Breast Cancer

• Breast Cancer Warning Signs
• Diagnosis, Imaging, Screening
• General Information
• Guidelines
• Internet Sites
• Risk Factors
• Risk Reduction
• Treatment

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Breast Cancer

NIH - Medical Encyclopedia Breast cancer "There are several different types of breast cancer. Ductal carcinoma begins in the cells lining the ducts that bring milk to the nipple and accounts for more than 75% of breast cancers. Lobular carcinoma begins in the milk-secreting glands of the breast but is otherwise fairly similar in its behavior to ductal carcinoma. Other varieties of breast cancer can arise from the skin, fat, connective tissues, and other cells present in the breast. … Some women have what is known as HER2-positive breast cancer. HER2, short for human epidermal growth factor receptor-2, is a gene that helps control cell growth, division, and repair. When cells have too many copies of this gene, cell growth speeds up. It’s believed that HER2 plays a key role in turning healthy cells into cancerous ones. Some women with breast cancer have too much HER2, and are therefore considered HER2-positive. … Some families appear to have a genetic tendency for breast cancer. Two variant genes have been found that appear to account for this: BRCA1 and BRCA2. … The body's reduced ability to get rid of abnormal cells leads to damage that gradually accumulates. Women carrying mutated BRCA1 and/or BRCA2 genes start with pre-existing dysfunction of this system and have a "head start" in this damaging process. Hormones are important because they encourage cell growth. High levels of hormones during a woman's reproductive years, especially when they are not interrupted by the hormonal changes of pregnancy, appear to increase the chances that genetically damaged cells will grow and cause cancer."

Types of breast cancer "Common types of breast cancer The most common types of breast cancer begin either in your breast's milk ducts (ductal carcinoma) or in the milk-producing glands (lobular carcinoma). The point of origin is determined by the appearance of the cancer cells under a microscope. In situ breast cancer In situ (noninvasive) breast cancer refers to cancer in which the cells have remained within their place of origin — they haven't spread to breast tissue around the duct or lobule. The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS), which is confined to the lining of the milk ducts. The abnormal cells haven't spread through the duct walls into surrounding breast tissue. With appropriate treatment, DCIS has an excellent prognosis. Invasive breast cancer Invasive (infiltrating) breast cancers spread outside the membrane that lines a duct or lobule, invading the surrounding tissues. The cancer cells can then travel to other parts of your body, such as the lymph nodes. Invasive ductal carcinoma (IDC). IDC accounts for about 70 percent of all breast cancers. The cancer cells form in the lining of your milk duct, then break through the ductal wall and invade nearby breast tissue. The cancer cells may remain localized — staying near the site of origin — or spread (metastasize) throughout your body, carried by your bloodstream or lymphatic system. Invasive lobular carcinoma (ILC). Although less common than IDC, this type of breast cancer invades in a similar way, starting in the milk-producing lobules and then breaking into the surrounding breast tissue. ILC can also spread to more distant parts of your body. With this type of cancer, you typically won't feel a distinct, firm lump but rather a fullness or area of thickening."

Breast lumps: Types of lumps and what they mean "Causes Breast lump causes: Breast cancer Breast cyst Fibroadenoma Fibrocystic changes Hamartoma Injury or trauma to the breast Intraductal papilloma Lipoma Mastitis Milk cyst (galactocele) Phyllodes tumor. "

NIH – Breast Cancer “Breast cancer affects one in eight women during their lives. Breast cancer kills more women in the United States than any cancer except lung cancer. No one knows why some women get breast cancer, but there are a number of risk factors. Risks that you cannot change include • Age - the chance of getting breast cancer rises as a woman gets older • Genes - there are two genes, BRCA1 and BRCA2, that greatly increase the risk. Women who have family members with breast or ovarian cancer may wish to be tested. • Personal factors - beginning periods before age 12 or going through menopause after age 55 Other risks include being overweight, using hormone replacement therapy, taking birth control pills, drinking alcohol, not having children or having your first child after age 35 or having dense breasts. Symptoms of breast cancer may include a lump in the breast, a change in size or shape of the breast or discharge from a nipple. Breast self-exam and mammography can help find breast cancer early when it is most treatable. Treatment may consist of radiation, lumpectomy, mastectomy, chemotherapy and hormone therapy. “

