PD MD Heiko B. G. Franz
Breast cancer: Information for patients, relatives and interested parties diagnosis, therapy and aftercare for breast cancer
Anatomy of the female breast. Female breast with glandular tissue and lymph nodes.
The female breast (Latin "mamma") consists of glandular, fatty and connective tissue. It is traversed by veins, lymph vessels and nerves. These are associated with the vascular system, the lymphatic system and the nervous system of the surrounding tissue. Lymphatic drainage of the breast includes lymph nodes in the armpits, above and below the collarbone, on the sternum and on the costal margin below the chest. The glandular tissue of the breast consists of so-called glandular lobes and smaller glandular lobules ("lobuli"), in which breast milk is formed. They pass into the milk ducts ("ductus"), which flow into the nipple. Connective tissue makes the breast elastic; however, their actual shape is determined by the stored fatty tissue and the breast skin. Muscles can not be found in the chest: the chest muscles lie on the chest or ribs under the mammary gland. In order to be able to specify the exact location of a change within the breast, it is divided into four quadrants or quarters. You think of a vertical and a horizontal line that cross on the nipple. Most malignant changes occur in the outer upper quadrant, ie between the armpit and collarbone. The mammary gland tissue responds to the cyclical ups and downs of female sex hormones, especially estrogens and progestins. Shortly before the menstrual period, the tissue swells between the glandular lobes under the influence of hormones. After the menstrual period the breast becomes softer again. A pregnancy changes the size and condition of the breast, also depending on the level of the hormones, last growth and maturation steps of the glandular tissue even take place during pregnancy. After the menopause, in the so-called menopause, these transformations come to a standstill. The mammary tissue remains in most women, even in advanced age sensitive to hormonal influences. Tumor cells in the breast also become dependent on hormones in many, but not all, patients.
The majority of tumors in the breast are found to be benign on examination. These may be connective tissue tumors, fluid-filled cysts and similar changes, more in the text "Benign breast changes". Malignant tumors almost always emanate from the glandular portion of the breast. "Lobular" carcinomas arise in the glandular lobes, often in several places in the chest at the same time or even in both breasts. "Ductal" carcinomas develop in the milk ducts, they start from their innermost cell layer (epithelium). So-called invasive tumors are accumulations of cancer cells that have exceeded the tissue boundaries during their growth and have grown from the glandular tissue or milk ducts into adjacent tissue. If they are not treated, there is a high risk that they will continue to grow and that metastases may occur. In-situ carcinomas are tumors that are still limited to the milk ducts (ductal carcinoma in situ, DCIS). They were long considered a breast cancer precursor or early form. Today we know that some of these tumors do not seem to develop. This would actually be unnecessary to treat affected women. However, there is a low risk of developing invasive breast cancer, and it may even, but rarely, happen that a woman has metastases without the DCIS continuing to grow in the breast itself. So far there is no way to know which DCIS will remain harmless and which not. Therefore, women with ductal in-situ carcinoma will also be treated today. The rather rare tumors, which develop from skin cells or the connective tissue of the breast, are in the narrower sense not among the breast cancer treated in this text: These may be one of the various types of skin cancer, or a connective tissue tumor called a sarcoma.
Mammary glands consist of three types of tissues – adipose, connective and glandular. Cancer of mammary glands is a malignant tumor that develops in glandular tissues. Despite the common misbelief, cancer of mammary glands develops in both women and men, but women tend to suffer from it more often.
Breast cancer develops the same way as any other malignant tumor in body. One or several cells of glandular tissues start multiplying abnormally because of some mutations that took place. A tumor forms, and starts growing into adjacent tissues and creating metastases (secondary tumor nidus).
Most often, tumors of mammary glands develop from the cells of mamillary ducts – in this case, doctors diagnose duct carcinoma of mammary glands. Pretty often, malignant tumors grow from cells of lobules of mammary glands, and this type of cancer is called “invasive lobular carcinoma”. It should be noted that the tumor can start growing from other cells of glandular tissues.
Unfortunately, scientists have no certain information about the causes of mammary gland cancer. However, there’s a list of risk factors that contribute to development of tumors, though all of these factors can be absent in a diseased person. Sometimes there’s the whole range of these factors, but a person still stays healthy. Anyway, doctors connect the risk of breast cancer development with some certain circumstances that precede the disease. Such factors include:
Scientists have proved that the most widespread genetic causes of mammary gland cancer are mutations of BRCA1 and BRCA2 genes. Women with BRCA1 mutation have a 55-65% risk of developing breast cancer, and women with mutation in gene BRCA2 — 45% risk.
