Introduction to Breast Care

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The incidence of breast cancer is increasing in the developing world due to increase life expectancy, increase urbanization and adoption of western lifestyles. Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages. Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.

Limited resource settings with weak health systems where breast cancer incidence is relatively low and the majority of women are diagnosed in late stages have the option to implement early diagnosis programmes based on awareness of early signs and symptoms and prompt referral to diagnosis and treatment.

Population-based cancer screening is a much more complex public health undertaking than early diagnosis and is usually cost-effective when done in the context of high-standard programmes that target all the population at risk in a given geographical area with high specific cancer burden, with everyone who takes part being offered the same level of screening, diagnosis and treatment services. So far the only breast cancer screening method that has proved to be effective is mammography screening.

Mammography screening is very costly and is cost-effective and feasible in countries with good health infrastructure that can afford a long-term organized population-based screening programmes. Low-cost screening approaches, such as clinical breast examination, could be implemented in limited resource settings when the necessary evidence from ongoing studies becomes available. Many low- and middle-income countries that face the double burden of cervical and breast cancer need to implement combined cost-effective and affordable interventions to tackle these highly preventable diseases.

WHO promotes breast cancer control within the context of national cancer control programmes and integrated to noncommunicable disease prevention and control.

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Until then, they are protected from cell suicide by several protein clusters and pathways. Sometimes the genes along these protective pathways are mutated in a way that turns them permanently "on", rendering the cell incapable of committing suicide when it is no longer needed. This is one of the steps that causes cancer in combination with other mutations. Mutations that can lead to breast cancer have been experimentally linked to estrogen exposure.

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Abnormal growth factor signaling in the interaction between stromal cells and epithelial cells can facilitate malignant cell growth. In the United States, 10 to 20 percent of people with breast cancer and people with ovarian cancer have a first- or second-degree relative with one of these diseases. The familial tendency to develop these cancers is called hereditary breast—ovarian cancer syndrome. The best known of these, the BRCA mutations , confer a lifetime risk of breast cancer of between 60 and 85 percent and a lifetime risk of ovarian cancer of between 15 and 40 percent.

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These mutations are either inherited or acquired after birth. Presumably, they allow further mutations, which allow uncontrolled division, lack of attachment, and metastasis to distant organs. This is caused by unobserved risk factors. GATA-3 directly controls the expression of estrogen receptor ER and other genes associated with epithelial differentiation, and the loss of GATA-3 leads to loss of differentiation and poor prognosis due to cancer cell invasion and metastasis.

Most types of breast cancer are easy to diagnose by microscopic analysis of a sample—or biopsy —of the affected area of the breast. Also, there are types of breast cancer that require specialized lab exams. The two most commonly used screening methods, physical examination of the breasts by a healthcare provider and mammography, can offer an approximate likelihood that a lump is cancer, and may also detect some other lesions, such as a simple cyst. A needle aspiration can be performed in a healthcare provider's office or clinic. A local anaesthetic may be used to numb the breast tissue to prevent pain during the procedure, but may not be necessary if the lump isn't beneath the skin.

A finding of clear fluid makes the lump highly unlikely to be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous cells. Together, physical examination of the breasts, mammography, and FNAC can be used to diagnose breast cancer with a good degree of accuracy. Other options for biopsy include a core biopsy or vacuum-assisted breast biopsy , [91] which are procedures in which a section of the breast lump is removed; or an excisional biopsy , in which the entire lump is removed. Very often the results of physical examination by a healthcare provider, mammography, and additional tests that may be performed in special circumstances such as imaging by ultrasound or MRI are sufficient to warrant excisional biopsy as the definitive diagnostic and primary treatment method.

High-grade invasive ductal carcinoma, with minimal tubule formation, marked pleomorphism , and prominent mitoses , 40x field. Micrograph showing a lymph node invaded by ductal breast carcinoma, with an extension of the tumor beyond the lymph node. Breast cancers are classified by several grading systems. Each of these influences the prognosis and can affect treatment response. Description of a breast cancer optimally includes all of these factors.

Breast cancer screening refers to testing otherwise-healthy women for breast cancer in an attempt to achieve an earlier diagnosis under the assumption that early detection will improve outcomes. A number of screening tests have been employed including clinical and self breast exams , mammography , genetic screening, ultrasound, and magnetic resonance imaging. A clinical or self breast exam involves feeling the breast for lumps or other abnormalities. Clinical breast exams are performed by health care providers, while self-breast exams are performed by the person themselves. During a screening, the breast is compressed and a technician takes photos from multiple angles.

