Breast Cancer: diagnosis and treatment.

 

DIAGNOSING BREAST CANCER

Women are usually diagnosed with breast cancer after a routine breast cancer screening, or after detecting certain signs and symptoms and seeing their doctor about them.

If a woman detects any of the breast cancer signs and symptoms described above, she should speak to her doctor immediately. The doctor, often a primary care physician (general practitioner, GP) initially, will carry out a physical exam, and then refer the patient to a specialist if he/she thinks further assessment is needed.

Below are examples of diagnostic tests and procedures for breast cancer:
Breast exam - the physician will check both the patient's breasts, looking out for lumps and other possible abnormalities, such as inverted nipples, nipple discharge, or change in breast shape. The lymph nodes in your armpit and above your collarbones may be palpated (felt), because enlargement or firmness of these lymph nodes might indicate spread of breast cancer.  The patient will be asked to sit/stand with her arms in different positions, such as above her head and by her sides. Your doctor will also do a complete physical exam to judge your general health and whether there is any evidence of cancer that may have spread.

X-ray (mammogram) - A mammogram is an x-ray of the breast. Screening mammograms are used to look for breast disease in women who have no signs or symptoms of a breast problem. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast.

Diagnostic mammograms are used to diagnose breast disease in women who have breast symptoms (like a lump or nipple discharge) or an abnormal result on a screening mammogram. A diagnostic mammogram includes more images of the area of concern. In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.

A diagnostic mammogram can show:

• That the abnormality is not worrisome at all. In these cases the woman can usually return to having routine yearly mammograms.
• That a lesion (area of abnormal tissue) has a high likelihood of being benign (not cancer). In these cases, it is common to ask the woman to come back sooner than usual for her next mammogram, usually in 4 to 6 months.
• That the lesion is more suspicious, and a biopsy is needed to tell if it is cancer.

Even if the mammograms show no tumor, if you or your doctor can feel a lump, a biopsy is usually needed to make sure it isn't cancer. One exception would be if an ultrasound exam finds that the lump is a simple cyst (a fluid-filled sac), which is very unlikely to be cancerous.

Breast ultrasound - Ultrasound, also known as sonography, uses sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with ultrasound gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. This test is painless and does not expose you to radiation. Breast ultrasound may help doctors decide whether a lump or abnormality is a solid mass or a fluid-filled cyst.

Biopsy - A biopsy is done when mammograms, other imaging tests, or the physical exam finds a breast change (or abnormality) that is possibly cancer. A biopsy is the only way to tell if cancer is really present. A sample of tissue from an apparent abnormality, such as a lump, is surgically removed and sent to the lab for analysis. It the cells are found to be cancerous, the lab will also determine what type of breast cancer it is, and the grade of cancer (aggressiveness). For an accurate diagnosis, multiple tumor sites need to be taken.

Breast MRI (magnetic resonance imaging) scan - MRI can be used along with mammograms for screening women who have a high risk of developing breast cancer, or it can be used to better examine suspicious areas found by a mammogram. MRI is also sometimes used for women who have been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast.In someone known to have breast cancer, it is sometimes used to look at the opposite breast, to be sure that it does not contain any tumors. 

STAGING

Staging describes the extent of the cancer in the patient's body and is based on whether it is invasive or non-invasive, how large the tumor is, whether lymph nodes are involved and how many, and whether it has metastasized (spread to other parts of the body). Breast cancer stages range from 0 to IV, with 0 indicating cancer that is very small and noninvasive. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body. Your cancer's stage helps determine your prognosis and the best treatment options. Tests and procedures used to stage breast cancer may include:

• Blood tests, such as a complete blood count
• Mammogram of the other breast to look for signs of cancer
• Breast MRI
• Bone scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan

Your doctor will select the appropriate tests based on your specific circumstances.Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage and grade, whether the cancer cells are sensitive to hormones, your overall health and your own preferences. Most women undergo surgery for breast cancer and also receive additional treatment, such as chemotherapy, hormone therapy or radiation.

BREAST CANCER TREATMENT OPTIONS

A multidisciplinary team consisting of an oncologist, radiologist, specialist cancer surgeon, specialist nurse, pathologist, radiologist, radiographer, and reconstructive surgeon are involved in a breast cancer patient's treatment. The team will take into account several factors when deciding on the best treatment for the patient, including:

• The type of breast cancer
• The stage and grade of the breast cancer - how large the tumor is, whether or not it has spread, and if so how far
• Whether or not the cancer cells are sensitive to hormones
• The patient's overall health
• The age of the patient (has she been through the menopause?)
• The patient's own preferences

The main breast cancer treatment options may include:

• Radiation therapy (radiotherapy)
• Surgery
• Biological therapy (targeted drug therapy)
• Hormone therapy
• Chemotherapy

Surgery

• Lumpectomy (Removing the breast cancer) - surgically removing the tumor and a small margin of healthy tissue around it. In breast cancer, this is often called breast-sparing surgery. Lumpectomy is typically reserved for smaller it will be easy to separate them from the tissue around. One fifth of breast cancer patients who choose breast-conserving surgery instead of mastectomy eventually need a reoperation.

• Mastectomy (Removing the entire breast) - Mastectomy is surgery to remove all of your breast tissue. Simple mastectomy involves removing the lobules, ducts, fatty tissue, nipple, areola, and some skin. Radical mastectomy means also removing muscle of the chest wall and the lymph nodes in the armpit. In a skin-sparing mastectomy, the skin over the breast is left intact to improve reconstruction and appearance.

