

Lobular carcinoma in situ (LCIS):

Although not a true cancer, this condition increases a woman's risk of developing cancer later.

Ductal carcinoma in situ (DCIS):

This is breast cancer at its earliest stage (stage 0). Nearly 100% of women with cancer at this stage can be cured.

Infiltrating (invasive) lobular carcinoma (ILC):

This cancer starts in the milk glands (lobules), breaks through the wall of the gland and invades the fatty tissue of the breast. Between 10% and 15% of breast cancers are of this type.

Infiltrating (or invasive) ductal carcinoma (IDC):

This cancer starts in the milk passage or duct, breaks through the wall of the duct, and invades the fatty tissue of the breast. IDC is the most common type of breast cancer. It accounts for nearly 80% of breast cancer.

Metastases:

This is cancer that has broken away from the place where it started. It has spread to lymph nodes or distant organs such as the lungs or the brain.

Node-positive and node-negative breast cancer:

Node-positive means that the cancer has spread (metastasized) to the lymph nodes under the arm on the same side. Node-negative means that the lymph nodes are free of cancer.

How Many Women Get Breast Cancer?

Breast cancer is the most common cancer among women, other than skin cancer. It is the second leading cause of cancer death in women. The first leading cause is lung cancer. Breast cancer is the leading cause of death among women aged 40 to 55.

What Causes Breast Cancer?

We do not yet know exactly what causes breast cancer, but we do know that certain risk factors are linked to the disease. A risk factor is something that increases a person's chance of getting a disease. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed. While all women are at risk for breast cancer, the factors listed below can increase the chances of having the disease.

Risk factors that cannot be controlled:

Age:

The chance of getting breast cancer goes up as a woman gets older.

Personal history of breast cancer:

A woman who has had cancer in one breast is more likely to have it in the other breast later.

Family history:

A woman with close relatives who had breast cancer is at greater risk herself. Your risk increases if a relative had breast cancer at an early age or if several of your relatives had the disease. Between 5% and 10% of breast cancers appear to be linked to changes in certain genes. Studies show that some breast cancer is linked to mutations or changes of the BRCA1 and BRCA2 genes. If a woman has inherited a mutated gene from either parent, she is more likely to develop breast cancer. About 55% of women with these inherited mutations will develop breast cancer by the age of 70. For some women, genetic testing (see below) may be a good idea.

Benign breast disease:

Women who have had certain types of benign breast disease are at greater risk. Since not all types of benign breast disease increase the risk, talk to your doctor if you have questions.

Early periods, late change of life:

Women who began having periods early (before 12 years of age) or who went through the change of life (menopause) after the age of 50 have a small increased risk of breast cancer. The same is true for women who have not had children or who had their first child after they were 30 years old.

Estrogen replacement therapy (ERT):

Some studies suggest that long-term use (10 years or more) of estrogen replacement therapy for relief of menopause symptoms may increase the risk of breast cancer. But it may lower the risk of heart attack. Therefore, women should talk to their doctors about the pros and cons of taking hormone replacements.

Risk factors that can be controlled

Alcohol:

Some studies suggest that use of alcohol is linked to a higher risk of breast cancer. People who drink should limit their intake to one drink per day.

Diet:

There may be a link between being overweight and a higher risk of breast cancer, especially for women over 50 years of age. Diets high in fat may increase the risk of breast cancer. More studies need to be done, though, before we can be certain of this.

Smoking:

While a direct link between smoking and breast cancer has not been found, smoking affects overall health and increases the risk for many other cancers, as well as heart disease.

Birth control pills:

It may be that women using birth control pills have a slightly greater risk of breast cancer. Women who stopped using the Pill more than ten years ago do not seem to have any increased risk. Women should discuss the risks and benefits of birth control pills with their doctor.

Environment:

Right now, there is no clear evidence that chemicals in the environment (pesticides, other chemicals) are linked to breast cancer. There is a great deal of research going on in this area, however.

Induced abortion:

A recent study suggests that there is no link between abortion and an increased risk of breast cancer. Studies continue in this field.

Can Breast Cancer Be Prevented?