NHS – Breast Cancer “Types of breast cancer: There are several different types of breast cancer, which can develop in different parts of the breast. The most common is known as ductal breast cancer, which develops in the cells that line the breast ducts. Ductal breast cancer accounts for about 80% of all cases of breast cancer. Other, less common types of breast cancer include lobular breast cancer, which develops in the cells that line the milk-producing lobules, inflammatory breast cancer, and Paget's disease of the breast. It is possible for breast cancer to spread to other parts of the body, such as the liver, bones, or lymph nodes (small glands that filter bacteria from the body). … Symptoms: The main symptom of breast cancer is usually a lump, or thickened area of tissue, in your breast. The majority of breast lumps are found by the women who have them, and it is very important that you are aware of any lumps, or changes in the appearance, feel, or shape of your breasts. This is important because the sooner a cancerous lump is detected, the better the chances are that it will be treated successfully. Changes to look out for You should see your GP if you notice any of the following: • a lump, or thickened area of tissue, in either breast, • discharge from either of your nipples (which may be streaked with blood), • a lump or swelling in either of your armpits,a change in the size, or shape, of one, or both, of your breasts, • dimpling on the skin of your breasts, • a rash on, or around, your nipple,a change in the appearance of your nipple, such as becoming sunken into your breast, or • pain in either of your breasts or armpits which is not related to your period. If you have a lump in your breast, it is important to remember that it may not be the result of breast cancer. In fact, 90% of breast lumps are benign (non-cancerous). For example, a breast lump may be caused by a harmless cyst (a small fluid-filled lump), or fibroadenoma (benign growths that are very common). You may also find that your breasts feel lumpy just before your period. However, if you notice any changes to one, or both, of your breasts, as listed above, you should always get it checked by your GP. “

NHS – Breast Cancer Expert (Video)

NHS – Breast Cancer Screening (Video)

Highlighted Articles

Primary tumor location impacts breast cancer survival. (Am J Surg. 2008) “CONCLUSIONS: Upper-outer quadrant breast cancers have a more favorable survival advantage when compared with tumors in other locations. Factors that negatively impacted survival included high-grade tumors, advanced stage, and race.”

Adulthood Lifetime Physical Activity and Breast Cancer. (Epidemiology. 2008) “Women who increased their recreational activity in their 50s had significantly reduced risk, with those in the highest tertile of change being at a 27% lower risk. CONCLUSIONS:: Leisure-time moderate-to-vigorous activities reduce breast cancer risk irrespective of underlying host characteristics.”

Cruciferous vegetables, the GSTP1 Ile105Val genetic polymorphism, and breast cancer risk. (Am J Clin Nutr. 2008) “CONCLUSIONS: Cruciferous vegetable intake consistent with high isothiocyanate exposure may reduce breast cancer risk. Cruciferous vegetable intake also may ameliorate the effects of the GSTP1 genotype.”

Breast Cancer: Benign Breast Lumps (2007) “Eighty percent of all breast lumps are benign, which means they're not cancerous. Benign breast lumps usually have smooth edges and can be moved slightly when you push against them. They are often found in both breasts.

Mammographic Breast Density as a General Marker of Breast Cancer Risk (Cancer Epidemiology Biomarkers & Prevention 2007) "Overall mammographic density seems to represent a general marker of breast cancer risk that is not specific to breast side or location of the eventual cancer."

Lifetime physical activity and the risk of breast cancer: A case-control study. (Cancer Detect Prev. 2007) "Conclusions: These data are in concordance with the hypothesis that lifetime total physical activity is associated with decreased breast cancer risk. They also suggest that recreational physical activity at ages 14-20 years is the most beneficial. In addition, these findings confirm the majority of previous reports which implicated physical inactivity as important risk factor for breast cancer."

Highlighted Internet Sites

NCI - Breast Cancer

NCI – What You Need To Know About Breast Cancer

NCI - Characteristics of Breast Cancer Cases (graphic data)

NIH – Breast Cancer

NCI - Breast Cancer (PDQ®): Prevention

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Breast Cancer

Diagnosis, Imaging, and Screening

NEWS:

Age 35 May Be Best Start for Screening Mammography in BRCA-Mutation Carriers

Alternating Breast Scans “New findings from the M.D. Anderson Cancer Center show magnetic resonance imaging (MRI) alternated with mammography at six-month intervals can detect breast cancer not found by mammography alone.”

