Every 3 minutes in the United States another woman is diagnosed with breast cancer. This amounts to around 80,000 cases of invasive breast cancer per year. It’s the most common type of cancer in women and the 2nd leading cause of cancer deaths in women after lung cancer. This year alone more that 40,000 US women will die from breast cancer. One out of every eight women living until their 80’s will develop breast cancer sometime during their lifetime. Got your attention?

Breast cancer is due to development of abnormal cells in the breast. There are several different types of breast cancer. The most common type (80% of cases) is infiltrating ductal cancer of which there are several different subtypes. Infiltrating lobular cancer involves another 10-15% of the cases. Many cancers begin as noninvasive precancerous disease referred to as carcinoma insitu. Through improved screening, more cases are being found sooner and at smaller sizes. In fact, over 37,000 cases of carcinoma insitu will be detected in the next year.

Who’s at risk?

Age certainly is a consideration as breast cancer is very rare prior to age 30. Peak risk seems to be in the 5th decade. Estrogen exposure is another factor. Those women with early onset of menstruation and those with late menopause are at increased risk. Pregnancy may afford some protection as women who have never been pregnant are at increased risk. Breast feeding your child is thought to reduce your risk. The role of oral contraceptives in terms of risk has been unclear. However, recent information has surfaced demonstrating increased risk in postmenopausal women on hormone replacement therapy. Family history is certainly one of the most well known risk factors. Women with 1st degree relatives on their mother’s side who have had breast cancer are at increased risk. Genetics also can have a role. A small percentage of women have gene mutations known as BRCA -1 and BRCA -2. Anywhere from 35-50% of these women will develop breast cancer. Another example of genetic risk is the fact that women of Eastern European Jewish descent have a slight increased incidence of breast cancer over the general population. Other risk factors include prior radiation exposure, obesity, and possibly a diet high in fats.

How can breast cancer be detected? 

Early detection is key as the sooner a cancer is detected and treated, the better the outcome in terms of survival. Detection is best accomplished through a combination of physical exam and radiographic studies. All women, particularly those at increased risk, need to be familiar with their own breasts and should examine their breasts on a regular basis. For menstruating women, the best time to examine your breasts is about one week after completion of your menstrual cycle. Non-menstruating women should simply do their exams the same time every month. An experienced physician should examine women at increased risk at least once a year. 

Physical exam is also complemented by radiographic study. The most familiar of these modalities is mammography. There is no doubt that mammography can detect breast cancers and areas of carcinoma insitu when they are too small to be felt on physical exam. All women, regardless of risk factors, should start having mammograms around age 40. These should be done every other year until age 50 and then yearly thereafter. If you fall into an increased cancer risk category, then mammography may need to be started sooner and be done even more frequently (yearly). One of the problems with mammography in young women, and in some older women, is that the breast tissue can appear very dense on mammography and breast cancers can be obscured. Ultrasound is becoming increasingly more popular as a method of studying dense breasts and also as a complementary study to mammography in those instances of palpable breast abnormalities not seen on the mammogram. Ultrasound is also very useful for differentiating between cystic lesions, which are usually benign, and solid lesions and it is an invaluable tool to assist with biopsies. In some instances, other imaging modalities such as CAT scans and MRI scans are utilized though this is infrequent.

Biopsy

Once an abnormality is detected by physical exam or radiographicly, some sort of biopsy is indicated to make a diagnosis. There are many options for this including fine needle aspiration cytology, core needle biopsy, stereotactic suction core needle biopsies, mammogram- or ultrasound-guided needle localization for incisional or excisional biopsy, and simple open excisional biopsies.