A general mammogram takes photos of the entire breast, while a diagnostic mammogram focuses on a specific lump or area of concern. A number of national bodies recommend breast cancer screening. For the average woman, the U. Preventive Services Task Force and American College of Physicians recommends mammography every two years in women between the ages of 50 and 74, [12] [] the Council of Europe recommends mammography between 50 and 69 with most programs using a 2-year frequency, [] and in Canada screening is recommended between the ages of 50 and 74 at a frequency of 2 to 3 years.

The Cochrane collaboration states that the best quality evidence neither demonstrates a reduction in cancer specific, nor a reduction in all cause mortality from screening mammography. Women can reduce their risk of breast cancer by maintaining a healthy weight, reducing alcohol use, increasing physical activity, and breast-feeding. Marine omega-3 polyunsaturated fatty acids appear to reduce the risk. Removal of both breasts before any cancer has been diagnosed or any suspicious lump or other lesion has appeared a procedure known as "prophylactic bilateral mastectomy " or "risk reducing mastectomy" may be considered in people with BRCA1 and BRCA2 mutations, which are associated with a substantially heightened risk for an eventual diagnosis of breast cancer.

It is not recommended routinely. Testing in an average-risk person is particularly likely to return one of these indeterminate, useless results. The selective estrogen receptor modulators such as tamoxifen reduce the risk of breast cancer but increase the risk of thromboembolism and endometrial cancer. The management of breast cancer depends on various factors, including the stage of the cancer and the person's age.

Treatments are more aggressive when the cancer is more advanced or there is a higher risk of recurrence of the cancer following treatment.

Screening does not prevent aggressive breast cancer

Breast cancer is usually treated with surgery , which may be followed by chemotherapy or radiation therapy, or both. A multidisciplinary approach is preferable. Monoclonal antibodies, or other immune-modulating treatments , may be administered in certain cases of metastatic and other advanced stages of breast cancer. Although this range of treatment is still being studied.

Surgery involves the physical removal of the tumor, typically along with some of the surrounding tissue. One or more lymph nodes may be biopsied during the surgery; increasingly the lymph node sampling is performed by a sentinel lymph node biopsy. Once the tumor has been removed, if the person desires, breast reconstruction surgery , a type of plastic surgery , may then be performed to improve the aesthetic appearance of the treated site.

Alternatively, women use breast prostheses to simulate a breast under clothing, or choose a flat chest. Nipple prosthesis can be used at any time following the mastectomy. Medications used after and in addition to surgery are called adjuvant therapy. Chemotherapy or other types of therapy prior to surgery are called neoadjuvant therapy. Aspirin may reduce mortality from breast cancer when used with other treatments. There are currently three main groups of medications used for adjuvant breast cancer treatment: hormone-blocking agents, chemotherapy, and monoclonal antibodies. Some breast cancers require estrogen to continue growing.

The use of tamoxifen is recommended for 10 years. Aromatase inhibitors are only suitable for women after menopause; however, in this group, they appear better than tamoxifen. Chemotherapy is predominantly used for cases of breast cancer in stages 2—4, and is particularly beneficial in estrogen receptor-negative ER- disease. The chemotherapy medications are administered in combinations, usually for periods of 3—6 months. One of the most common regimens, known as "AC", combines cyclophosphamide with doxorubicin.

Sometimes a taxane drug, such as docetaxel , is added, and the regime is then known as "CAT". Another common treatment is cyclophosphamide, methotrexate , and fluorouracil or "CMF". However, the medications also damage fast-growing normal cells, which may cause serious side effects.

Damage to the heart muscle is the most dangerous complication of doxorubicin, for example. Radiotherapy is given after surgery to the region of the tumor bed and regional lymph nodes, to destroy microscopic tumor cells that may have escaped surgery. It may also have a beneficial effect on tumor microenvironment.

Conventionally radiotherapy is given after the operation for breast cancer.