At this time, there is no certain way to prevent breast cancer. For now the best strategy is to reduce risk factors whenever possible and follow the guidelines for finding breast cancer early.

A personal or family history of breast cancer may make genetic testing a good idea for some women. About 50%-60% of women with BRCA1 or BRCA2 mutations will develop breast cancer by the age of 70. They also have an increased risk of cancer of the ovary. Genetic testing can tell if a woman has these mutated genes, but it cannot predict whether a woman will get breast cancer. This is not a screening test for all women. Talk to your doctor if you have a history of breast cancer in your family.

In some rare cases, a woman might consider a preventive (prophylactic) mastectomy. This is a controversial operation in which one or both breasts are removed before there is any known breast cancer. The reasons for considering this type of surgery need to be

very strong. They would include one or more of the following: inherited mutated genes, an earlier breast cancer, a strong family history of breast cancer, and diagnosis of certain conditions such as lobular carcinoma in situ or atypical hyperplasia. Clearly this is something a woman should discuss carefully with her doctor.

How Is Breast Cancer Found?

Symptoms of breast cancer include a lump or swelling in the breast, skin dimpling or puckering, redness or scaling of the nipple or nipple turning inward, or leaking from the nipple other than breast milk. While most of these changes are not cancer, you should see your doctor if you notice any of them.

The earlier breast cancer is found, the better the chances for successful treatment. You should report any symptoms to your doctor right away.

Because early breast cancer does not produce symptoms, it's important for all women to follow the guidelines for finding breast cancer early. These include a mammogram every year for women over the age of 40, an exam by a doctor or nurse (clinical examination), and breast self-examination (BSE). Together, they offer the best chance of finding breast cancer early. Each is covered in more detail below.

Mammogram

A mammogram is an x-ray of the breast done with a special type of machine. The breast is squeezed between two plates for a few seconds while pictures are taken. Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not significantly increase the risk for breast cancer. For example, a woman who has radiation as treatment for breast cancer will receive several thousands Rads, the unit that measures radiation. If a woman has yearly mammograms beginning at age 40 and continuing until she is 90, she will have received only 10 Rads.

Mammograms can save lives by finding breast cancer early, before any symptoms appear. Studies show that more lives can be saved if women in their forties have a yearly mammogram. The American Cancer Society recommends that all women age 40 and older have a mammogram every year. Talk to your doctor about when and how often you should have a mammogram. The doctor may suggest earlier screening if you have a history of breast cancer in your family.

You should have a breast exam by a doctor or nurse every year if you are 40 or over. For best results, the exam should be done close to the time of your mammogram. If you are between 20 and 40, you should get this exam every three years.

If something unusual is found on your mammogram, or if you or your doctor finds a breast lump, the next step is often a biopsy. A biopsy is the only way to know for sure if you have breast cancer. Cells from your breast are removed so they can be studied in the lab. There are several kinds of biopsies. In some, a very thin needle is used to draw fluid and cells from the lump. Other methods use a larger needle or surgery to remove more tissue. Ask your doctor which kind of biopsy will be done and what you can expect during and after the procedure.

Staging:

Staging is the process of finding out how far the cancer has spread. This is very important because your treatment and the outlook for your recovery depend on the stage of your cancer.

There is more than one system for staging. The TNM system, described below, is the one used most often.

The TNM system:

T refers to the size of the Tumor, N describes how far the cancer has spread to nearby lymph Nodes and M shows whether the cancer has spread (Metastasized) to other organs of the body

Letters or numbers after the T, N, and M give more details about each of these factors. To make this information somewhat clearer, stages, labeled stage 0 through stage IV In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

Treatment for Breast Cancer

There is a lot for you to think about when choosing the best way to treat or manage your cancer. Often there is more than one treatment (also called therapy) to choose from. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. Talk to your cancer care team. Look at the list of questions at the end of this piece to get some ideas.

Each type of treatment has benefits and drawbacks. There may be side effects. Your age, your overall health, and the stage of your cancer are all factors to consider Surgery, radiation therapy, hormone therapy, and chemotherapy are the most common treatments for breast cancer. In addition, you may hear about autologous stem cell or bone marrow transplantation.

