Breast Cancer


Student 1, Student 2

Background Information


(from The National Cancer Institute (2005) Breast Cancer Information, www.cancer.gov/cancertopics/types/breast)

Breast cancer is the most common cause of cancer in women and the second most common cause of cancer death in women in the U.S. While the majority of new breast cancers are diagnosed as a result of an abnormality seen on a mammogram, a lump or change in consistency of the breast tissue can also be a warning sign of the disease. Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and a resultant improvement in survival rates. Still, breast cancer is the most common cause of death in women between the ages of 45 and 55. Although breast cancer in women is a common form of cancer, male breast cancer does occur and accounts for about 1% of all cancer deaths in men.Research has yielded much information about the causes of breast cancers, and it is now believed that genetic and/or hormonal factors are the primary risk factors for breast cancer. Staging systems have been developed to allow doctors to characterize the extent to which a particular cancer has spread and to make decisions concerning treatment options. Breast cancer treatment depends upon many factors, including thee type of cancer and the extent to which it has spread. Treatment options for breast cancer may involve surgery (removal of the cancer alone or, in some cases, mastectomy), radiation therapy, hormonal therapy, and/or chemotherapy.With advances in screening, diagnosis, and treatment, the death rate for breast cancer has declined by about 20% over the past decade, and research is ongoing to develop even more effective screening and treatment programs.

Biology of the Disease

(from the National Breast Cancer Foundation (2005), http://www.nationalbreastcancer.org)

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.Tumors can be benign or malignant. Benign tumors are not cancer: Benign tumors are rarely life-threatening. Generally, benign tumors can be removed. They usually do not grow back. Cells from benign tumors do not invade the tissues around them. Cells from benign tumors do not spread to other parts of the body.

Malignant tumors are cancer: Malignant tumors are generally more serious than benign tumors. They may be life-threatening. Malignant tumors often can be removed. But sometimes they grow back. Cells from malignant tumors can invade and damage nearby tissues and organs. Cells from malignant tumors can spread (metastasize) to other parts of the body. Cancer cells spread by breaking away from the original (primary) tumor and entering the bloodstream or lymphatic system. The cells invade other organs and form new tumors that damage these organs. The spread of cancer is called metastasis.When breast cancer cells spread, the cancer cells are often found in lymph nodes near the breast. Also, breast cancer can spread to almost any other part of the body. The most common are the bones, liver, lungs, and brain. The new tumor has the same kind of abnormal cells and the same name as the primary tumor.

Symptoms and Treatments

(from The Mayo Clinic (2004) Breast cancer symptoms and treatments,www.mayoclinic.com/health/breast-cancer)

Common symptoms of breast cancer include:
  • A change in how the breast or nipple feels A lump or thickening in or near the breast or in the underarm area Nipple tenderness
  • A change in how the breast or nipple looks A change in the size or shape of the breast. A nipple turned inward into the breast The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
  • Nipple discharge (fluid)Early breast cancer usually does not cause pain. Still, a woman should see her health care provider about breast pain or any other symptom that does not go away. Most often, these symptoms are not due to cancer.

Other health problems may also cause them. Any woman with these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

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Treatment choices by stage
  • Your treatment options depend on the stage of your disease and these factors:
  • The size of the tumor in relation to the size of your breast
  • The results of lab tests (such as whether the breast cancer cells need hormones to grow)
  • Whether you have gone through menopause
  • Your general health

Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS)

LCIS: Most women with LCIS do not have treatment. Instead, the doctor may suggest regular checkups to watch for signs of breast cancer.Some women take tamoxifen to reduce the risk of developing breast cancer. Others may take part in studies of promising new preventive treatments.Having LCIS in one breast increases the risk of cancer for both breasts. A very small number of women with LCIS try to prevent cancer with surgery to remove both breasts. This is a bilateral prophylactic mastectomy. The surgeon usually does not remove the underarm lymph nodes.

DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some women choose to have a total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.

Stages I, II, IIIA, and operable IIIC. Women with Stage I, II, IIIA, and operable (can treat with surgery) IIIC breast cancer may have a combination of treatments. Some may have breast-sparing surgery followed by radiation therapy to the breast. This choice is common for women with Stage I or II breast cancer. Others decide to have a mastectomy.With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in 1 to 3 lymph nodes under the arm, or if the tumor in the breast is large. If cancer cells are found in more than 3 lymph nodes under the arm, the doctor usually will suggest radiation therapy after mastectomy.The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors: The size, location, and stage of the tumor The size of the woman's breast Certain features of the cancer How the woman feels about saving her breast How the woman feels about radiation therapy The woman's ability to travel to a radiation treatment centerSome women have chemotherapy before surgery. This is neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.

