Breast Cancer (Mammary Carcinoma)

Breast cancer is the most common malignancy in women, and second only to lung cancer in female cancer mortality. Presently, about one in nine American women develops this disease at some time in her life, compared to one in 17 in 1950. Experts are uncertain whether this represents a true rise in the incidence of breast cancer or improved detection of it due to mammography and better public awareness.

The risk of breast cancer increases with age, especially after menopause. Risk is also higher among women who had their first child after age 30 or never had children; already have had cancer in one breast; had an early first menstrual period or a late menopause; or have a close relative, such as a sister or mother, who was diagnosed with breast cancer before menopause.

Some studies have linked a high-fat diet to an increased risk of breast cancer, but others have shown otherwise. Cancer specialists emphasize that about 70 percent of all cases of breast cancer arise in women with none of the above risk factors. In rare instances, men also develop breast cancer, accounting for less than five percent of occurrences.

Diagnostic Studies and Procedures

Early detection is the single most important factor in surviving breast cancer, because early, localized malignancies are more than 90 percent curable. The American Cancer Society (ACS) recommends that all women age 20 or older perform a monthly self-examination of their breasts. Although more than percent of the lumps found by women during self-examination are benign, women initially discover more than 85 percent of all breast cancers.

Breast examination by a physician is recommended every three years between the ages of 20 and 40 and annually thereafter. The age at which a woman should begin regular screening with mammography remains controversial. Present guidelines from the National Cancer Institute recommend starting annual mammography at age 50, but many cancer experts advocate beginning at age 40. There is no doubt, however, that mammography is the most effective means of early breast cancer detection in women over 50 because it can locate suspicious areas of calcification, a common sign of cancer, long before a tumor is large enough to be felt by a woman or her doctors. Mammography is not as effective in younger women because they have denser, lumpier breasts, making it harder to discern normal from abnormal tissue.

Mammography should be scheduled for the week after menstruation, when breasts are unlikely to be swollen and painful, to help assure an accurate mammogram and avoid repeats, no deodorant, powder, cream, or other substance should be applied to breasts or the underarm area that day because they can cause misleading results.

If any suspicious areas are found by mammography or physical examination, a biopsy is necessary to rule out cancer. In most cases, a doctor will attempt to obtain a tissue sample by aspiration, a procedure in which a hollow needle is inserted into the lump. If fluid can be withdrawn, it will be analyzed for malignant cells, but such lumps, especially those that disappear after aspiration, are usually harmless cysts. If a lump returns rapidly, no fluid can be withdrawn, or malignant cells are detected in the fluid, another biopsy is necessary. Again, this may be done by needle. With a new procedure called stereotaxic needle aspiration, a special X-ray scanning technique is used during aspiration to locate suspicious areas too small to be felt.

In some cases, a surgical biopsy is necessary. This may be excisional, in which the entire mass is removed, or incisional, in which only part of the lump is taken out. A pathologist will then determine whether the tissue is cancerous, and if so, what kind of cancer it is. Cells from a cancerous lump will also be tested to determine if they are stimulated by estrogen or progesterone, a finding that may influence the choice of anticancer drugs.
If breasi cancer is diagnosed, additional tests are needed to find out if it has metastasized to other parts of the body. These may include a bone scan. X-rays, and sampling of lymph nodes.

Medical Treatments

Surgery. Treatment varies according to the type and stage of cancer, but surgery remains the first choice for most tumors. The majority of operations now are less disfiguring than the radical mastectomy that was standard until the 1970s. Operations for breast cancer are:

Extended radical mastectomy involves removal of the breast, underarm lymph nodes, and underlying chest muscles. This procedure, rarely performed today, is reserved for women with large tumors that are attached to or have invaded the chest muscle and its connective tissues. If the mammary lymph nodes deep in the chest are involved, they will also be removed.

Modified radical mastectomy is the removal of the breast, underarm lymph nodes, and sometimes pan of the chest muscle. The amount of tissue removed from the underarm depends on the spread of the tumor. This remains the most common operation for women with invasive breast cancer.