Treatment

Except for very large and/or inflammatory breast cancers, the first aspect of treatment is surgery. With very small invasive cancers or with precancerous lesions, the initial biopsy (if large enough) may be all the surgery that is needed except for possibly sampling the lymph nodes in the armpit area. However, for most breast cancers, surgery is the mainstay of all treatment. Complete surgical removal of the cancer gives the patient their only chance of complete cure. This surgical removal can consist of wide excision (lumpectomy; partial mastectomy) or complete removal of the breast (mastectomy). With most patients, lymph node sampling is also done with the surgical excision procedure. This provides prognostic information and can influence subsequent decisions regarding additional treatment such as radiation therapy and/or chemotherapy. When lymph nodes are removed at the time of a mastectomy, the procedure is referred to as a modified radical mastectomy. A true radical mastectomy where chest wall musculature is removed is an older surgical approach rarely done anymore. Within the past few years a technique called the sentinel node (SN) biopsy has been developed to try to identify the node or nodes most likely to be involved by tumor spread so that only they can be removed potentially avoiding complications from more extensive lymph node excisions. Some surgeons now are removing only the sentinel node(s) while others remove the SN but also other nodes. Sentinel node procedures involve injecting a weakly radioactive substance +/– a blue dye into the breast where the tumor is or was. These agents then travel to the lymph system theoretically going to the sentinel node(s) first. The node(s) is then identified through an incision in the axilla with the assistance of a radiation detection probe and visual (the blue dye) inspection and removed.

Mastectomy procedures can be supplemented by breast reconstruction procedures. These are designed to restore breast mass, shape, and form to the chest wall where the breast has been removed. These reconstruction procedures are usually done by plastic surgeons. They can involve placement of implants and/or transfer of tissue from other parts of the body. The reconstruction procedure can be done at the time of the mastectomy or in a delayed procedure. It’s possible that the plastic surgeon may need to perform surgery to the opposite breast as well in order to achieve symmetry.

Once a patient has completed their surgery, adequate treatment of their breast cancer may involve additional treatment (adjuvant therapy) with chemotherapy, hormone therapy, and/or radiation therapy. Radiation therapy to the remainder of the breast is considered a routine part of the therapy for patients having a partial mastectomy procedure. It is also used in those instances of complete mastectomy done for larger tumors. Radiation therapy is done under the supervision of a radiation oncologist and is usually an outpatient procedure given daily for several weeks.

Chemotherapy is frequently given to younger patients with large tumors and/or lymph node involvement. Hormone therapy is, in a way, a type of chemotherapy but with much better tolerance (i.e.-less side effects) by the patient. It sometimes is the only extra therapy in older patients but at times is used in younger patients after conventional chemotherapy or in situations of recurrent disease. Hormone therapy is even being used prophylacticly for breast cancer prevention in younger patients with increased risk factors for breast cancer development. Chemotherapy is typically administered under the guidance of a medical oncologist and often can be given in the outpatient setting. Treatment duration may be several months.

Metastatic Disease

The preceding treatment discussion was based of the assumption that the patient had their breast cancer confined to the breast or only a couple of lymph nodes in the armpit area. However, breast cancer can extensively involve the lymph nodes or can spread metastaticly to such sites as the brain, liver, lungs, or bone. These patients have systemic disease and aggressive treatment is necessary. “Cures” in these circumstances are extremely rare. However, significant strides have been made in the treatment of these patients. Their life spans have been lengthened through the combined use of surgery, radiation, and chemotherapy.

Recurrent Disease

Some patients who have completed their surgery and adjuvant therapy, if any, will do well for several months only then to develop recurrent tumor in the remaining breast tissue or

chest wall. These “local recurrences” usually are surgically resected and the area treated with radiation therapy. At times, the patients are also placed on hormonal therapy if they are not already receiving this.

Summary

Breast Cancer can be a life-changing event for the patient and those around them. The finding of an abnormality in a patient’s breast on physical exam or by radiographic methods invokes a very complex series of options. The patient’s surgeon plays a pivotal role in this process and must be prepared to fully discuss the subsequent diagnostic and treatment options with the patient. He or she may also need to call upon the assistance of medical and radiation oncologist when appropriate. The ultimate goal being a “cure” or, at least, maximum survival for the patient.