Stages IIIB and inoperable IIIC. Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer usually have chemotherapy. (Inoperable cancer means it cannot be treated with surgery.)If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment: Mastectomy: The surgeon removes the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the chest and underarm area. Breast-sparing surgery: The surgeon removes the cancer but not the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the breast and underarm area. Radiation therapy instead of surgery: Some women have radiation therapy but no surgery. The doctor also may recommend more chemotherapy, hormone therapy, or both. This therapy may help prevent the disease from coming back in the breast or elsewhere.Stage IVIn most cases, women with Stage IV breast cancer have hormone therapy, chemotherapy, or both. Some also may have biological therapy. Radiation may be used to control tumors in certain parts of the body. These treatments are not likely to cure the disease, but they may help a woman live longer.Many women have supportive care along with anticancer treatments. Anticancer treatments are given to slow the progress of the disease. Supportive care helps manage pain, other symptoms, or side effects (such as nausea). It does not aim to extend a woman's life. Supportive care can help a woman feel better physically and emotionally. Some women with advanced cancer decide to have only supportive care.

Recurrent breast cancer. Recurrent cancer is cancer that has come back after it could not be detected. Treatment for the recurrent disease depends mainly on the location and extent of the cancer. Another main factor is the type of treatment the woman had before.If breast cancer comes back only in the breast after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again.If breast cancer recurs in other parts of the body, treatment may involve chemotherapy, hormone therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body.Treatment can seldom cure cancer that recurs outside the breast. Supportive care is often an important part of the treatment plan. Many patients have supportive care to ease their symptoms and anticancer treatments to slow the progress of the disease. Some receive only supportive care to improve their quality of life.

Diagnostic Testing

These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.Clinical breast examYour health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram. Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.Doctors can remove tissue from the breast in different ways: Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab. Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy. Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells. An incisional biopsy takes a sample of a lump or abnormal area. An excisional biopsy takes the entire lump or area.If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

Case A Description

While Elizabeth is reading the morning newspaper, she notices an ad for a free genetic screening for breast cancer at the clinic next week. The ad specifically invites women of Ashkenazi Jewish ancestry to participate. According to the newspaper ad, subjects will be tested to see whether they have mutations in the BRCA1 gene which would predispose them to breast cancer. Elizabeth, age 27, had heard about the discovery of the gene and about the mutation linked to Jewish women. Her paternal grandmother had been diagnosed with breast cancer at age 51 and died two years later, and Elizabeth worried that she had inherited the disease. She also worried about her mother, age 52 and apparently cancer-free so far, and her 7-year old daughter. Her daughter is not allowed to participate in the screening, but Elizabeth convinces her mother to go with her to get tested.

Case A Results

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Case A Statement to Family

The tests came back that both Elizabeth and mother have the 185 mutation. This means that you are both at high risk and need to take good care of your bodies. You can do self examines as well as meet with your doctor regularly. I wish the best for you both and we all hope for a positive outcome.

Case B Description

The time passes slowly as Deborah waits for Aunt Millie to come out of surgery. It had come as no surprise when Aunt Millie was diagnosed with breast cancer. After all, for as long as Deborah could remember, her mother had talked about how breast cancer “ran in the family.” Deborah has already read the literature the doctor gave them about genetic testing for breast cancer susceptibility genes. It is one thing to know that several women in her mother’s family had developed breast cancer; it is quite another to learn that Aunt Millie has tested positive for such a gene and therefore, Deborah and her mother are at higher risk. Her mother has made it clear that she has no intention of being tested but as Deborah sits in the surgery waiting room, she comes to the inevitable conclusion that she has to find out if she carries the gene.

Case B Testing Results
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Case B Statement to Family

I am happy to say that Deborah's test came back clear of mutations, but this just means you are low risk, you should still have your regular check ups and do self examines and comtinue to take care of your body. Unfortunetly for Aunt Millie you tested positive for one mutation, and we will continue to do more tests. We all are here to help you and we will help you to overcome this disease.

Case C Description

  • Cindy took the news very hard when her mother was diagnosed with breast cancer. The surgery and chemotherapy her mother has gone through have taken a significant toll on the whole family. Discovering that the breast cancer is related to the presence of a breast cancer susceptibility gene has only added to the concern. Cindy’s sister, Ellen, decided to have genetic testing done to determine if she carried the gene, but Cindy chose not to go with her for testing. The news that Ellen tested positive was devastating to Cindy and it has been even more difficult to accept Ellen’s subsequent decision to have a prophylactic double mastectomy. These events have caused Cindy to reevaluate her decision not to be tested; she almost feels an obligation to go through this experience for her sister. She schedules the appointment for testing, still undecided how she will react if the test is positive.

Case C Testing Results

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Case C Statement to Family

  • For Cindy you have tested negative for the 3 mutations, but this just means you have a low risk and may develop it in the future, so continue to your self examines and see the doctor regularly, also maintain a healthy diet and continue to take care of your body.As you already know mother has been tested and diagnosed and as for Ellen we regret to inform you that you also have tested positive, it has not developed quite yet but you should have regular check ups and maintain a healthy diet. We all hope the best for all of you.


References

www.wikipedia.com
www.nationalbreastcancer.org
www.mayoclinic.com/health/breast-cancer
www.cancer.gov/cancertopics/types/breast