Total, or simple, mastectomy is the removal of the entire breast, including its extensions to the armpit and sometimes near the collarbone. Because the lymph nodes are left intact, radiation therapy usually follows the operation.

Subcutaneous mastectomy involves removing the breast tissue but leaving the skin and nipple intact. A prosthesis is then slipped under the skin to restore normal appearance. This procedure is rarely performed, because it may miss cancer cells and the cosmetic results are often poor.

Lumpectomy or partial mastectomy involves removal of the cancerous lump and a surrounding margin of normal tissue. Some of the armpit lymph nodes are also taken out and examined for spread, and the operation is followed by radiation therapy.

Preventative, or prophylactic, mastectomy is the removal of a breast to prevent the development of cancer. This operation is done only if a woman has a very high risk of breast cancer and is so worried by the prospect that she cannot live a normal life. Breast reconstruction by a plastic surgeon can sometimes be performed immediately following a mastectomy, but more often it is done after the original incision has healed. If the opposite breast is larger, it may be reduced in size to match the reconstructed one, either at the same time as the reconstruction or in a later operation.

In the past, a prosthetic implant filled with silicone gel was the first choice for reconstruction. Because questions have arisen about the long-term safety of silicone, many women are now opting for implants filled with a saline solution, or a more extensive procedure in which fatty tissue from the woman's own buttocks or elsewhere is used to reconstruct a breast.

Radiation Therapy. The purpose of this treatment is to destroy any cancer cells that may have escaped surgical removal. Radiation is routinely administered after a simple mastectomy and a lumpectomy, or if numerous lymph nodes have been affected. It is also prescribed for recurring or inoperable cancer, and to alleviate the pain of advanced cancer.

Typically, radiation treatments are begun two or three weeks after the surgery, or after the scar has healed and the woman has regained the use of her arm. Immediate side effects include blistering of the skin and fatigue. Later, the skin exposed to the radiation may darken, thicken, and lack sensitivity if any nerve endings have been damaged. Long-term complications may include impaired lung function due to scar tissue, an increased risk of heart disease, and easy fracturing of the ribs.

Chemotherapy. Studies indicate that adjunct chemotherapy greatly increases long-term survival, even for women; with localized stage cancer. Chemotherapy may begin before surgery; however, it is usually started a few weeks afterwards. This treatment is also prescribed for recurrent or inoperable cancers.

Chemotherapy appears to be most effective in preventing a recurrence among younger women who have not gone through menopause. The side effects -- loss of hair, nausea, reduced immunity to infections, mouth sores, fatigue, and bleeding problems -- are temporary, but still very trying. For this reason, chemotherapy may not be recommended for an older woman, especially if her cancer is localized.

Hormone Therapy. Cancer specialists now believe that almost all breast cancer patients can benefit from hormone therapy, even if their tumors are not the type stimulated by estrogen or progesterone. Tamoxifen (Nolvadex), a drug that blocks estrogen, is the treatment of choice. It has fewer side effects than anticancer drugs, although it may cause hot flashes and other menopausal symptoms in younger women.
Other, more radical approaches to hormone manipulation include ovarian ablation, a procedure in which the ovaries are either surgically removed or destroyed by chemicals or radiation and perhaps the removal of other hormone-producing glands.

Experimental Treatments. Women with advanced breast cancer may be candidates for experimental therapies such as hyperthermia, in which very high fevers are induced to kill cancer cells; photodynamic therapy, which uses a light-sensitive anticancer drug; and bone marrow transplantation, in which the woman's bone marrow is destroyed by drugs and then replaced with healthy marrow to bolster the body's ability to fight the cancer.

Alternative Therapies

Cancer requires scrupulous medical and surgical treatment. Nonetheless, certain alternative therapies may play an adjunctive role in its care.

Herbal Medicine. Herbalists have long recommended tropical periwinkle to treat breast cancer and other malignancies. Indeed, a periwinkle alkaloid is used to make vincristine, a very potent chemotherapy agent. Oncologists stress, however, that this drug should be used only under careful medical supervision rather than to resort to herbal periwinkle extracts, which can be highly toxic.

