What you need to know about breast cancer

The breasts are composed of lobes. Each of the lobes has a duct that opens to the galactophorous duct located under the nipple. Between the lobes of the breast there is fibrous and adipose tissue, as well as lymph ducts. Blood vessels and nerves are distributed along the breast. The breasts sit on the chest muscles that cover the ribs.

The breast also contains lymph vessels that lead to lymph nodes. They are located in the axilla (underarm), in the collarbone area and inside the breast. Lymph nodes can also be found in many other parts of the body.

A. Ducts
B. Lobes
C. Galactophorous duct
D. Nipple
E. Adipose tissue
F. Chest muscle
G. Rib

There are many types of breast cancer. The most common appears in the ducts and is called ductal carcinoma. The second most common breast cancer is lobular carcinoma, which appears in the lobes. When the cancer is confined within the ducts, it is called non-invasive or in situ. It is called invasive carcinoma when it has invaded the nearby breast tissue or other parts of the body.

No one can explain why one woman develops breast cancer and another does not. It is clear that breast cancer is not caused by a blow or hematoma.. Different studies including a significant group of women have shown that there are certain risk factors that may increase the chance of developing breast cancer. However, there are other factors remain unknown. Having risk factors means that one is more likely to develop this disease. Nevertheless, studies show that manywomen with risk factors never develop breast cancer, whereas other women with no known risk factor do develop it.

Some of the risk factors are:

Age: The chance of getting breast cancer goes up as women get older. Most cases of breast cancer occur in 50-year-old women and the risk is particularly high in women over 60. However, breast cancer may appear at any age.

Familiy history: A woman's risk of breast cancer is higher if her mother, sister or daughters have had breast cancer . The risk is higher if her family member got breast cancer before menopause or if it affected both breasts.

Over 5-10% of women with breast cancer have a hereditary factor. Women with this type of cancer develop the disease at an early age (before menopause) and they usually have first-grade relatives that have developed this disease. For this type of patients we have genetic counselling.

Personal history: A woman who had breast cancer has an increased risk of getting breast cancer again. Over 10-15% of women treated for breast cancer develop a new breast cancer.

There are other factors, such as: women who had an early menstrual period (before age 12) and a late menopause (after age 55). The risk is higher for women who had their first child after age 30 as well as those women who never had children .

There are certain benign breast disorders that increase the risk of developing breast cancer, such as atypical hyperplasia. Many aspects in a woman's lifestyle may affect in the development of breast cancer. For instance, several studies have shown that the risk is higher in those women who drink alcohol. The more a woman drinks, the greater her chance of breast cancer. It has also been observed that physical activity may reduce the risk to develop breast cancer in young women.

It is essential that women take an active role in the early detection of breast cancer. The screening tests for early detection include:

Mammograms: is a special x-ray study. It is the best tool to find breast cancer early, but, sometimes, it cannot detect all tumors. Some studies have shown that having a mammogram regularly reduces mortality due to breast cancer in women over age 50. It also reduces mortality, althought to a lesser degree, in women between ages 40 and 50.

Mammograms use small doses of radiation. Your breast will be placed between two plates, which will press it. This compression may be uncomfortable, but it only lasts a few seconds. Tumors can be seen before they can be felt.

Mammograms can also show tiny specks of calcium, called microcalcifications. These specks tend to be benign, but they can also be an early sign of cancer.

Clinical breast exam: a breast exam must be performed by the specialist together with the mammogram.

Breast self-exam: You should perform monthly breast self-exams. It is important to remember that every breast is different and that changes can occur because of aging, your menstrual cycle, pregnancy, menopause or taking hormones. It is normal for breasts to be uneven. It is also common for your breasts to be swollen and tender during your menstrual period.

We recommend to have a mammogram and a clinical breast exam yearly as of age 40.

Cancer does not usually cause pain. In fact, breast cancer does not usually have symptoms. However, when cancer grows, it can cause changes that a woman detects, such as:

    * A lump or thickening in the breast or in the underarm area.

    * Changes in the shape or size of the breast.

    * Nipple discharge.

    * Changes in the colour or in the feeling of the skin of the breast, areola or nipple (sunken, wrinkled, scaly tissue...)

Should you detect any change in your breast, please see your health care provider.

An abnormal area in the mammogram, a lump or any other breast changes may indicate cancer or other less-serious problems. Depending on the assessment, different tests will be performed:

    * Palpation: Through palpation, your doctor screens for the characteristics of the lesion: size, texture or if it moves easily, and he/she checks the area and the type of tissue. Benign tumors often feel different from malignant ones.

    * Mammogram: are x-ray pictures of the breast that provide important information on the tumor to the doctor. If the mammogram area is suspicious or it is not clear, additional mammograms or test should be performed.