Breast exam guidelines now call for less testing “Several patient advocacy groups and many breast cancer experts welcomed the new guidelines, saying they represent a growing recognition that more testing, exams and treatment are not always beneficial and, in fact, can harm patients. Mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes-disfiguring biopsies and unneeded treatment, including surgery, radiation and chemotherapy.”

Breast Ultrasounds Spot More Cancers

Can You Trust Your Mammogram?

Cost-effective mammography screening in Korea: High incidence of breast cancer in young women. (Cancer Sci. 2009)

Even With Very Small Breast Tumors, Studies Find HER2 Status Matters “Two retrospective studies have found that women with HER2-positive breast tumors (that is, tumors that produce too much of the HER2 protein) that are 1 centimeter or smaller had a higher risk of their disease returning within 5 years than women with similarly small HER2-negative tumors. The findings, published online November 2 in the Journal of Clinical Oncology, may shed some light on an area of clinical uncertainty: Whether women with small, HER2-positive tumors should receive post-surgical, or adjuvant, treatment with the targeted agent trastuzumab (Herceptin).”

Experts contest article declaring breast MRI causes more harm than good “A review article asserting breast MRI does not improve surgical planning, reduce follow-up surgeries, or reduce the risk of local recurrences is drawing fire in the breast imaging community. In the past few years, radiologists have used MRI in preoperative staging for women with newly diagnosed breast cancer because it detects additional cancer. The recent review article questions the utility of MRI and says the modality does more harm than good, since there is evidence MRI changes surgical management from breast conservation to more radical surgery (CA Cancer J Clin 2009;59:epub ahead of print). … It's important to keep in mind this is a review article, and thus two people's opinion, said Dr. Constance Lehman, the head of breast imaging at the University of Washington in Seattle. Breast MRI finds additional disease, and that's a good thing, according to Lehman. Since more cancer is found, fewer patients return with recurrence and cancer is found at earlier stages, she said. Because more cancer is found, it makes sense more extensive surgery would take place. Additionally, a situation where a false positive on MRI leads to mastectomy is extremely rare, amounting to just 1% of cases, Lehman said. That could reflect decisions to proceed to surgery without biopsy confirmation. It's very easy for a benign lesion to appear malignant on MRI, which underscores the importance of image-guided needle biopsies, she said. A radiologist never wants to rely solely on an MRI to determine preoperative staging and should always do a needle biopsy to ensure patients receive the proper care.”

Mammograms may harm young BRCA mutation carriers “Due to the risk of radiation-induced breast cancer, mammographic screening in young BRCA mutation carriers may have a net harmful effect, according to a report in the Journal of the National Cancer Institute.”

Mammograms Should Continue Up to Age 75 Years, and 3-Year Intervals Are Sufficient

New advice: Wait until 50 for mammograms “Most women should wait until age 50 to get mammograms and then have one every two years, a government task force said Monday in a major reversal that conflicts with the American Cancer Society's long-standing recommendation of annual screening starting at 40. Also, the task force said breast self-exams do no good and women shouldn't be taught to do them.”

New Breast Cancer Screening Guidelines Opposed by Societies “Several professional organizations and expert groups have voiced their objections to new recommendations for breast cancer screening issued by the US Preventive Services Task Force (USPSTF) and published in the November 17 issue of the Annals of Internal Medicine. "[The American Cancer Society] continues to recommend [mammography] screening annually for women 40 to 49 years of age," Victor G. Vogel, MD, MHS, FACP, national vice president for research at the American Cancer Society (ACS) in Atlanta, Georgia, told Medscape Medical News. "Clinicians should recognize that very few agencies, including the ACS, are altering their screening guidelines based on the USPSTF modeling results, which simply reanalyze previously published data." Based on an evidence review, the updated USPSTF guidelines recommend against routine mammography screening for women before age 50 years, suggest that screening end at age 74 years, and recommend changing the screening interval from 1 year to 2 years.”