Meditation, Self-Hypnosis, and Visualization. Studies indicate that women with advanced breast cancer who participate in group support sessions that include these techniques have significantly longer survival rates than those who do not. Scientists have not yet been able to explain this effect, but some theorize that the methods mobilize the immune system to fight the further spread of cancer.

Nutrition Therapy. Some nutritionists recommend daily supplements of beta carotene (precursor to vitamin A) and vitamins C and E, both to help prevent cancer and to slow its growth. However, studies suggest that foods high in these antioxidants are more effective. Good sources of beta carotene are orange and dark green vegetables and yellow and orange fruits; of vitamin C, many fruits and vegetables, especially citrus fruits and bell peppers; of vitamin E, wheat germ, legumes, seafood, and poultry.

Although the role of other dietary components remains controversial, some studies suggest that a low-fat diet may cut the risk of breast cancer and its recurrence. Such a regimen requires limiting the intake of all fats, especially those from animals, as well as animal protein, while increasing foods high in fiber, such as whole-grain products and fresh fruits and vegetables.

Other nutrition therapists and some naturopaths may recommend extreme macrobiotic and other restricted, low-calorie diets for breast cancer patients. Oncologists warn that these diets should be avoided because they do not provide adequate calories, protein, and other nutrients that the body needs for recovery or to prevent the wasting that occurs in advanced cancer.

Yoga. Regular practice of yoga, meditation, and other relaxation techniques can help alleviate the stress and anxiety caused by cancer, which in turn may boost immune system function.

Self-Treatment

Increasingly, women are expected to play a decision-making role in their overall treatment. This demands being well-informed and not hesitating to question your doctor and voice your concerns. Under the best of circumstances, a diagnosis of breast cancer is psychologically devastating. Joining a support group such as the American Cancer Society's Reach to Recovery program, or simply talking to women who have recovered from breast cancer, can be reassuring.

Concerns about physical appearance following a mastectomy are normal. However, women who do not undergo immediate breast reconstruction are usually relieved to find that, with a well-fit prosthesis, they can wear most of their clothing without anyone being able to tell they have had this surgery.

Initially, use a temporary prosthesis such as cotton fluff inserted into your regular bra, or one that is slightly larger to accommodate bandages. Take this to the hospital with you to avoid the stress of finding something to wear for the trip home. After healing is complete, plan to shop for a permanent prosthesis. Some regular lingerie departments sell breast prostheses, but you may feel more comfortable and find a wider selection at a specialty shop. Make sure that you try on several different types. Prices vary, but many insurance policies and Medicare cover at least part of the cost. If you cannot find a ready-made prosthesis that looks and feels right, consider investing in a customized one made to match exactly the contour of your other breast.

A prosthesis usually is not necessary after a lumpectomy, but a bra should be worn day and night for several days following surgery to prevent traction of the wound and to help the breast regain its previous shape.
Self-help measures can help to minimize common complications affecting the arm and hand on the mastectomy side. To minimize swelling, exercise your arm as soon as your surgeon says it is okay. Lift it as high as you comfortably can several limes a day to promote the flow of lymph. Also, "walk" your fingers up a wall as high as possible and do isometric, or pumping, exercises for the hand such as squeezing a rubber ball. If arm swelling still occurs, talk to your doctor about wearing an elastic sleeve to reduce swelling and improve lymph flow.

If lymph nodes have been removed, the arm and hand on that side are more vulnerable to infection. It is best to avoid anything that constricts or burdens them. Wear loose fitting clothing and switch your watch and purse to the opposite arm. Also have blood drawn or blood pressure measured on the opposite arm. Try to minimize cuts or injuries; for example, use an electric razor if you shave underarm hair; wear protective gloves for gardening and other tasks; and use special care when trimming nails and cuticles.

If you do get a cut or burn, wash it immediately with soap and water and apply an antiseptic plus an antibiotic cream. Consult your doctor promptly if an infection develops.

Other Causes of Breast Symptoms

Many women experience swelling and tenderness of the breasts as part of premenstrual syndrome. Benign fibrocystic breast lumps are also exceedingly common. Nursing mothers often develop mastitis, a bacterial breast infection.