BREAST CANCER AWARENESS
MAMMOGRAPHY is the process of using low-dose amplitude-X-rays to examine the breast, and is used as a diagnostic as well as a screening tool. The goal of mammography is the early detection of breast cancer.
BREVARD COUNTY, FLORIDA – Breast cancer (BCA) remains the most common cancer among American women. A woman has a 1 in 8 chance of developing invasive BCA during her life. However, only 1 in 35 women will ultimately die of the disease. The death rates from BCA have been declining due to earlier detection. This optimistic outlook reflects the years of research into better detection and treatment of this disease.
BCA attracts significant attention in the media and health forums because it is common and affects a woman’s self-image. But we should also consider that lung cancer remains the leading cause of cancer death in women and heart disease is still the top cause of overall death in American women. We have yet to make an impact on these devastating diseases. Over 65 percent of cases of BCA involve women aged 55 and older and 70-80 percent of women with BCA do not have a family history of the disease. BCA is a rare disease in men and accounts for less than 1 percent of all BCA cases.
BCA STARTS within the lining of the lobules and ducts (carcinoma in situ). Later, invasive BCA starts to grow into deeper tissues of the breast and can spread to lymph nodes.
Breasts produce and store human milk. Lobules produce the milk that the ducts channel toward the nipple. The breast is also composed of fat, nerves, blood vessels, lymph nodes and connective tissue for structure and support. The breasts lay on top of the pectoralis muscles. Lymph nodes are located alongside the breastbone, in the breast, above and below the collarbone and in the axilla or armpit Breast development is influenced by estrogen and progesterone.
Risk Factors for BCA
- Female sex; due to the effects of estrogen and progesterone
- Age; more common in women aged 55 years or older
- History of cancer in one breast increases risk of disease in other breast
- White women more likely to develop BCA
- African-American women develop more aggressive cancer; more likely to die
- Proliferative breast lesions slightly increase risk (i.e. atypical ductal hyperplasia)
- First degree relative with BCA increases your risk (mother, sister, daughter)
- History of BCA on father or brother’s side also increases risk
- Inherited BCA makes up 5-10 percent of cases (mutations in DNA or genes). Most common are BRCA1 and BRCA2 gene mutations. Affected women have 80 percent chance of developing BCA
- Obesity and lack of physical activity
- Alcohol (more than 1 drink daily)
- History of radiation to the chest as a child or adolescent
- Hormone replacement therapy (estrogen and progesterone).
Non-cancerous breast lumps (i.e. fibrocystic disease), high fat diet, tobacco use, large breast size and abortion are not clear risk factors for BCA. Tamoxifen, a drug with anti-estrogen activity, has been shown to be effective in BCA prevention in women at high-risk for BCA.
BEGINNING IN THEIR 20s, women should be aware of the benefits and limitations of breast self-exam. Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found.
Diagnosis
Before mammograms, BCA was often diagnosed in advanced stages. Women had lumps in the breast or lymph nodes or the disease had already spread to the bones, lungs and other organs. Mammograms have been shown to save lives by detecting BCA in its earliest stages (carcinoma in situ or small invasive BCAs), before a woman may have signs or symptoms. Earlier detection may also reduce the need for extensive surgery and chemotherapy.
Other signs and symptoms of BCA include changes in the color, texture and shape of the breast skin, areola or nipple; enlargement or retraction of the breast; lumps in the armpit or neck; swelling of the arm (lymphedema); chest pain; severe bone pain; weight loss; and fatigue.
Mammograms are x-rays of the breast. They show small tumors and identify abnormal patterns of calcium deposits. However, not all BCA are seen on mammograms. Ultrasounds can help identify if a tumor is solid or cystic. Breast MRI is a special scan, which can help to find tumors not seen on mammogram due to dense breasts or women with multiple cysts, fibroadenomas, scars etc. All three techniques can help us to biopsy a suspicious area.
Once diagnosed with BCA, a woman must undergo surgery to remove the tumor and the lymph nodes in the axilla must be sampled to detect spread of cancer. Several factors are very important in determining prognosis.