Radiation Exposure From Annual Mammography Increases Breast Cancer Risk in Young High-Risk Women “The low doses of radiation associated with annual screening mammography could be placing high-risk women in even more jeopardy of developing breast cancer, particularly if they start screening at a young age or have frequent exposure, according to new research presented here at the Radiological Society of North America 95th Scientific Assembly and Annual Meeting. A meta-analysis of 6 studies found that women with BRCA1 or BCRA2 gene mutations or a family history of breast cancer who were exposed to radiation, either from mammography or chest x-rays, before the age of 20 had a risk for breast cancer that was 2.5 times higher than their counterparts who were not exposed to radiation (95% confidence interval [CI], 1.9 - 3.2). The analysis, which examined 9420 high-risk women, also found that 5 or more mammograms increased risk 2.5-fold (95% CI, 1.6 - 3.9), Marijke C. Jansen-van der Weide, PhD, from the University Medical Center Groningen in the Netherlands, reported.”

Should Women Stop HT Temporarily Before Undergoing Screening Mammography?

Study Challenges Routine Use Of MRI Scans To Evaluate Breast Cancer

Task Force Doctor Stands by Mammogram Advice

What Should A Teenage Girl Do If She Finds A Lump In Her Breast? “Among girls younger than 19, there are fewer than 25 cases of breast cancer per 100,000 per year, according to the National Cancer Institute. The vast majority of breast lumps in adolescents are benign and tend to wax and wane. Over time, many disappear. Many teenage girls undergo biopsy of breast lumps because of parental anxiety and surgeons' concerns, Vade said. Vade and colleagues wrote that for adolescents who present with solid masses that appear benign on ultrasound examination, "we conclude that excisional biopsy may not always be necessary." “

ARTICLES:

Slide show: Stages of breast cancer

JOURNAL ARTICLES:

A single institutional experience of factors affecting successful identification of sentinel lymph node in breast cancer patients. (Surgery. 2009)

Breast cancer: role of SPECT and PET in imaging bone metastases. (Semin Nucl Med. 2009) “Breast cancer is the most common cause of bone metastases in women. Imaging studies are useful to identify bone involvement and associated complications, for follow-up of disease spread and for the assessment of response to therapy. Bone scintigraphy with (99m)technetium-labeled diphosphonates is most widely used, due to its availability, high sensitivity, and low cost, despite the relatively low specificity. The addition of single-photon emission computed tomography and recently single-photon emission computed tomography/computed tomography improves the diagnostic accuracy of this modality.”

Clinicopathological characteristics of invasive lobular carcinoma of the breast. (Asian J Surg. 2009)

Contribution of Clinical Breast Examination to Breast Cancer Screening (Journal of the National Cancer Institute 2009)

Ductal Lavage in Women from BRCA1/2 Families: Is There a Future for Ductal Lavage in Women at Increased Genetic Risk of Breast Cancer? (Cancer Epidemiol Biomarkers Prev. 2009) “CONCLUSIONS: Ductal lavage is unlikely to be useful in breast cancer screening among BRCA1/2 mutation carriers because the procedure fails to yield adequate specimens sufficient for reliable cytologic diagnosis or to support translational research activities.”

MRI of the breast: does the internet accurately report its beneficial uses and limitations? (Breast J. 2009) “The reading level was close to high school graduate. Internet sites describing breast MRI were mostly commercially sponsored, more often described the potential beneficial uses of the procedure than its limitations, and were of variable quality and high reading level. With the lack of enforceable standards for display of medical information on the Internet, providers should encourage patients to direct their searches to the most credible sites.”

Screening for breast cancer with mammography. (Cochrane Database Syst Rev. 2009)

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement (Annals 2009)

The predictive value of incidental PET/CT findings suspicious for breast cancer in women with non-breast malignancies. (Am J Surg. 2009)

The role of MRI in breast cancer screening. (J Natl Compr Canc Netw. 2009) “The NCCN now recommends considering breast MRI as an adjunct to annual mammography and clinical breast examination for women who have a BRCA1 or -2 mutation or who have a first-degree relative who has a BRCA1 or -2 mutation but who have not undergone genetic testing themselves; those who are determined to have a lifetime risk greater than 20% based on models that are highly dependent on family history; and those with a history of lobular carcinoma in situ. MRI is also recommended for patients who underwent radiation treatment to the chest between 10 and 30 years of age, and in those who carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni, Cowden, and Bannahyan-Riley-Ruvalcaba syndromes). MRI is specifically not recommended for screening women at average risk for breast cancer.”

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