Pretty often, breast cancer exhibits no symptoms at early stages of disease. However, sometimes there are some signs telling about this disease, and you can easily notice them.
First and foremost, the main symptom that should alarm a woman is some kind of induration in mammary glands, nearby and in armpits. In 9 cases out of 10, the indurations are benign, but this can be defined for sure only during examination by a mammologist.
Women should also check breast for nodes and other alterations once a month after the end of menstruation period. Home diagnostics should better be performed in shower or while bathing. If you have some changes and alterations, these should be reported to a doctor as soon as possible. Only a doctor can reveal the nature and cause of changes.
The symptoms of breast cancer include:
70% of cases of mammary glands are revealed by patients during self-examination and palpation of breasts. This is why it’s crucial to perform checking on a regular basis: the earlier cancer is revealed, the higher is the chance of survival and successful treatment.
If you have any of the above mentioned symptoms, or any other changes of mammary glands (for instance, strange sensations and moderate or severer pain), you should consult with a mammologist right away.
At the beginning of the statutory cancer screening program, an anamnesis and explanatory meetings about risk factors are offered starting from the age of 20 (78, 79). The most important risk factor for breast cancer is age. Quality-assured breast cancer screening tests are useful for any woman whose age suggests a high probability of a disease, irrespective of other disease risks. The anamnesis includes: age, menarche, menopause, BMI (body mass index), cycle phase, first full-term pregnancy, lactation period, cancer and radiation therapy, benign breast disease, premalign breast disease, breast surgery, hormonal therapy (preparations, duration, actual intake), socio-economic status, known cancer burdens, especially breast and ovarian cancer (genetic risk constellation).
Self-examination of breasts contributes significantly to the individual motivation and promotion of consciousness for preventive measures. Regular and proper self-examination favors the discovery of carcinomas. Even if the efficacy of the self-examination should not be overestimated, the self-examination of the breast must be an integral part of an early detection program. It can not be learned and started too early, but should be performed regularly from the age of 30. Women should be informed and enlightened about the effects, advantages and disadvantages of this measure in the early detection program.
The medical palpatory and inspectorial examination of the mammary gland and regional lymph drainage areas must be an integral part of every early detection program and should be carried out at regular intervals starting from the age of 30. Study results show that from the age of 40 and onwards, breast cancer screening can be made more effective using the medical palpatory and inspectorial examination of the mammary gland and lymph drainage areas in combination with mammography.
Mammography is a chest radiograph. Through radiographs the doctor can determine more precisely whether the palpated node is breast cancer or another type of disease.
Mammary sonography is an examination of the breast using ultrasound. In addition to mammography, mammary sonography plays the most important role in the diagnosis of conspicuous findings. For some women - especially younger ones - changes in mammography are more difficult to detect. With the aid of mammary sonography, abnormalities in the breast can be further evaluated and clarified.
Magnetic resonance tomography is mainly used when, according to previous investigations, uncertainties about the findings still persist. In this method, sectional images of the body are produced with the aid of a strong magnetic field. This results in no radiation exposure during this examination. The representation of the breast requires the usage of special contrast agent introduced over the vein.
A biopsy is sampling of the suspect tissue. Only the microscopic examination of a breast tissue sample can ultimately clarify whether a tumor is benign or malignant. At our breast center you will get the result of a tissue sample within 24 hours. The biopsy is a very safe, low-risk examination procedure in which no tumor cells can be "carried away".
Can mammary gland cancer be treated? The way of cancer treatment depends on the stage of its development.
The first stage is characterized by:
At this stage, treatment of mammary gland cancer is pretty efficient, and the prognosis of the disease is positive. The diagnosis is based on mammography and tissue biopsy that has shown reborn cancer cells.
Can cancer at the first stage be treated? For Stage I the following treatment types are prescribed:
Besides, women are also prescribed opiates that help to restore nervous system after considerable stress. If necessary, pain killers and anti inflammatory drugs are prescribed. At this stage, lumpectomy can be avoided.
The peculiarities of cancer treatment at this stage mainly depend on cancer type. Specialists distinguish two types of stage II:
The second stage is the threshold when the tumor has not escaped the locus yet, and there’s a chance to save both mammary gland and its tissue. The struggle against mammary gland cancer at this stage can end up with a positive prognosis, without lumpectomy.
The strategy of cancer treatment:
Mammary gland cancer at Stage II can be treated without lumpectomy and it allows saving mammary glands.
