Breast Cancer Education

Breast cancer survival is improving each year due to advancement in surgical techniques, improved tumor suppressing drugs and chemotherapy as well as more targeted radiation methods. Since 1990, deaths from breast cancer have declined by 34%. This is due to early detection via increased use of mammograms as well as a drop in the use of menopause hormone therapy following the Woman’s Health Initiative Study which found the use of these hormones increase the risk of breast cancer and uterine cancer.

It is estimated that 1 in 8 women in the United States will develop breast cancer during their lives. White women are more likely to develop breast cancer but the mortality rate is higher among African American women. Trends for newly diagnosed cases of breast cancer have remained stable since 2002; however death rates have been falling by almost 2% per year. The latest data available from the National Cancer Institute indicates that the 5 year breast cancer survival rate is now almost 90%.

There is estimated to be 235,000 new cases of cancer diagnosed this year with 2,360 of these being male.

Breast cancer is usually detected when a mass or lump is found through a physical breast examination or as a result of an imaging test such as a mammogram. Most lumps detected are not cancer but further testing must be done to rule out cancer.

Other symptoms of breast cancer are:

• Sudden discharge from the nipple
• Itchy, scaly rash on the nipple
• Swelling or redness
• Change in shape or size of a breast
• Puckering or dimpling of the skin on the breast
• Pain in one spot that does not go away

These symptoms can be due to other factors but must be thoroughly checked out by a breast specialist to properly identify the source of these symptoms.

There is no ONE cause of breast cancer. Environmental factors, drugs, behavioral choices and genetics all play a role. The majority of women who develop breast cancer have no identifiable risk factors other than being a woman in the western hemisphere in the 21st century.

Dr. Memsic

The strongest risk factors for breast cancer are one’s sex and one’s age. Breast cancer is 200 times more common in women than men and 400 times more common in women age 50 than women age 20.

Some women do have additional risks:

• Caucasian and Jewish women have the highest incidence of breast cancer;
• Women of color have a lower rate of breast cancer but a higher mortality;
• Asian women have the lowest risk of breast cancer.

It is interesting to note that genetics and environment are connected in the development of breast cancer. Once Asian women move to the United States, their risk of getting breast cancer rises for every year of residence.

Women with a history of breast cancer have a lifetime increased risk of getting another breast cancer. Due to this increased risk, these women must continue to be monitored closely for the duration of their lives for early signs of a recurring or new cancer life. Five year survival history is very encouraging but not completely foolproof. Women with a history of breast cancer may develop a second cancer or a recurrence of the original cancer after more than 20 years. It is vital to know your risks so that you can modify what you can, and monitor what you cannot.

Family history of breast cancer, especially if associated with ovarian cancer, increases the risk of breast cancer, though hereditary breast cancer accounts for only 5-10% of cases. There may be other, as yet, undiscovered genes that increase the risk of breast cancer. However, most breast cancer is thought to be a spontaneous mutation of cells related to environmental carcinogens such as pollution or chemical exposure, as well as genetic makeup.

A woman with a strong family history of breast cancer should be tested with the BRCA genetic test for the presence of the BRCA 1 and BRCA 2 genes. These are genes that produce tumor suppressing proteins. These proteins repair damaged DNA which ensures that the cells function properly. If either of these genes are mutated, DNA may not be repaired properly which can lead to cancer.

Although less than 10 percent of women with breast cancer have this gene, there is an extremely high risk of developing breast, ovarian, colon, lung and pancreatic cancers for those who test positive for these genes. As unwelcome as this result is, knowledge of this risk factor opens the door to the various preventative treatment options available. Aggressive surveillance in the form of diagnostic imaging, physical exam and blood work is indicated. Another preventative treatment is the use of Tamoxifen anti-hormone drug therapy, which controls hormone receptors in cells. Surgery may also be indicated to proactively remove the site of a future cancer.

Since the majority of women who get breast cancer do not have the BRCA gene mutation, absence of it does not guarantee that you will not get breast cancer. Discussion with a breast cancer specialist will determine whether or not you should be tested for the mutation and what your treatment options are, should you carry the mutation.

