Breast Cancer

Breast Carcinoma

Breast cancer usually begins in the glands that produce milk or in the ducts that carry it to the nipple. It can grow larger in the breast and spread to nearby lymph nodes or through bloodstream to other organs. 

Common Symptoms of Breast carcinoma

  • A lump or thickening in or near the breast or in the underarm area.
  • A change in the size or shape of the breast.
  • A dimple or puckering in the skin of the breast.
  • A nipple turned inward into the breast.
  • Fluid, other than breast milk, from the nipple, especially if it’s bloody.
  • Scaly, red, or swollen skin on the breast, nipple, or areola 
  • Skin of the breast look like the skin of an orange, called peau d’orange.

Breast Cancer Risk Factors 

  • Age. Women over 50 are more likely to get breast cancer than younger women.
  • Family history. A personal history of invasive breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS).
  • A personal history of benign (non cancer) breast disease.
  • A family history of breast cancer in a first-degree relative (mother, daughter, or sister).
  • Inherited changes in the BRCA1 or BRCA2 genes or in other genes that increase the risk of breast cancer.
  • Breast tissue that is dense on a mammogram.
  • Menstruating at an early age.
  • Starting menopause at a later age.
  • Older age at first birth or never having given birth.
  • Taking hormones such as estrogen combined with progestin for symptoms of menopause.
  • Treatment with radiation therapy to the breast/chest.
  • Drinking alcohol.
  • Obesity.
  • Older age is the main risk factor for most cancers. The chance of getting cancer increases as you get older.

Still, most women who are at high risk for breast cancer don’t get it. On the other hand, 75% of women who develop breast cancer have no known risk factors.

Diagnosis–

  • Ultrasound. 
  • Mammogram. This detailed X-ray gives doctors a better view of lumps and other problems.
  • Magnetic resonance imaging (MRI). .
  • Biopsy. For this test, the doctor removes tissue or fluid from the breast and look at it under a microscope to check for cancer cells. Common procedures include:

                                     Excisional biopsy: The removal of an entire lump of tissue.

                                     Incisional biopsy: The removal of part of a sample of tissue.

                                     Core biopsy: The removal of tissue using a wide needle.

                                     Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.

Tests needed for Decision regarding Treatment-

Estrogen and progesterone receptor test: A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. 

Human epidermal growth factor type 2 receptor (HER2/neu) test: If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. The cancer may be treated with drugs that target the HER2/neu protein, such as trastuzumab and pertuzumab.

Multigene tests:Tests in which samples of tissue are studied to look at the activity of many genes at the same time. These tests may help predict whether cancer will spread to other parts of the body or recur.

Based on these tests, breast cancer is described as one of the following types:

Hormone receptor positive or hormone receptor negative 

HER2/neu positive or HER2/neu negative.

Triple negative (estrogen receptor, progesterone receptor, and HER2/neu negative).

Sometimes the breast cancer cells will be described as triple negative or triple positive.

Triple negative. If the breast cancer cells do not have estrogen receptors, progesterone receptors, or a lesser than normal amount of HER2 receptors, the cancer cells are called triple negative.

Triple positive. If the breast cancer cells do have estrogen receptors, progesterone receptors, and a larger than normal amount of HER2 receptors, the cancer cells are called triple positive.

There are drugs that can stop the receptors from attaching to the hormones estrogen and progesterone and stop the cancer from growing. 

Other drugs may be used to block the HER2 receptors on the surface of the breast cancer cells and stop the cancer from growing.

Treatment Option Overview

  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Hormone therapy
  • Targeted therapy
  • Immunotherapy

New types of treatment are being tested in clinical trials.

Surgery

Most patients with breast cancer have surgery to remove the cancer.

Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. 

The sentinel lymph node is the first lymph node in a group of lymph nodes to receive lymphatic drainage from the primary tumor. It is the first lymph node the cancer is likely to spread to from the primary tumor. 

A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. Sometimes, a sentinel lymph node is found in more than one group of nodes. 

After the sentinel lymph node biopsy, the surgeon removes the tumor using breast-conserving surgery or mastectomy. If cancer cells were found, more lymph nodes will be removed through a separate incision. This is called a lymph node dissection.

Types of surgery include the following:

Breast-conserving surgery–BCS is an operation to remove the cancer and some normal tissue around it, but not the breast itself. This type of surgery may also be called lumpectomy, partial mastectomy, segmental mastectomy, quadrantectomy, or breast-sparing surgery.

Radiotherapy is also generally advised when BCS is done

Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed and checked for cancer. This may be done at the same time as the breast surgery or after. This is done through a separate incision.

Modified radical mastectomy:Surgery to remove the whole breast that has cancer. This may include removal of the nipple, areola (the dark-colored skin around the nipple), and skin over the breast. Most of the lymph nodes under the arm are also removed.

Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Treatment given before surgery is called preoperative therapy or neoadjuvant therapy.

POST OPERASTIVE TREATMENT

Some patients may be advised radiation therapy, chemotherapy, targeted therapy, or hormone therapy after surgery, to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called postoperative therapy or adjuvant therapy.

If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at some time after. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline or silicone gel.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.

Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. Monoclonal antibodies, tyrosine kinase inhibitors, cyclin-dependent kinase inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and PARP inhibitors are types of targeted therapies used in the treatment of breast cancer.

Immunotherapy

Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.

SIDE EFFECTS OF TREATMENT

Late effects of radiation therapy are not common, 

Arm lymphedema, especially when radiation therapy is given after lymph node dissection. 

In women younger than 45 years who receive radiation therapy to the chest wall after mastectomy, there may be a higher risk of developing breast cancer in the other breast.

Late effects of chemotherapy depend on the drugs used, but may include:

  • Heart failure.
  • Blood clots.
  • Premature menopause.
  • Second cancer, such as leukemia.
  • Late effects of targeted therapy with trastuzumab, lapatinib, or pertuzumab may include:

Adapted from NCI patient information

Heart problems such as heart failure.