• Sentinel node biopsy (Removing a limited number of lymph nodes )- one lymph node is surgically removed. If the breast cancer has reached a lymph node it can spread further through the lymphatic system into other parts of the body. If no cancer is found in the lymph nodes that receive the lymph drainage from your tumor, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.

• Axillary lymph node dissection (Removing several lymph nodes )- if the sentinel node was found to have cancer cells, the surgeon may recommend removing several nymph nodes in the armpit.

• Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure.

• Breast reconstruction surgery - a series of surgical procedures aimed at recreating a breast so that it looks as much as possible like the other breast. This procedure may be carried out at the same time as a mastectomy. The surgeon may use a breast implant, or tissue from another part of the patient's body.

Radiation therapy (radiotherapy)

Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. Controlled doses of radiation are targeted at the tumor to destroy the cancer cells. Usually, radiotherapy is used after surgery, as well as chemotherapy to kill off any cancer cells that may still be around. Typically, radiation therapy occurs about one month after surgery or chemotherapy. Each session lasts a few minutes; the patient may require three to five sessions per week for three to six weeks.

The type of breast cancer the woman has will decide what type of radiation therapy she may have to undergo. In some cases, radiotherapy is not needed.

Radiation therapy types include:

• Breast radiation therapy – this is given to patients after they have undergone lumpectomy surgery. radiation is administered to the remaining breast tissue

• Chest wall radiation therapy - this is applied after a mastectomy

• Breast boost - a high-dose of radiation therapy is applied to where the tumor was surgically removed. The appearance of the breast may be altered, especially if the patient's breasts are large.

• Lymph nodes radiation therapy - the radiation is aimed at the axilla (armpit) and surrounding area to destroy cancer cells that have reached the lymph nodes

• Breast brachytherapy - This treatment is given to patients after they have undergone lumpectomy surgery.  Researchers have found out that women who received strut-based breast brachytherapy had lower recurrence rates, as well as fewer and less severe side effects.

Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as damage to the heart or lungs or, very rarely, second cancers in the treated area.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. These medications are called cytotoxic drugs. The oncologist may recommend chemotherapy if there is a high risk of cancer recurrence, or the cancer spreading elsewhere in the body. This is called adjuvant chemotherapy.

If the tumors are large, chemotherapy may be administered before surgery. The aim is to shrink the tumor, making its removal easier. This is called neo-adjuvant chemotherapy.

Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.
Chemotherapy may help stop estrogen production which  can encourage the growth of some breast cancers.

Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing infection. Rare side effects can include premature menopause, damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.


Hormone therapy (hormone blocking therapy)

Used for breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers. The aim is to prevent cancer recurrence. Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control

If for health reasons, the patient cannot undergo surgery, chemotherapy or radiotherapy, hormone therapy may be the only treatment she receives. Hormone therapy will have no effect on cancers that are not sensitive to hormones. It usually lasts up to five years after surgery.

The following hormone therapy medications may be used:

• Tamoxifen - prevents estrogen from binding to ER-positive cancer cells. Side effects may include changes in periods, hot flashes, weight gain, headaches, nausea, vomiting, fatigue, and aching joints. some breast cancer patients do not respond to  or are resistant to Tamoxifen.
  
  
  
• Aromatase inhibitors - this type of medication may be offered to women who have been through the menopause. It blocks aromatase. Aromatase helps estrogen production after the menopause. Before the menopause, a woman's ovaries produce estrogen. Examples of aromatase inhibitors include letrozole, exemestane, and anastrozole. Side effects may include nausea, vomiting, fatigue, skin rashes, headaches, bone pain, aching joints, loss of libido, sweats, and hot flashes.

·         Ovarian ablation or suppression - pre-menopausal women produce estrogen in their ovaries. Ovarian ablation or suppression stop the ovaries from producing estrogen. Ablation is done either through surgery or radiation therapy - the woman's ovaries will never work again, and she will enter the menopause early.

A luteinising hormone-releasing hormone agonist (LHRHa) drug called Goserelin will suppress the ovaries. The patient's periods will stop during treatment, but will start again when she stops taking Goserelin. Women of menopausal age (about 50 years) will probably never start having periods again. Side effects may include mood changes, sleeping problems, sweats, and hot flashes.

Biological treatment (targeted drugs)

• Trastuzumab (Herceptin) - Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2), which helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include headaches, diarrhea and heart problems.

• Lapatinib (Tykerb) - Lapatinib targets HER2 and is approved for use in advanced or metastatic breast cancer. Tykerb is used on patients who did not respond well to Herceptin. Potential  Side effects include painful hands, painful feet, skin rashes, mouth sores, extreme tiredness, diarrhea, vomiting, and nausea.

• Bevacizumab (Avastin) – It stops the cancer cells from attracting new blood vessels, effectively causing the tumor to be starved of nutrients and oxygen. Side effects may include congestive heart failure, hypertension (high blood pressure), kidney damage, heart damage, blood clots, headaches, mouth sores. Bevacizumab is no longer approved for the treatment of breast cancer in the United States. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times.

• Low dose aspirin
  
  Research carried out on laboratory mice and test tubes suggests that regular low-dose aspirin may halt the growth and spread of breast cancer. Their research involved assessing aspirin's effects on two types of cancer, including the aggressive "triple-negative" breast cancer which is resistant to most current treatments.
  
  Cancer campaigners cautioned that although the current results show great promise, this research is at a very early stage and has yet to be shown to be effective on humans.

 Breast Cancer: facts and types. 

Breast Cancer: risk factors, symptoms and prevention.

Beast Cancer: When to see the doctor.





 source: http://www.cancer.org