Radiation can also be given at the time of operation on the breast cancer. The stage of the breast cancer is the most important component of traditional classification methods of breast cancer, because it has a greater effect on the prognosis than the other considerations. Staging takes into consideration size, local involvement, lymph node status and whether metastatic disease is present. The higher the stage at diagnosis, the poorer the prognosis. The stage is raised by the invasiveness of disease to lymph nodes, chest wall, skin or beyond, and the aggressiveness of the cancer cells.

The stage is lowered by the presence of cancer-free zones and close-to-normal cell behaviour grading. Size is not a factor in staging unless the cancer is invasive. The breast cancer grade is assessed by comparison of the breast cancer cells to normal breast cells. The closer to normal the cancer cells are, the slower their growth and the better the prognosis. If cells are not well differentiated, they will appear immature, will divide more rapidly, and will tend to spread.

source link Well differentiated is given a grade of 1, moderate is grade 2, while poor or undifferentiated is given a higher grade of 3 or 4 depending upon the scale used. The most widely used grading system is the Nottingham scheme. Younger women with an age of less than 40 years or women over 80 years tend to have a poorer prognosis than post-menopausal women due to several factors. Their breasts may change with their menstrual cycles, they may be nursing infants, and they may be unaware of changes in their breasts. Therefore, younger women are usually at a more advanced stage when diagnosed.

There may also be biologic factors contributing to a higher risk of disease recurrence for younger women with breast cancer. Not all people with breast cancer experience their illness in the same manner. Factors such as age can have a significant impact on the way a person copes with a breast cancer diagnosis.

Premenopausal women with estrogen-receptor positive breast cancer must confront the issues of early menopause induced by many of the chemotherapy regimens used to treat their breast cancer, especially those that use hormones to counteract ovarian function. Worldwide, breast cancer is the most-common invasive cancer in women. Breast cancer comprises In , breast cancer caused , deaths worldwide The incidence of breast cancer varies greatly around the world: it is lowest in less-developed countries and greatest in the more-developed countries.

The number of cases worldwide has significantly increased since the s, a phenomenon partly attributed to the modern lifestyles. However, age-adjusted deaths from breast cancer per , women only rose slightly from Because of its visibility, breast cancer was the form of cancer most often described in ancient documents. Breast cancer, however, could be felt through the skin, and in its advanced state often developed into fungating lesions : the tumor would become necrotic die from the inside, causing the tumor to appear to break up and ulcerate through the skin, weeping fetid, dark fluid.

The oldest discovered evidence of breast cancer is from Egypt and dates back years, to the Sixth Dynasty. The writing says about the disease, "There is no treatment. Ancient medicine, from the time of the Greeks through the 17th century, was based on humoralism , and thus believed that breast cancer was generally caused by imbalances in the fundamental fluids that controlled the body, especially an excess of black bile. Although breast cancer was known in ancient times, it was uncommon until the 19th century, when improvements in sanitation and control of deadly infectious diseases resulted in dramatic increases in lifespan.

Previously, most women had died too young to have developed breast cancer. Because ancient medicine believed that the cause was systemic, rather than local, and because surgery carried a high mortality rate, the preferred treatments tended to be pharmacological rather than surgical. Herbal and mineral preparations, especially involving the poison arsenic , were relatively common. Mastectomy for breast cancer was performed at least as early as AD , when it was proposed by the court physician Aetios of Amida to Theodora.

The French surgeon Jean Louis Petit — performed total mastectomies which included removing the axillary lymph nodes , as he recognized that this reduced recurrence. Their successful work was carried on by William Stewart Halsted who started performing radical mastectomies in , helped greatly by advances in general surgical technology, such as aseptic technique and anesthesia. The Halsted radical mastectomy often involved removing both breasts, associated lymph nodes, and the underlying chest muscles.

This often led to long-term pain and disability, but was seen as necessary in order to prevent the cancer from recurring. Radical mastectomies remained the standard of care in America until the s, but in Europe, breast-sparing procedures, often followed by radiation therapy, were generally adopted in the s. Breast cancer staging systems were developed in the s and s. During the s, a new understanding of metastasis led to perceiving cancer as a systemic illness as well as a localized one, and more sparing procedures were developed that proved equally effective.

Modern chemotherapy developed after World War II. The first case-controlled study on breast cancer epidemiology was done by Janet Lane-Claypon , who published a comparative study in of breast cancer cases and controls of the same background and lifestyle for the British Ministry of Health. In the s and s, thousands of women who had successfully completed standard treatment then demanded and received high-dose bone marrow transplants , thinking this would lead to better long-term survival.

