Breast Cancer

This text belongs to the issue of malignant diseases. The article dedicated to cancers can be found here.

 

Breast cancer is one of the most common cancers in the female population. Before we begin the description of causes, symptoms and treatment of this disease, it is appropriate to say a few words about the anatomy of the mammary gland.

 

The mammary gland occurs in embryonic phase of development in both sexes. In males, the mammary gland degenerates and it is not functional under normal circumstances. The existence of male mammary gland however explains the possibility of breast cancer occurrence in men. The breast tissue in women further develops during puberty due to hormone estrogen and also during pregnancy. This is another important information – breast cells are influenced by sex hormones.

 

The breast of an adult woman contains mature mammary gland which consists of lobules (milk production) and milk ducts (milk transport to the surface). All ducts join in the area of nipple. The majority of breast cancers occur from the cells of the milk ducts (ductal carcinoma - about 80% of breast cancers) and only minority occurs from the lobules (lobular cancers - about 15% of malignant breast neoplasms).

 

Breast cancer

 

Scheme - Tumor mass arising from a milk duct

 

Note: As suggested above, breast cancer also affects men, because they also have rudimentary mammary glands. The incidence is about 1 breast cancer in a man to 100 breast cancers in women. Male breast cancer is usually more aggressive and has a generally much worse prognosis than in women. Is it also frequently detected in later stage.

Causes

There are many factors that increase the risk of breast cancer, we shall mention the most frequent and most clinically important.

Age

Age is an important factor. The risk of developing breast cancer increases with age. Can a 20 years old woman have a breast cancer? She can, but the probability is much lower than in a 50 years old woman.

Genetic factors

Genetics has a big impact. We know about some genes that are directly related to breast cancer (for example so-called BRCA-1, BRCA-2). Generally, woman has a higher risk of developing a breast cancer when this malignant disease occurs in her close relatives (mother, grandmother, etc.). Of course, breast cancer can also occur in women with negative family history.

 

Breast cancer is a big problem for Jewish population. It is the result of certain social separation of Jews in medieval Europe (Jewish diaspora), when frequent marriages within a relatively small group of individuals have caused much more frequent occurrence of certain genetically determined diseases such as certain forms of breast cancer.

Estrogen effect

Prolonged effect of estrogen during a woman's life increases the risk of breast cancer. More vulnerable are women who had their first menstrual period at an early age, women who experienced later menopause and women using hormonal preparations aimed to delay the onset of menopause. Users of hormonal contraception have not increased risk of the tumor as the preparation contain large amount of progesterone. Women who become pregnant during their lives have lower risk of breast cancer than childless women. It is also caused by hormone progesterone, whose concentration increases during pregnancy.

Lifestyle

The risk of breast cancer may be higher in smokers, women with excessive alcohol consumption and in obese women with lack of physical exercise.

Types and symptoms of breast cancer

Ductal carcinoma

The cancer is based on the cells of milk ducts and constitutes about 80% of all breast cancers. Tumors of this type usually tend to be more bordered and manifest as small lumps in the breast tissue.

Lobular carcinoma

The cancer cells occur from the lobules where the milk is normally produced. These tumors constitute around 15% of the breast tumors and the finding is more difficult than for ductal carcinoma. Lobular carcinoma forms less rigid and less bordered lesions.

Paget’s carcinoma

This is a rare subtype of ductal carcinoma, which affects the nipple tissue. It looks like an ulcerative lesion located in or around the nipple. The nipple may bleed.

Inflammatory breast cancer

This is one of the deadliest forms of the breast cancer. It is an aggressive subtype of ductal carcinoma, which spreads quickly throughout the breast tissue. The affected breast is swollen, reddish and painful and the condition resembles benign inflammation of breast (mastitis). Therefore, inflammation of the breast in any non-lactating woman must be approached with great caution. This “inflammatory” form of breast cancer is luckily very rare.

 

In addition to all above-mentioned possible local manifestation, the breast cancer can cause various symptoms when it spreads into the body. It can cause painless enlargement of local lymph nodes (usually in the armpits and in the area of collar bone) and form distant metastases. Typical problem is bone pain when the metastases affect vertebral column or other bones. Brain metastases can cause various neurological disorders.

 

Summary: A woman should visit a doctor (gynecologist) when one of her breasts changed its size or color, when it hurts, when its nipple bleeds, or when the woman palpates a breast subcutaneous lump or painlessly enlarged lymph nodes.

Diagnosis

It is crucial to determine the right diagnosis as early as possible. The examination should start with a dialogue with the patient about her (or his!) clinical symptoms. Physical examination should focus on the affected breast (inspection, palpation) and exclusion of local enlarged lymph nodes. It was reported that regular self-examination of breasts by the patient has a much better chance to find a tumor than physical examination by a gynecologist.

 

Any suspicious lump in breast should be examined by an imaging method. We use two common methods – ultrasound and mammography. Ultrasound does not threaten the woman with radiation energy and it is best used in younger women whose breasts contain only little fat.

 

Mammography is probably the most frequently used imaging method. It is suitable for older women whose breasts contain more fat. The mammography is essentially an X-ray that is selectively used to examine the breast tissue. It is great in finding small tumor lesions, but it represents a certain radiation load.

 

When there is found a breast lesion, it is advisable to perform a biopsy by fine needle. The biopsy is performed under ultrasonographic control. The aim is to obtain a sample of tissue for histological examination, which can not only confirm the diagnosis, but also determine the subtype of the tumor and its attributes – it is important for proper therapy.

Prevention

The basic prevention is self-awareness and regular self-examination of breasts by palpation. Many countries have special screening programs that ensure possibility of regular mammographic examination in every woman from certain age. Women with a high genetic risk of breast cancer may undergo special screening programs.

Treatment

Modern medicine has experienced a great progress in therapy of breast cancer, resulting is significant decrease of mortality. There are more therapeutic options that are usually combined to achieve the best effect. The approach is strictly individual.

Surgery

Surgical intervention is the main way of therapy. It aims to remove the tumor tissue with a certain part of the breast tissue. Frequently, the whole affected breast is removed (breast ablation) and the operation may include removal of local lymph nodes from the armpit (axillary exenteration). The lymph nodes should be histologically examined to evaluate their affection by tumor cells.

Radiotherapy

Irradiation is commonly used as a local supplement to surgical therapy. In addition, irradiation of bone metastases is a potent way of palliative therapy due to its analgesic effect. Palliative therapy does not focus on curative treatment and it is used to improve the overall life quality.

Chemotherapy

Chemotherapy is also typically used in combination with surgical solution. Before surgery, it can shrink the tumor and make it better operable. After surgery, it can destroy remaining cancer cells and any distant micrometastases.

Hormonal therapy

Some breast cancer cells retain the capability of the original breast cells to respond to estrogen stimulation by proliferation. In these tumors, we use hormonal therapy. The point is that we give the woman substances that dampen the production of estrogen in her body, or at least block the effect of estrogen on the cells of mammary gland. This therapy significantly slows the tumor growth and makes it much more sensitive to other means of treatment.

Biological treatment

This is a relatively new special way of therapy that is used in some forms of breast cancers to inhibit the proliferation of tumor cells.