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Breast cancer

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of breast cancer.

Alternative Names

Mammograms; Mastectomy

Diagnosis

Breast Examination by a Health Professional. Early detection of breast cancer significantly reduces the risk of death. Women between the ages of 20 and 49 should have a physical examination by a health professional every 1 -2 years. Those over age 50 should be examined annually. A breast exam by a health professional can find 10 - 25% of breast cancers that are missed by mammograms. Between 6 - 46% of the lumps detected by examination are malignant. (The yield is lowest in younger women and highest in older women.)

Self-Examinations. Woman have been encouraged to perform a self-examination each month, but well-conducted studies in 2002 reported no difference in mortality rates between women who were intensively instructed in self-examination and those who were not. This does not mean women should stop attempting self-examinations, but they should not replace the annual examination done by a health professional, which evidence suggests is beneficial.

Monthly Self-Examination 1. Pick a time of the month that is easy to remember and perform self-examination at that time each month. The breast has normal patterns of thickness and lumpiness that change within a monthly period, and a consistently scheduled examination will help differentiate between what is normal from abnormal. 2. Stand in front of a mirror . Breasts should be basically the same size (one may be slightly larger than the other). Check for changes or redness in the nipple area. Look for changes in the appearance of the skin. With hands on the hips, push the pelvis forward and pull the shoulders back and observe the breasts for irregularities. Repeat the observation with hands behind the head. Move each arm and shoulder forward. 3. Lie down on the back with a rolled towel under one shoulder. Apply lotion or bath oil over the breast area. The finger action should be as follows: Using the 2nd, 3rd, and 4th finger pads (not tips) held together, make dime-sized circles. Press lightly first to feel the breast area, then press harder using a circular motion. Using this motion, start from the collarbone and move downward to underneath the breast. Shift the fingers slightly over, slightly overlapping the previously checked region, and work upward back to the collarbone. Repeat this up-and-down examination until the entire breast area has been examined. Be sure to cover the entire area from the collarbone to the bottom of the breast area and from the middle of the chest to the armpits. Move the towel under the other shoulder and repeat the procedure. Examine the nipple area, by gently lifting and squeezing it and checking for discharge. 4. Repeat step 3 in an upright position. (The shower is the best place for this, using plenty of soap.) Note: A lump can be any size or shape and can move around or remain fixed. Of special concern are specific or unusual lumps that appear to be different from the normal varying thicknesses in the breast.

Mammograms

Current Recommendations for Screening. Mammograms are very effective low-radiation screening methods for breast cancer. At this time, the U.S. Preventive Services Task Force recommends screening mammograms, with or without breast examination, every 1 - 2 years for all women over age 40.

Guidelines from the American College of Physicians, however, debate whether women with a low risk for breast cancer should begin mammogram screening at age 40. The 2007 guidelines, instead, recommend that women in their 40s ask their doctor when they should begin having the test.

After age 50, experts recommend annual screenings. (Women over age 65 account for most new cases of breast cancer.) Women with risk factors for breast cancer, including a close family member with the disease, should consider having annual mammograms starting 10 years earlier than the age at which the relative was diagnosed. (Uninsured women or those who have not been referred to a mammogram center can contact their local American Cancer Society for available low-cost programs.)

Issues Involved with Screening. Mammograms are not foolproof. They miss up to 25% of cancers (which can sometimes be caught on a physical examination). Furthermore, between 80 - 90% of suspicious mammograms turn out to be benign. According to one study, by the time a woman has nine mammograms, she has a 43% chance of having a false-positive mammogram (one that suggests cancer that isn't really there). This means many women who receive biopsies do not have cancer (but the only way to be sure is to perform the biopsy). Digital mammography is a recent technique that converts the image of the breast so it can be viewed and manipulated on a computer screen. It is improving accuracy, but no screening technique is perfect.

Even given current recommendations, there are several issues as to who should screen be screened and when to screen.

For Women between Ages 50 and 60. Evidence suggests that annual mammograms save lives in this age group. Furthermore, according to one study, because regular screening tends to find cancers in earlier stages, there has also been a decline in the number of mastectomies (surgical removal of the breast).

For Women between Ages 40 and 49. Whether premenopausal women should have routine mammograms is controversial. The areas of debate are as follows:

• Arguments against Regular Screening. Numerous studies report that any survival benefits from regular mammography in this group are likely to be small compared to breast examinations alone. Most of the arguments against mammography in this population are due its inefficiencies in this age group. The probability that woman in this age group with a suspicious mammogram will actually have breast cancer is only 2 - 4%. Frequent screening becomes very cost-inefficient and produces many unnecessary biopsies. In addition, breast tissue is dense in premenopausal women, and mammography often fails to detect breast cancers that are present. Breast cancers in this age group are also often aggressive, and 2-year intervals may not detect them early enough to affect survival.
• Arguments for Regular Screening. Breast cancer fatality rates are highest in women between ages 40 and 49. In spite of some negative studies, recent ones find some survival benefits for screening every 1 - 2 years. Advances in imaging techniques are helping to improve accuracy.