    * Ultrasound: is commonly used. It is used to diagnose whether the tumor is solid or filled with fluid. This test may be used along with a mammogram.

    * Magnetic Resonance Imaging of the breast.

Depending on the result of this test, it will be decided whether additional tests are needed as well as the type of treatment.

Types of biopsy:

   Fine-needle aspiration: A thin needle is used to remove fluid or cells from a breast lump. This procedure can show whether the tumor is fluid (the lump is not cancer) or a solid mass (which may o may not be cancer). These cells are analyzed by a pathologist.

    Core biopsy : A biopsy is taken using a thicker needle obtains a sample of core tissue.

    Both types of biopsy can be mammogram or ultrasound-guided.

    Surgical biopsy: A biopsy performed in the operating theatre. The surgeon removes a part of the tumor or the suspicious area. The pathologist checks the tissue for cancer cells.

Should you have any breast problem, please do no hesitate to consult a specialist. In most cases, breast lumps are benign, but if a breast cancer is diagnosed, the first thing to do is to find a team of specialists devoted to breast treatment who can inform you on your disease and plan treatment. If your breast cancer is at an early stage, you will need less treatment and the outcome will be better.

Several treatments are used for treating breast cancer. The treatment depends on the size and location of the tumor within the breast, as well as the extent (stage) of the disease. Your doctor may perform more diagnostic tests and blood tests as well as other type of tests (x-rays, CT scan, nuclear scans...) to determine the extent of the disease.

Women with breast cancer usually have questions and doubts about the different treatment options. Should you have any doubt concerning your treatment, please do not hesitate to question, as both you and your doctor must decide on your treatment. Your doctor is the most appropriate person to answer to any question concerning the different treatment options, results and characteristics of each treatment. You can also discuss with him/her whether you can be a part of studies on new medical treatments. Many patients need to know how they will look like after the treatment and whether they will have to change their normal activities.

It often helps to make a list of questions to help remember of everything you want to ask your doctor. You may also want to have a family member or friend with you to take part in the discussion, to take notes or just to listen. There is a lot of information to learn about breast cancer and its treatments.

Breast cancer treatment is either local therapy or systemic therapy . Local therapy is based on destroying cancer cells in a specific area. Surgery and radiotherapy are local treatments. Systemic treatments are used to destroy cancer cells throughout the body. Chemotherapy and hormone therapy are systemic treatments. The patient may just have one treatment or the combination of several treatments.

    Surgery: is the most common treatment for breast cancer. There are several types of surgeries. Your doctor can explain the benefits and risks of each type and describe how each will change the way you look. There are three main types of surgery:

   Lumpectomy or quadrantectomy: The surgeon removes the tumor and a small amount of nearby breast tissue. The size of the tumor is the main factor to assess whether this type of surgery is appropriate. The surgeon sometimes removes the axillary lymph nodes as well. Usually, this surgery is used along with radiation therapy to the breast. The combination of quadrantectomy and radiation therapy is called breast-conserving surgery.

Total mastectomy: the whole breast is removed, areola and nipple included, but the axillary lymph nodes are not.

    Modified radical mastectomy: The breast and the axillary lymph nodes are removed. The muscles located under the breast are not removed.

   Radical mastectomy: In radical mastectomy (usually called Halsted radical mastectomy), the surgeon removes the whole breast, the chest muscles, the lymph nodes under the arm and an additional fat and tissue area. For many years, this was the breast cancer operation used most often, but it is rarely used now.

    Breast reconstruction: When the breast needs to be removed and the patient needs a mastectomy, we always consider the option of reconstructing the shape of the breast at the same time as the mastectomy. In the Breast Department of Teknon Oncology Institute, we perform mastectomy but save the skin of the breast, so the aesthetic results are much better.

   There are several breast reconstruction options; breast implants or the use of the patients' own tissue.. The plastic surgeons will inform you about the risks and benefits of each type of breast reconstruction.

   Axillary lymph node dissection: A procedure to remove the underarm lymph nodes. It helps determine whether they have a tumor as well as the prognosis and treatment method the patient needs. This procedure has some side effects such as the risk of arm swelling (edema). The patient will be informed about the care for his/her arm and how to best avoid edema. Should lymphedema appear exercises will be suggested or the patient will be referred to the physical therapist.

    In recent years, the sentinel lymph node biopsy has been developed and some patients do not need an axillary dissection.

   Sentinel lymph node biopsy: This is a new advancement in the treatment of breast cancer, which reduces the amount of surgery the patient needs. It consists of detecting the first nodes where the tumor is spreading, called sentinel nodes. Once they are removed, the nodes are checked for tumor and, if there is no tumor, no more surgery is done in the underarm and the patient can avoid a complete dissection.

