[MOL] Deucational Series -Cancer/Breast Cancer [00699] Medicine On Line


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[MOL] Deucational Series -Cancer/Breast Cancer



Causes and risk factors:

Many factors are known to increase the risk of development of breast cancer:


Signs and Symptoms:

More women are now being diagnosed by means of a routine mammogram. Others may feel a lump in the breast or notice abnormal discharge from the nipple, or feel thickness or swelling of the skin or nipple. It is frequently diagnosed by a physician during a routine breast examination.

Any lump in the breast and any mammogram abnormality must be studied very carefully. If any degree of suspicion exists as to the nature of the lump, it should be biopsied. This may be accomplished by Fine Needle Aspiration, a Core Biopsy or Surgical Biopsy.


Staging:

What is the extent of cancer? How advanced is the cancer? What areas of the body are involved? Has the cancer spread to lymph glands, bones, liver, etc.? Resolving these questions is referred to as staging. These are the most important questions to be answered prior to an effective treatment plan being implemented. The answers to these questions should be obtained by a minimal amount of tests and by least invasive methods.

Once the diagnosis is established, the next step is determination of the extent of the disease and appropriate treatment planning. A cancer specialist should be engaged to plan for proper testing and studies. A chest x-ray is always a routine part of workup. Further tests will depend on the findings by the physician and his intuition. Other x-rays, CT scans, Bone scan, MRI study, etc. are performed to determine the extent of the cancer.


Treatment

Treatment of breast cancer is discussed in a different page. Please click here to go there.


Pattern of Spread, Natural History

If breast cancer is left untreated, or fails to respond to treatment, it will progress in a gradual fashion and may involve any of the following areas or cause any of the following complications:


Pathological Types

Breast cancer's appearance under microscope is categorized into two major groups with two totally different behavior patterns:

Invasive breast cancer refers to the most common type of breast cancer, which we have already discussed.

Non-Invasive breast cancers are significantly less aggressive than regular breast cancers and there are two distinct diseases in this category:


Prognosis

The outcome of breast cancer depends on a variety of factors.

Good prognostic factors are:

Poor prognostic factors are;


Family Member issues

First degree relatives of all patients with this cancer should be monitored carefully.  This cancer has a tendency to run in families and be associated with genetic abnormalities, for which they can be tested for.  Family members should consider genetic counseling to determine their risk and possible work up for early detection of the cancer.


 

Treatment of Breast cancer

Every breast cancer patient should preferably be seen by a Surgeon, Medical Oncologist, Radiation Oncologist and Plastic Surgeon before anything is done. Then a treatment plan has to be made and implicated by each member of the team. Different strategies have to be explained an discussed with the patient and her input has to direct the course of treatment.

This is a very difficult thing for the patients to do. Imagine a woman being just diagnosed with breast cancer. The anxiety and depression levels are so high at the onset,. However, this is the most important time for a group effort to treat her problem. In best case scenario, the first physician who sees her will arrange for all her care, but unfortunately, this is not the case for every patient. Some patients suffer from inefficiencies of our healthcare system and receive less than adequate care.

There are two important aspects to the treatment and control of the breast cancer

  1. Local control and treatment of the breast itself
  2. Systemic Control of the illness.

1- Local Control is achieved by surgery, whereby surgeon will attempt to remove the tumor as well as some normal tissue around the tumor. The extent of surgery on the breast will depend on the size and location of of tumor as well as the size of the breast. Another aspect of surgery is removal of the lymph glands from the area under the arm on the same side as cancer is diagnosed. The findings, and status of these lymph glands, in respect to cancer involving them, is the most important determining factor for further care of patients. Some complementary laboratory tests are also performed on the cancer tissue in order to determine the presence or absence of receptor molecules to Estrogen (ER) or Progesterone (PR) (female sex hormones) as well as genetic and chromosome studies.

Mastectomy is complete removal of one breast and some surrounding tissues. This is done under general anesthesia and in a hospital setting.

Lumpectomy is partial removal of the breast tissue that contains the cancer, whereby most of the breast architecture is preserved. Since some cancer cells may be left behind with this procedure, the reminder of the breast has to be treated with radiation to achieve similar results as with Mastectomy.

2- Systemic Control is achieved by Chemotherapy or Hormonal treatments. Whether or not there is a need for chemotherapy is a question that is best answered by Medical Oncologist. He has to determine the risk of recurrence of the cancer and gauge the benefits and side effect of this treatment. The determination of the necessity for Chemo or hormonal therapy is dependent on the following factors

Following is a list of common rules and guidelines to assess the needs for Chemo or hormone therapy:

Rule # 1: The younger the patient, the more aggressive the treatment, with the goal being to cure the disease. This is achieved by aggressive chemotherapy or even bone marrow transplantation.

Rule # 2: Hormone treatment for patients with positive hormone receptor tumors, ER+, PR+

Rule # 3: All women with any stage of breast cancer, regardless of extent of initial disease should be considered for adjuvant chemotherapy. This includes hormone positive, node negative disease.

Systemic treatment of each patient has to be tailored to her specific situation. Click here for some examples.

Chemotherapy for Breast cancer


Long Term Complications

Osteoporosis is one of the most important complications of chemotherapy. It is due to ovarian failure and  premature menopause.

Coronary Artery Disease is also due to ovarian failure.  These complications can be managed by hormone replacement therapy using Estrogens.


Chemotherapy for Breast Cancer

The medical oncologist will be in charge of the patient's chemotherapy. He will take time with his patients to educate them regarding this illness and treatment options. He should explain the details of chemotherapy regimens, potential side effects and any long-term ill effects. Patients should feel comfortable to discuss their problems with him and he should be available to them at all times.

There are a few established regimens of chemotherapy for breast cancer including CMF and CAF. Other new active drugs are Taxol,Taxotere Topotecan. Some older drugs are Mitomycin, Alkeran, Velban, Vincristine, Mitoxantrone.

With rare exceptions, every patient should have a Port-A-Cath to receive chemotherapy. These regimens are outpatient regimens which are administered in the oncologist's office or in a hospital outpatient setting.