High-risk factors
• Larger breast tumors (i.e. > 2 cm)
• Number of positive lymph nodes and location
• Skin or chest muscle involvement or inflammatory BCA
• High-grade tumors
• Metastatic disease – spread of BCA to bones, lungs, brain, etc.
• Tumors that do not grow under the influence of hormones (“estrogen receptor/ progesterone receptor –negative”)
• Tumors that carry many copies of the gene Her2/neu
Stages of Breast Cancer
After surgery, the extent of a woman’s BCA is “classified” or “staged” to gain an understanding of her prognosis and treatment options. BCA stages are I through IV and are based on the size of the tumor, the number of lymph nodes involved and metastatic disease.
Surgery
Surgery is part of the curative approach to BCA. Even with metastatic disease, some women have improved survival with removal of the breast tumor. Options include:
- Simple mastectomy: removal of the breast
- Modified radical mastectomy: more complete removal of the breast
- Lumpectomy: removal of tumor alone, thus conserving the breast
- Axillary sentinel lymph node biopsy: sampling of lymph nodes to determine if they are positive for cancer
- Axillary lymph node dissection: removal of many lymph nodes
- The type of surgery performed depends a great deal on a woman’s preference and the size, location and extent of her BCA.
Radiation Therapy
Radiation therapy involves the use of high energy x-rays. Radiation has been shown to improve survival in some cases of BCA by reducing the risk of cancer returning locally. In women who cannot have surgery, radiation can help to relieve pain, bleeding and infection from extensive BCA. After a mastectomy, most women do not require radiation therapy. However, some women do benefit from radiation to the chest scar or axilla, including women with large breast tumors, positive lymph nodes, involvement of the skin and chest muscles and other factors.
After a lumpectomy, women do require radiation therapy to reduce the risk of cancer returning in the remaining breast tissue and/or axilla. Radiation usually starts within 4 weeks of surgery or after chemotherapy is completed.
Traditional regimens use high-energy external x-rays over 6 weeks. Older woman with small breast tumors who have had a lumpectomy may be eligible for an accelerated program of radiation over 5 days (Mammosite or SAVI).
Systemic Therapy
Hormonal therapy refers to the use of “anti-estrogen” drugs after surgery and radiation therapy. Tamoxifen and the aromatase inhibitors fall into this category. They block the proliferative effects of estrogen on breast tissue, which may promote BCA. These drugs are taken daily for 5 years. Only women with cancers that are influenced by estrogen/progesterone (receptor-positive) are eligible for these drugs.
Chemotherapy involves the use of medication delivered through the circulation to reduce the risk of spread of cancer in women with high-risk, advanced stage or metastatic BCA. Chemotherapy usually takes several months to administer and has been shown to improve survival in patients.
Targeted therapies like Herceptin and Avastin are also very important in BCA treatment. They target specific signaling pathways in the life cycle of a BCA cell that become aberrant, leading to unregulated growth and spread of cancer.
There is active research into better understanding the biology of particular BCA through gene testing in order to develop more customized chemotherapy and targeted therapy.
The diagnosis, staging and treatment of BCA require a coordinated effort between a woman and her team of cancer specialists. This multidisciplinary approach is one of the hallmarks of modern approaches to BCA treatment and provides more personalized, state-of-the art therapy to the 21st century woman living with BCA … and one day, a cure.
DR. NICOLA ALLY is a board certified radiation oncologist with Cancer Care Centers of Brevard. She specializes in adult oncology and is specially trained in the use of radiation therapy in the management of cancer and benign disease. Dr. Ally enjoys a close relationship with her patients and has a special interest in radiosurgery and prostate, lung, breast, colorectal and skin cancers; and she serves on the Board of the American Cancer Society. Dr. Ally and her colleagues at Cancer Care Centers of Brevard provide state-of-the art radiation therapy in their locations in Merritt Island, Melbourne and Sebastian. They are a comprehensive cancer center and also provide medical oncology and hematology services. To reach Dr. Ally call 321-952-0898.
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