BREAST CANCER

A cancer that has no single, specific cause rather, a combination of

hormonal, genetic, and possibly environmental events may contribute to its
development.

Etiology
The two ovarian hormones, estradiol and progesterone, have an important
role in breast cancer and are altered in the cellular environment by a variety of
factors, and these may affect growth factors for breast cancer.

Hormones
Laboratory studies shows that tumors grow much faster when exposed to
estrogen, and epidemiologic research suggests that women who have longer
exposure to estrogen have a higher risk for breast cancer, while early menarche,
nulliparity, childbirth after 30 years of age, and late menopause are considered
as minor risks.

Genetics
Growing evidence indicates that genetic alterations are associated with
the development of breast cancer. These genetic alterations include changes or
mutations in normal genes and the influence of proteins that either promote or
suppress the development of breast cancer. Two gene mutations are identified
that may play a role in the development of breast cancer. These two gene
mutations are BRCA-1 which is a gene on chromosome 17 that, when damaged
or mutated, places a woman at greater risk for breast or ovarian cancer, or both,
compared with women who do not have the mutation, and BRCA-2 which is a
gene on chromosome 17 that, when damaged or mutated, places a woman at
greater risk for breast cancer (though less so than BRCA-1) compared with
women who do not have the mutation.

Risk Factors

 BRCA-1 or BRCA-2
Women with gene mutation have a 50% to 90% chance of developing breast
cancer and a 50/50 possibility of developing breast cancer before 50 years
of age
 Increasing age
Greatest risk for breast cancer occurs after age 50.
 Personal or family history of breast cancer
Risk of developing breast cancer in the other breast increases about 1% per
year.
Risk increases twofold *if first-degree female relatives (sister, mother, or
daughter) had breast cancer.
Risk increases four to six times if breast cancer occurred in two first-degree
relatives.
 Risk increases if the mother was affected with cancer before 60 years of
age.
 Early menarche
Menses beginning before 12 years of age.
 Nulliparity and late maternal age at first birth
Women having their first child after 30 years of age have twice the risk for
breast cancer as women having first child before 20 years of age.
 Late menopause
Menopause after 55 years of age but women with bilateral oophorectomy
before 35 years of age have one third the risk.
 Obesity
Weak risk among obese postmenopausal women: estrogen is stored in the
body adipose tissue, and dietary fat increases pituitary prolactin, thus
increasing estrogen production. Obese women diagnosed with breast cancer
have a higher mortality rate, which may be related to these hormonal
influences or perhaps a delayed diagnosis.
 Alcohol intake
As a risk factor, alcohol use remains controversial; however, a slightly
increased risk is found in women who consume even one drink daily. The
risk doubles among women drinking three drinks daily. Some research
findings suggest that young women who drink alcohol are more vulnerable in
later years.

Protective Factors
Certain factors may be protective in relation to the development of breast
cancer. Regular, vigorous exercise has been shown to decrease risk, suppress
menstruation, and like pregnancy, reduce the number of ovulatory menstrual
cycles. Exercise can also decrease body fat, where estrogens are stored and
produced from other steroid hormones. Breast feeding is also thought to
decrease risk because it prevents the return of menstruation and having had a
full-term pregnancy before the age of 30 years is also thought to be protective.

Clinical Manifestations
Breast cancer can occur anywhere in the breast, but most are found in the
upper outer quadrant. The lesions are non-tender rather than mobile, and hard
with irregular borders rather than encapsulated and smooth. Diffused breast pain
and tenderness with menstruation are usually associated with benign breast
disease. Dimpling or a peu d’orange (orange-peel appearance of the skin, and
nipple retraction and lesions fixed to the chest wall may also be evident.

Assessment and Diagnosis

Assessment to determine the histology and tissue diagnosis of breast cancer
includes Fine-needle aspiration (FNA), the removal of fluid for diagnostic analysis
from a cyst or cells from a mass using a needle and syringe; excisional (or open)
biopsy, incisional biopsy, needle localization, core biopsy, and stereotactic biopsy.
Surgical Management
The procedures most often used for the local management of invasive
breast cancer are mastectomy with or without reconstruction and breast-
conserving surgery combined with radiation therapy which typically begins about
6 weeks after the surgery to allow the incision to heal.

 Breast-Conserving Surgery
Consists of lumpectomy, wide excision, partial or segmental mastectomy,
or quadrantectomy and removal of the axillary nodes for tumors with an invasive
component, followed by a course of radiation therapy to treat residual,
microscopic disease. The goal of breast conservation is to remove the tumor
completely with clear margins while achieving an acceptable cosmetic result.

 Axillary lymph node dissection

Removal of some or all fat-enmeshed axillary lymph nodes for
determination of extent of disease spread: the single most important determinant
for prognosis and for need for adjuvant treatment.

 Total mastectomy
removal of the breast tissue only; this procedure is generally done
for the treatment of carcinoma in situ, typically ductal.

 Modified radical mastectomy

Removal of the breast tissue and an axillary lymph node dissection;
the pectoralis major and minor muscle remain intact.

 Radical mastectomy
Removal of the breast tissue along with pectoralis major and minor
muscles inn conjunction with an axillary lymph node dissection.