Surgery:

Surgery is often the main treatment for breast cancer. The purpose is to remove as much of the cancer as possible. It may also be combined with other treatments like chemotherapy, hormone therapy, or radiation therapy. In many cases, surgery can be done to restore a more normal appearance. Sometimes surgery is used to relieve symptoms of advanced cancer. Below are some of the common types of breast cancer surgery.

Lumpectomy:

Removal of only cancerous tissues and a rim of normal tissue.

Partial mastectomy:

Removal of one-quarter or more of the breast. Lymph nodes under the arm may also be removed.

Simple or total mastectomy:

Removal of the entire breast.

Modified radical mastectomy:

Removal of the entire breast and lymph nodes under the arm.

Reconstructive or breast implant surgery:

These procedures do not treat the cancer. They are done to restore normal appearance after mastectomy.

Chemotherapy:

Chemotherapy refers to the use of anti-cancer drugs to kill cancer cells. The drugs are given in the form of shots or pills. They enter the bloodstream and reach all areas of the body. Chemotherapy may be used along with surgery and other types of treatment in hopes of a cure, or as a means of relieving symptoms in advanced cancer. Chemotherapy can have some side effects. They will depend on the type of drug, how much you are given, and how long you take it. Most of the side effects go away when treatment is over.

Radiation therapy:

Radiation therapy uses high-energy x-rays to kill cancer cells. External beam radiation, the type used to treat breast cancer, focuses radiation from outside the body on the cancer. Local radiation treatment uses a small pellet of radioactive material placed directly into the cancer. Having radiation treatment does not make you radioactive.

After surgery, radiation can kill small areas of cancer that may not be seen during surgery. Radiation is nearly always used after lumpectomy or partial mastectomy in treating invasive breast cancer.

If the size or location of a tumor makes surgery hard, radiation may be used before the surgery to shrink the tumor. In advanced cancer, radiation may also be used to relieve symptoms such as pain.

There can be side effects from radiation. Most of these will go away after a short while. The skin in the area treated may look sunburned and then tan. The skin returns to normal within 6-12 months. You may also feel tired. Be sure to talk with your doctor about any side effects. Often there are ways to help.

Some Questions to Ask Your Doctor:

You should feel free to ask any question that's on your mind, no matter how small it might seem. Here are some questions you might ask. Please be aware that the following questions are just a template and a patient should not treat the questions as the only questions that one can ask. You may feel free to add any other questions of your choice to your doctor.

1. Would you please write down the specific type of cancer I have?

2. May I have a copy of my pathology report?

3. Has my cancer spread to another site?

4. What is the stage of my cancer? What does that mean in my case?

5.What treatment choices do I have? What do you recommend? Why?

6. What are the risks or side effects of different treatments?

7. How long will each course of treatment last?

8. Will I be out of work? For how long?

9. What are the chances of my cancer coming back with the treatment you suggest?

10. What should I do to get ready for treatment?

11. Should I follow a special diet?

12. What kinds of breast reconstruction are possible in my case?

13. What are my chances of survival, based on my cancer as you see it?

Further Reading:

1. A Cancer Survivor's Almanac: Charting Your Journey. Edited by Barbara Hoffman, JD. National Coalition for Cancer Survivorship. Chronimed Publishing, 1996.

2. Choices, by Marion Morra and Eve Potts. Avon Books, 1994.

3. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery, by Gerald P. Murphy, MD, Lois B. Morris, and Dianne Lange. The American Cancer Society. Viking, 1997.

4. Sexuality and Fertility After Cancer, by Leslie R. Schover, Ph.D. John Wiley & Sons, Inc., 1997.

5. Share the Care: How to Organize a Group for Someone Who Is Seriously Ill, by Cappy Capossela and Shelia Warnock. Simon and Schuster, 1995.

6. To Be Alive: A Woman's Guide to a Full Life After Cancer, by C.D. Runowicz and D. Haupt. Henry Holt & Co., 1996.

HARRY KOCHAT
BioNumerik Pharmaceuticals Inc.
(An oncology based company based in San Antonio, Texas, USA)


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