For Women Over 69. Most breast cancers appear in women over 70 and such women are more likely to be diagnosed at a later stage, most often because of less frequent screenings. Still, experts disagree about the benefits of regular screening in older women. Some evidence suggests that regular screening would prevent only about 1 death per 1,000 women screened. Elderly women are also particularly likely to have non-malignant abnormalities in their breasts and so undergo unnecessary biopsies.

Other Imaging Techniques

Magnetic Resonance Imaging (MRI) and Ultrasound. MRI and ultrasound techniques can detect very small tumors (less than half an inch). However, they are expensive and time-consuming procedures. Nevertheless, some experts believe they are important in identifying small tumors missed on mammography in women who are receiving lumpectomy or breast-conserving surgeries. Such findings would allow the surgeons to remove the optimal amount of abnormal tissue. Ultrasound may also be particularly important for women with dense breast tissue who show signs of breast cancer.

In a report published in 2007, the American Cancer Society recommended that high-risk women have an MRI of their breast with their annual mammogram, including those who have:

• A BRCA1 or BRCA2 mutation
• A first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
• A lifetime risk of breast cancer that has been scored at 20 - 25% or greater
• Had radiation to the chest between ages 10 - 30
• Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative

Scintimammography. In scintimammography, a radioactive chemical is injected into the circulatory system, which is then selectively taken up by the tumor and revealed on mammograms. This method is very accurate in detecting the presence or absence of breast cancer, and some experts hope that it might eventually reduce the number of unnecessary invasive biopsies.

Biopsy

A definitive diagnosis of breast cancer can be made only by a biopsy (a microscopic examination of a tissue sample of the suspicious area).

• When a lump can be felt and is suspicious for cancer on mammography, an excisional biopsy may be recommended. This biopsy is a surgical procedure for removing the suspicious tissue and typically requires general anesthetic.

• A core biopsy involves a small incision and the insertion of a spring-loaded hollow needle that removes several samples. The patient only requires local anesthetic.
• A wire localization biopsy may be performed if mammography detects abnormalities but there is no lump. With this procedure, using mammography as a guide, the doctor inserts a small wire hook through a hollow needle and into the suspicious tissue. The needle is withdrawn, and the hook is used by the surgeon to locate and remove the lesion. The patient may receive local or general anesthetic.
• A new vacuum-assisted device may be useful for some biopsies. This uses a single probe through which a vacuum is used to draw out tissue. It allows several samples to be taken without having to remove and re-insert the probe.

Final analysis of the breast tissue may take several days.

Lymphadenectomy

If breast cancer has been determined, the next diagnostic step is to find out how far it has spread. To do this, the doctor performs a procedure called an axillary lymphadenectomy , which partially or completely removes the lymph nodes in the armpit beside the affected breast (called axillary lymph nodes). It may require a hospital stay of 1 - 2 days.

Once the lymph nodes are removed, they are analyzed to determine whether subsequent treatment needs to be more or less aggressive:

• If no cancer is found in the lymph nodes, then the condition is referred to as node negative breast cancer. The chances are good that the cancer has not spread and is still local.
• If cancer cells are present in the lymph nodes, the cancer is called node positive . Their presence increases the possibility that the cancer has spread microscopically to other areas of the body. In such cases, however, it is still not known if the cancer has metastasized beyond the lymph nodes or, if so, to what extent. The doctor may perform further tests to see if the cancer has spread to the bone (bone scan), lungs (x-ray or CT scan) or brain (MRI or CT scan).

Side effects of the procedure include increased risk for infection and pain, swelling in the arm from fluid build-up, and impaired sensation and restricted movement in the affected arm. Patients might ask their doctor about the availability of physical therapy or upper-body exercises after treatment. In two studies, such programs resulted in quicker recovery and no fluid build-up in the arm.

Sentinel Node Biopsy

A technique known as a sentinel node biopsy is a less invasive alternative to axillary lymph node dissection. This procedure can help determine if cancer has spread beyond the nodes. If the doctor finds no evidence of cancer, the patient may not need to have a complete axillary lymphadenectomy.

Sentinal node biopsy involves:

• The procedure uses an injection of a tiny amount of a tracer, either a radioactively-labeled substance (radioisotope) or a blue dye, into the tumor site.
• The tracer or dye then flows via the lymphatic system into the sentinel node . This is the first lymph node to which any cancer would spread.
• The sentinel lymph node and possibly one or two others are then removed.
• If they do not show any signs of cancer, it is highly likely that the remaining lymph nodes will be cancer free, making further surgery unnecessary.

Patients who have a sentinel node biopsy tend to have better arm function and a shorter hospital stay than those who have an axillary node biopsy. The American Society of Clinical Oncology’s 2005 guidelines recommend sentinel node biopsy instead of axillary lymph node dissection for women with early stage breast cancer who do not have nodes that can be felt during a physical exam. It is still not known if the sentinel node biopsy has any survival advantages compared to standard lymph node removal procedures.

• Review Date: 4/3/2007
• Reviewed By: Editorial Team: Greg Juhn, M.T.P.W., David R. Eltz, Kelli A. Stacy. Previously reviewed by Harvey Simon, M.D., Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital (10/2/2006).

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