   Intraoperative ultrasound : This technique uses an ultrasound device, similar to other medical devices, but the important thing is that the surgeon uses it within the operating theatre for image-guided excision of breast lesions. The advantages are numerous thereby enabling the detection and the accurate localization of nonpalpable lesions.

   Radiation therapy: It uses radiation to kill cancer cells. Patients must go daily to the hospital or the medical centre to receive radiation therapy. When breast-conserving surgery is performed, radiation therapy is usually given 5 days a week for 5 or 6 weeks. At the end of the cycle, an extra dose of radiation is often administered exactly where the tumor was located.

   Radiation therapy is painless. Some women feel heat in the treated area and others feel tired during the treatment. In general, normal activitie cna be maintained and in some cases reduced during the treatment.

   Chemotherapy: Different types of drugs are used to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given in pill form or by injection into a vein. It is a systemic treatment because the drugs enter the bloodstream and travel throughout the body.

   Chemotherapy is administered in cycles: it is based in the administration, a recovery period and the follow-up cycle. As it affects any multiplying cell, normal cells may also be damaged (though at a lower level) . Your doctor will explain the side effects and the treatment to be followed so as to diminish side effects as much as possible. Many of these side effects are just a phase and will disappear after chemotherapy is over.

    Sometimes, chemotherapy is administered as the sole treatment if breast cancer disappeared from the rest of the body, but it is usual to have it together with surgery, radiation therapy or both, in order to reduce the chance for the tumor to appear again. On some occasions, it is administered prior to surgery to try to reduce the size of the tumor and assess its response to the treatment.

   Hormone therapy: It is used to block the effects that hormones have in the growth of the tumor. The hormone therapy is also a systemic treatment, like chemotherapy. Hormone therapy is not effective for all kinds of breast tumors. Assessment of use is based on the cytology of tumor tissue which determines the hormone receptors of the tumor study shows what the hormone receptors of the tumor are. This treatment is more effective in those cancer with positive receptors.

Recovery is an important part of breast cancer treatment. Suitable health care leads to an earlier recovery for the patient, so that she can go back to her daily routines as soon as possible. Recovery is different for each person: depending on the extent of the disease, the treatment carried out and other factors.

Doing exercise after surgery may help recover the movement and strength in your arm and your shoulder. It can also reduce pain and numbness in your neck and back. You can start doing exercise as soon as your doctor suggests. At the beginning, these exercises have to be gentle and slow. Exercise can be increased gradually and must become part of your daily routine.

Nutrition

Loss of apetite can be a problem in patients with cancer. Many side effects of cancer treatment, such as nausea,and vomiting, can make it hard to eat. Patients eating well usually fell better and have more energy. Eating well means having enough calories and proteins to maintain your weight, keep up your strength and regenerate tissues.

Doctors, nurses and dietitians can explain the effects of the treatment and suggest ways to improve your nutrition.

Monitoring

Regular examinations are important in breast cancer. Your doctor will continue performing regular examinations to check for recurrence of the cancer. Regular examinations include physical examinations as well as mammograms, analysis, x-rays, MRI... Patients treated with chemotherapy or hormone therapy may need additional examinations.

The diagnosis of breast cancer can change your life and the lives of those close to you. These changes can be hard to cope with. Breast cancer affects the whole family; the patients and their relatives may be frightened, angry and depressed, but this behaviour is normal. Friends and relatives are also an important part of your support network.

Women who have had breast cancer experience changes in their bodies that affect not only how they look, but also how they feel. These changes may affect your sexual relationships. It is important to talk with your partner about your concerns during the treatments and to communicate openly.

It is also important to talk to your children about the disease so that they understand what is going on. You have to talk to them as simply as possible about the disease, and assure them that their daily routine will soon be re-established.. Meetings with nurses, social workers, advisers, volunteers or members of organizations may be helpful for patients who need to talk about their feelings, doubts or fears.

Researchers are testing new treatments, new chemotherapy treatments and the planning thereof, as well as new ways to combine treatments. We are working with several anticancerous drugs and combinations and hormone therapies. New ways to combine chemotherapy with hormone therapies and radiation therapy are also being studied. Many trials include biological therapies : they are treatments that used substances stimulating the immune system to react to cancer or to help the body recover from the side effects of the treatment.

In some trials, doctors try to learn whether more doses of a drug are more effective than the ones usually used to kill cancer cells. However, high doses are dangerous to the bone marrow of the patient, where blood cells are created. Research is also focusing on new ways to replace bone marrow or to help it recover.