Can cancer at Stage III be treated? The cancer at this stage is called "locally advanced". The vast majority of women ask for medical help at this stage of disease that is characterized by:
Locally advanced cancer is not a locus disease, but a systematic malaise. It means that tiny metastases are likely to be present in organs and can cause disease recurrence. The main signs of fast metastases development are: fast tumor growth, significant damage of regional lymph nodes, growing of tumor in the skin. The prognosis for cancer at stage III is less optimistic, but recent advances of global oncology allow treating the disease with positive outcomes.
Treatment strategy is the following:
When going through treatment of cancer at stage III, a woman should visit the doctor every 3 months for him to control efficiency of treatment.
Cancer at this stage cannot be reversed: there are too many cancer cells that spread over the entire patient’s body.
It’s accompanied by the following symptoms:
Cancer at this stage has very poor prognosis. However, modern methods of mammary gland treatment help patient to recover partially and prolong life for several years. It includes:
Stage IV of mammary gland cancer is performed under permanent medical control, the doctors check efficiency of drugs with the help of CT (computer tomography) and MRT (magnetic resonance therapy). To perform it, they select big metastases and evaluate its dynamics – whether they shrank, enlarged or stayed the same. At this stage, lumpectomy cannot be avoided.
As a rule, the attending female doctor takes the aftercare, but it can also be performed by the family doctor. However, the patient herself also takes important part in the aftercare performing the monthly self-examination of the breast.
After completion of the treatment, in case of adjuvant chemotherapy six months after the operation, regular check-ups are advised. These investigations are primarily aimed to detect localized relapses at an early stage, a so-called local recurrence, or a new carcinoma in the other breast. The follow-up appointments are also used to monitor the possible consequences and side effects of previous tumor treatment. Finally, it is also the task of the aftercare to help the cancer patient to resolve and handle physical, mental and social problems.
On the other hand, intensive search for distant metastases in patients who have no symptoms and complaints, does not, as a rule, give any advantages for the treatment. For this reason, there is still no reason to be cautious during elaborate examinations or tumor carcinogen determination. Only if there is a specific suspicion of metastasization, further instrumental and laboratory tests are carried out.
In the first three years the tests are carried out every three months, in the fourth and fifth year every six months.
If after five years there is no relapse, inspections at annual intervals are sufficient.
After a breast-conserving surgery, the affected breast is mammographed every six months in the first three years, then annually. In case of the unaffected breast, annual mammograms are sufficient from the beginning.
The first physical examination is used to get the general picture of your body and to identify possible signs of illness. Among other things, your chest is thoroughly scanned in order to understand the size and position of a posible breast tumor. The armpit is also thoroughly scanned to detect potentially enlarged lymph nodes. During the interview, the physician will ask for further information, which will help them to diagnose and subsequently plan the therapy.
Women with breast tumors have primary interest for survival rates at this or that stage of disease, methods of its treatment and chances for recovery. The results of treatment directly depend on how fat the tumor spreaf in mammary glands, lymph nodes, and whether there are metastases in other organs and tissues. As a rule, the disease at the fist stage is successfully treated with 95% probability.
This is the leading diagnosis among female malignant diseases. Annually, about 1.5 mln people are diagnosed with cancer of mammary glands. About 400 thousand cases are lethal. During one year, a quickly progressing cancer kills people in 10% of cases.
To estimate the results of treatment, doctors consider 5-year survival rate, e.g. the number of patients who survived during this period after having a malignant tumor diagnosed. About 50% of women getting adequate treatment can survive for 5 years, if they get appropriate treatment. Without treatment, survival rate during 5 years decreases to 12-15%.
There are many different factors that influence the prognosis for such disease. For example, advantage factors include hormonal sensitivity to the tumor (when the surfaces of malignant cells have receptors susceptible to progesterone and estrogen). Adverse factors include Her2neu newgrowth cell marker (it means that the tumor develops very aggressively and quickly, and is hard to control).
Depending on the size of tumor and spread of malignant process (whether metastases are formed), there are 4 basic stages of disease. Survival rate decreases according to the stage when the tumor process has been revealed:
As for ten-year survival rate during cancer of mammary glands, the numbers can be a bit different:
The overall number of lymph nodes affected by metastases is also important for overall analysis. If there are no regional metastases, ten-year survival rate can reach 75%, if there are some – 25%. If 3 or less lymph nodes are damaged, ten-year survival rate is about 35%; if 4 or more lymph nodes are damaged, the prognosis for breast cancer decreases to 15%.
Can the statistics be changed anyhow? Of course! Timely treatment will definitely give positive results. The most optimal treatment complex includes chemotherapy, ray therapy and surgical treatment. If you strictly follow doctor’s instructions and stick to a diet, you can greatly prolong your life.