The reports from the Nurses' Health Study and the conclusions of the Women's Health Initiative trial conclusively proved that hormone replacement therapy significantly increased the incidence of breast cancer. Before the 20th century, breast cancer was feared and discussed in hushed tones, as if it were shameful. As little could be safely done with primitive surgical techniques, women tended to suffer silently rather than seeking care. When surgery advanced, and long-term survival rates improved, women began raising awareness of the disease and the possibility of successful treatment.

In , the first peer-to-peer support group , called "Reach to Recovery", began providing post-mastectomy, in-hospital visits from women who had survived breast cancer. The breast cancer movement of the s and s developed out of the larger feminist movements and women's health movement of the 20th century.

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A pink ribbon is the most prominent symbol of breast cancer awareness. Pink ribbons, which can be made inexpensively, are sometimes sold as fundraisers, much like poppies on Remembrance Day. They may be worn to honor those who have been diagnosed with breast cancer, or to identify products that the manufacturer would like to sell to consumers that are interested in breast cancer. The pink ribbon is associated with individual generosity, faith in scientific progress, and a "can-do" attitude. It encourages consumers to focus on the emotionally appealing ultimate vision of a cure for breast cancer, rather than on the fraught path between current knowledge and any future cures.

Wearing or displaying a pink ribbon has been criticized by the opponents of this practice as a kind of slacktivism , because it has no practical positive effect. It has also been criticized as hypocrisy , because some people wear the pink ribbon to show good will towards women with breast cancer, but then oppose these women's practical goals, like patient rights and anti-pollution legislation.

Breast cancer culture, also known as pink ribbon culture, is the set of activities, attitudes, and values that surround and shape breast cancer in public. The dominant values are selflessness, cheerfulness, unity, and optimism. In breast cancer culture, breast cancer therapy is viewed as a rite of passage rather than a disease. Anger, sadness, and negativity must be silenced.


As with most cultural models, people who conform to the model are given social status, in this case as cancer survivors. Women who reject the model are shunned, punished and shamed. The culture is criticized for treating adult women like little girls, as evidenced by "baby" toys such as pink teddy bears given to adult women. The primary purposes or goals of breast cancer culture are to maintain breast cancer's dominance as the pre-eminent women's health issue, to promote the appearance that society is doing something effective about breast cancer, and to sustain and expand the social, political, and financial power of breast cancer activists.

Compared to other diseases or other cancers, breast cancer receives a proportionately greater share of resources and attention. In MP Ian Gibson , chairman of the House of Commons of the United Kingdom all party group on cancer stated "The treatment has been skewed by the lobbying , there is no doubt about that. Breast cancer sufferers get better treatment in terms of bed spaces, facilities and doctors and nurses. Some subjects, such as cancer-related fatigue , have been studied little except in women with breast cancer. One result of breast cancer's high visibility is that statistical results can sometimes be misinterpreted, such as the claim that one in eight women will be diagnosed with breast cancer during their lives—a claim that depends on the unrealistic assumption that no woman will die of any other disease before the age of The emphasis on breast cancer screening may be harming women by subjecting them to unnecessary radiation, biopsies, and surgery.

One-third of diagnosed breast cancers might recede on their own. According to H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice , research on screening mammography has taken the "brain-dead approach that says the best test is the one that finds the most cancers" rather than the one that finds dangerous cancers. Pregnancy at an early age decreases the risk of developing breast cancer later in life. Diagnosing new cancer in a pregnant woman is difficult, in part because any symptoms are commonly assumed to be a normal discomfort associated with pregnancy.

Some imaging procedures, such as MRIs magnetic resonance imaging , CT scans , ultrasounds, and mammograms with fetal shielding are considered safe during pregnancy; some others, such as PET scans are not. Treatment is generally the same as for non-pregnant women. In some cases, some or all treatments are postponed until after birth if the cancer is diagnosed late in the pregnancy. Early deliveries to speed the start of treatment are not uncommon. Surgery is generally considered safe during pregnancy, but some other treatments, especially certain chemotherapy drugs given during the first trimester , increase the risk of birth defects and pregnancy loss spontaneous abortions and stillbirths.

