Introduction to breast cancer

Statistics
Breast cancer is the most common malignancy in women among American
women. About 1 in 8 women in the United States (US) will develop invasive
breast cancer in their lifetime. It is estimated that in 2015, there would be
about 231, 840 new cases of breast cancer diagnosed, about 60, 290 new
cases of carcinoma in situ diagnosed and nearly 40, 290 women will die from
breast cancer (1). The mortality rates had decreased as a result of early
detection and improved treatment. After the women are diagnosed with
breast cancer, they have increased risk of developing a contralateral breast
cancer (CBC) (2). However, this risk depends of many factors such as tumor
biology, adjuvant theraphy and oncogenetics.
Surveillance, Epidemiology, and End Results Program (SEER) data from the
US (3) has reveals about 150% increase in rates of contralateral prophylactic
mastectomy (CPM) among women with unilateral breast cancer, over a
decade. This trend had been observed around the US excluding the Europe
(4). This high rise is maybe due to increased risk rates among selectively
vulnerable women. Usually, women with unilateral breast cancer will not
develop contralateral breast cancer during their lifetime (5) and obtained no
benefits if they do CPM (6). Furthermore, the potential benefit of CPM in
reducing breast cancer mortality has not been adequately studied. In patient
diagnosed with breast cancer with positive gene mutation, CPM inproved the
overall survival but does not improved breast cancer-specific survival (7).
The improvement in overall survival came from a reduction in the occurrence
of ovarian cancer in these patients.
Risk factors for breast cancer
The incidence of breast cancer increases with age, doubling about every 10
years until the menopause, when the rate progressively decreasing. The
incidence of breast cancer is higher in younger age groups. Women who start
menstruating early in their life or those who have a late menopause have an
increased risk of developing breast cancer.
Some studies revealed that up to 10% of breast cancer in Western countries
associated with genetic predisposition. Breast cancer susceptibility is
generally inherited as an autosomal dominant with limited penetrance. Some
family members may transmit the abnormal gene without developing cancer
themselves. BRCA 1 and BRCA 2 are two breast cancer genes identified in

high risk families; those with four or more breast cancers among close
relatives. Molecular screening to detect mutations in these genes is
demanding in the high risk patients. A womans risk of breast cancer is about
two timer greater or more if she has first degree relatives who develop the
disease before the age of 50. The risk increases by four to six times of two
first degree relatives develop the disease.
Women that have previous history of presence of proliferative changes such
as severe atypical epithelial hyperplasia have a four to five times risk to
develop breast cancer. In patients having palpable cysts, complex
fibroadenomas, duct papillomas, sclerosis adenosis and moderate or florid
epithelial hyperplasia, they have slightly higher risk of breast cancer (1.5-3
times) than other women without these changes.
There is small increase in relative risk of developing breast cancer in women
taking oral contraceptives and stopping the medications for 10 years.
Woman who begin the medications before age of 20 have a higher risk than
women who begin the oral contraceptive use at older age (Table 1).

Table 1 reveals relative risk of breast cancer in relation to use of oral

contraceptives.
Source: Breast cancer- epidemiology, risk factors, and genetics (8)
Diagnosis
The diagnosis of breast cancer is based on clinical examinations, radiological
imaging and pathological examinations. Clinical examinations include
bimanual palpation of the breasts and local regional lymph nodes. In
radiological imaging, physicians may request to do bilateral mammography
of the breasts and ultrasound of the breasts and local regional lymph node.
MRI is not one of the routine procedures, but it can be included in cases that

have diagnostic challenges. Pathological examinations should be done by

taking core needle biopsy manually or preferably with ultrasound or
stereotactic guidance. Other alternatives include at least fine needle
aspiration; indicating carcinoma should be obtained before any surgical
operations. All pathological findings of biopsy should be assessed according
to the World Health Organization (WHO) classification and the tumor-nodemetastases (TNM) staging system analyzing all tissues removed. (9)
Staging and risk assessment
Patient- related staging examinations include complete personal medical
history, family history relating to breast/ovarian and other cancers, physical
examinations, performance status, full blood count, liver and renal function
tests, alkaline phosphatase and calcium. Preoperatively, physicians should
include clinical TNM staging and pathological examinations of the core
needle biopsy in determine the stage of breast cancer. Postoperatively, the
physician should include the characteristics of tumor in the tissue removed
and performed beneficial follow up to the patient to exclude any metastases
(9).
Treatment plan
Breast conserving surgery (BCS) is beneficial in case of intraductal
carcinoma, along with excision of safety margin; provided that the cancer is
localized. However, BCS is not the only absolute treatment. Other surgical
modality is BCS with mastectomy. Adjuvant breast irradiation after BCS
decreases the risk of local recurrence but has no effect on survival. In cases
of invasive breast cancer, the tumor is operated by using BCS or
mastectomy, both should be followed with sentinel node biopsy (SNB) alone,
SNB followed with axillary dissection or axillary dissection without SNB,
depending on clinical situation. Post- mastectomy radiotheraphy is always
recommended for patients with four or more positive axillary nodes and
indicated for patient with T3, T4 tumors independent of nodal status (9).
Follow up
The aims of follow up are to detect early possible local recurrences or
contralateral breast cancer and to evaluate any possible treatment related
complications (such as menopausal symptoms and osteoporosis). Treatment
needed to be given to the patients. Psychological support and information
need to be provided in order to enhance returning to normal life after breast
cancer (9).

References
1. http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancerkey-statistics
2. I. M. Lizarraga, S. L. Sugg, R. J. Weigel, and C. E. H. Scott-Conner. Review of
risk factors for the development of contralateral breast cancer. The American
Journal of Surgery, vol. 206, no. 5, pp. 704708, 2013.
3. T. M. Tuttle, E. B. Habermann, E. H. Grund, T. J. Morris, and B. A. Virnig.
Increasing use of contralateral prophylactic mastectomy for breast cancer
patients: a trend toward more aggressive surgical treatment. Journal of
Clinical Oncology, vol. 25, no. 33, pp. 52035209, 2007.
4. U. Gth, M. E. Myrick, C. T. Viehl, W. P. Weber, A. M. Lardi, and S. M.
Schmid. Increasing rates of contralateral prophylactic mastectomya trend
made in USA. European Journal of Surgical Oncology, vol. 38, no. 4, pp. 296
301, 2012.
5. McDonnell SK, Schaid DJ, Myers JL, et al. Efficacy of contralateral
prophylactic mastectomy in women with a personal and family history of
breast cancer. J Clinical Oncology 2001; 19(19):3938-3943
6. Hamm RM, Lawler F, Scheid D. Prophylactic mastectomy in women with a
high risk of breast cancer. N England J Med 1999;340(23):1837-1838;author
reply 9
7. Van Sprundel TC, Schmidt MK, Rookud MA, et al. Risk reduction of
contralateral breast cancer and survival after contralateral prophylactic
mastectomy in BRCA1 or BRCA2 mutation carriers. Br J Cancer. 2005;
93(3):287-292
8. K McPherson, C M Steel, J M Dixon. Breast cancer- epidemiology, risk
factors and genetics. BMJ. 2000 Sep 9; 321 (7261): 624-628.
9. V. Kataja, M. Castiglione. Primary breast cancer: ESMO Clinical
Recommendations for diagnosis, treatment and follow up. Annals of
Oncology 20 (Supplement 4): iv10-iv14, 2009 doi: 10.1093/annonc/mdp114