Dense and cystic breasts make mammograms less accurate at finding early cancers; Lumpy breasts and multiple breast biopsies for even benign masses indicate a “proliferative” or lump making breast which slightly increases the risk of developing breast cancer. Additional imaging studies such as breast ultrasound and MRI as well as more frequent physical exams by a health professional may be recommended.

Atypical ductal or lobular hyperplasia (ADH, ALH), identified by biopsy, also increases the risk of developing breast cancer. Lobular carcinoma in situ is considered a marker indicating increased risk for breast cancer, but is not itself a cancer. Increased surveillance is recommended. More aggressive treatment may be indicated if additional risk factors are identified in an individual.

Nulliparity means a woman has never had children. Pregnancy interrupts the hormone cycle and decreases the risk of breast cancer, particularly if a woman has her children before age 30. Women who have never had children, and to a lesser extent, those who have had children later in life, have a slightly increased risk of developing breast cancer. The younger a woman starts menstruating and the older a woman enters into menopause is relative to the risk of developing breast cancer. The longer one is exposed to hormones increases the risk of breast cancer. Hormones clearly play a role.

The lifetime reduction in breast cancer associated by bilateral oophorectomy (removal of the ovaries) before age 40 is about 50 percent. Removing ovaries in adolescence appears to prevent breast cancer entirely; however this is not feasible or recommended. Breast feeding has a modest protective effect.

Dr. Memsic

Postmenopausal hormones, particularly the combination of estrogen and progesterone, increase the risk of breast cancer. This is especially true if hormones are taken longer than 10 years. Premenopausal hormones such as birth control pills do not seem to increase the risk of breast cancer significantly, if at all and they definitely decrease the risk of ovarian cancer. Birth control pills taken after menopause act as postmenopausal hormones and do have added risk not found in the younger women. The hormone regimens given to treat infertility have not been studied adequately to come to any conclusions regarding their cancer risk.

Excess body fat is a risk factor in multiple cancers including breast cancer. Postmenopausal obese women have at least twice the risk of breast cancer as their ideal weight peers. Estrogen is stored in body fat, and it is felt that these higher estrogen levels in obese postmenopausal women may contribute to their increased risk.

Regular moderate EXERCISE (30 minutes 3 times a week) has been shown to decrease the risk of breast cancer independent of weight loss.

The size of a breast cancer and whether or not it has spread to an axillary (armpit) lymph node are the important features of a cancer which have traditionally been used to predict a tumor’s aggressiveness and on which treatment has been based. Recent advances in technology that analyze a cancer’s molecular makeup are proving more accurate in providing prognostic (predictive) and therapeutic information. Specific information relating to a tumor enables a specific individualized treatment targeted to a specific case. This minimizes under- and over-treating a patient and optimizes the curing process, while avoiding unnecessary therapy with potential side effects.

Normal breast tissue contains estrogen and progesterone hormone receptors. The closer a breast cancer resembles normal breast tissue, the more favorable and less aggressive that tumor is. All breast cancers are evaluated for estrogen and progesterone receptors. Tumors are also evaluated for the number of cells that are dividing (Ki67) and how much they look like normal breast tissue. The lower the Ki67, and the fewer cells dividing, the better.

A tumor which is “well differentiated” looks more like breast tissue than one that is “poorly differentiated” and has a more favorable prognosis.

“HER2/neu” is a gene found in a small percentage of breast cancers (10-20%) that indicates an aggressive cancer which generally always requires intravenous chemo therapy in addition to a specific anti-HER2/neu drug like Herceptin.

The pathologist also looks for vascular (blood vessels) and lymphatic “invasion” in which tumor cells are traveling outside the mass. Absence of vascular or lymphatic invasion is favorable.

After lumpectomy or mastectomy, MARGINS are included in the pathology report confirming whether or not all the cancer has been removed. Lymph nodes are analyzed for cancer involvement as part of the analysis.

All this information is included in the pathology reports. Some may be on the biopsy report with the remainder on the final surgical report. Ask your surgeon or oncologist to review this information with you so you have an understanding of your personal tumor characteristics. This will help you better understand and participate in the decisions regarding your breast cancer treatment.