Radiation treatments may interfere with the mother's ability to breastfeed her baby because it reduces the ability of that breast to produce milk and increases the risk of mastitis. Also, when chemotherapy is being given after birth, many of the drugs pass through breast milk to the baby, which could harm the baby. Regarding future pregnancy among breast cancer survivors , there is often fear of cancer recurrence.

In breast cancer survivors, non-hormonal birth control methods should be used as first-line options. Progestogen -based methods such as depot medroxyprogesterone acetate , IUD with progestogen or progestogen only pills have a poorly investigated but possible increased risk of cancer recurrence, but may be used if positive effects outweigh this possible risk.

In breast cancer survivors, it is recommended to first consider non-hormonal options for menopausal effects, such as bisphosphonates or selective estrogen receptor modulators SERMs for osteoporosis, and vaginal estrogen for local symptoms. Observational studies of systemic hormone replacement therapy after breast cancer are generally reassuring.

If hormone replacement is necessary after breast cancer, estrogen-only therapy or estrogen therapy with an intrauterine device with progestogen may be safer options than combined systemic therapy. Treatments are being evaluated in trials. This includes individual drugs, combinations of drugs, and surgical and radiation techniques Investigations include new types of targeted therapy , [] cancer vaccines , oncolytic virotherapy, [] gene therapy [] [] and immunotherapy.

Gallen Oncology Conference in St. Gallen, Switzerland. Fenretinide , a retinoid, is also being studied as a way to reduce the risk of breast cancer retinoids are medications related to vitamin A.

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As of cryoablation is being studied to see if it could be a substitute for a lumpectomy in small cancers. A considerable part of the current knowledge on breast carcinomas is based on in vivo and in vitro studies performed with cell lines derived from breast cancers. These provide an unlimited source of homogenous self-replicating material, free of contaminating stromal cells, and often easily cultured in simple standard media. The first breast cancer cell line described, BT , was established in Since then, and despite sustained work in this area, the number of permanent lines obtained has been strikingly low about Indeed, attempts to culture breast cancer cell lines from primary tumors have been largely unsuccessful.

This poor efficiency was often due to technical difficulties associated with the extraction of viable tumor cells from their surrounding stroma. Most of the available breast cancer cell lines issued from metastatic tumors, mainly from pleural effusions. Effusions provided generally large numbers of dissociated, viable tumor cells with little or no contamination by fibroblasts and other tumor stroma cells. Many of the currently used BCC lines were established in the late s.

A very few of them, namely MCF-7 , TD , and MDA-MB , account for more than two-thirds of all abstracts reporting studies on mentioned breast cancer cell lines, as concluded from a Medline -based survey. NFAT transcription factors are implicated in breast cancer, more specifically in the process of cell motility at the basis of metastasis formation. Clinically, the most useful metabolic markers in breast cancer are the estrogen and progesterone receptors that are used to predict response to hormone therapy. From Wikipedia, the free encyclopedia.

This is the latest accepted revision , reviewed on 22 September Breast cancer Mammograms showing a normal breast left and a breast with cancer right, white arrows. Main article: Risk factors of breast cancer. See also: List of breast carcinogenic substances. Main article: Carcinogenesis. Neuropilin-2 expression in normal breast and breast carcinoma tissue. Main article: Breast cancer classification. Main article: Breast cancer screening. Main article: Breast cancer management. Main article: Epidemiology of breast cancer.

See also: Breast cancer awareness and List of people with breast cancer. Main article: Pink ribbon. See also: List of breast cancer cell lines. Archived from the original on 5 July Retrieved 29 June World Health Organization. Chapter 5. Archived from the original on 27 November Archived from the original on 3 July Retrieved 18 June Office for National Statistics. Archived PDF from the original on 29 November January Archived from the original on 25 June Breast cancer 1.

Oxford: Oxford University Press. Chapter Archived from the original on 25 October The Cochrane Database of Systematic Reviews. Annals of Internal Medicine. International Agency for Research on Cancer. Archived from the original PDF on 20 July Retrieved 26 February Chapter 1. National Cancer Institute. Archived from the original on 4 July Archived from the original on 2 October Retrieved 5 February Archived from the original PDF on 10 April Retrieved 26 April New England Journal of Medicine.

Archived from the original on 12 February CO;2-P inactive 7 September