Breast Cancer
From Encyclopedia of Sex and Sexuality
Contents |
[edit] Introduction
Breast cancer is the most common malignancy encountered in women and is one of the leading causes of all deaths from cancer in women. The incidence of breast cancer has steadily risen in the West, and is the number one cause of death for women in their forties. One in nine American women develops carcinoma (the medical term for cancer) of the breast during her lifetime.
Mortality from breast cancer has not changed noticeably over the past fifty years. The American Cancer Society estimates that 182,000 women and 1,000 men—will be diagnosed with it in the United States in 1994 and 46,000 women and 300 men will die of the disease.
There is no known method of preventing the disease. Survival rates vary depending on the size of the tumor, whether it is localized in the breast or has spread to other areas at the time of diagnosis, and on the microscopic character of the tumor cells. Therefore, the major opportunity to alter the natural course of the disease lies in early detection and diagnosis.
It should be remembered that breast cancer is an eminently curable disease. Five-year survival rates for early and localized forms of the disease are 93 percent, compared to 18 percent for the most advanced stage of the disease. A woman’s fear of possible breast cancer may lead to denial of an obvious lump. Whatever a woman’s fears, she should not hesitate to see her doctor when she discovers a lump or other changes in one of her breasts. The chances of early detection and cure are in her hands.
The risk factors for the development of breast cancer are poorly understood. Epidemiologists have documented some factors that appear to increase or decrease the likelihood that breast cancer will occur. Caucasian women are at higher risk than Latin, Mediterranean, and especially black women. Women born in the West are at higher risk compared to women born in Asia or Africa. The frequency of breast carcinoma increases directly with the patient’s age. Breast cancer is almost non-existent before puberty; the incidence gradually increases during women’s reproductive years and peaks after age forty. Eighty-five percent of breast cancers occur after age forty-two.
A genetic predisposition to develop breast carcinoma has been recognized in some families. No specific genetic pattern has been identified, but first-degree relations of cancer patients, their daughters and sisters, are at two to three times a higher risk of developing breast carcinoma than others in the general population. The highest genetic risk, six to nine times, occurs in first degree relatives of a premenopausal woman who develops cancer in both breasts.
Women with fibrocystic breast disease (a benign condition), previous cancer of the other breast, or ovarian, endometrial, or colon carcinoma are at a greater risk of developing breast cancer. Women who experience early first menstruation or late menopause are also at increased risk. The age of delivery of a first child is important. If a woman’s first birth occurs before age twenty, she has a lower risk of developing breast cancer than a woman who has never given birth or who had her first term pregnancy after age thirty-five. Obese women are also at higher risk; studies have demonstrated that differences in incidences of breast cancer are directly related to the amount of fat in the diet. Women of upper socioeconomic classes are at increased risk. It is known that large doses of radiation to the breast constitute a definite risk factor.
Many risk factors are additive, but these identify only 25 percent of the women who eventually develop breast carcinoma. Studies are nonconclusive in relating the use of oral contraceptive pills to the likelihood of developing breast cancer. Some recent studies, have suggested that long term use and early use of the pill may increase the risk of breast cancer, but further investigations will be needed. The United States Food and Drug Administration takes the position that no change in oral contraceptive use is currently warranted.
Much concern has been expressed that postmenopausal estrogen replacement, used by many women, may encourage the development of breast cancer. The issue is not settled. It is, therefore, mandatory to examine the breasts and to perform a mammogram before initiating estrogen therapy in postmenopausal women and to repeat these examinations regularly.
[edit] Screening and Early Diagnosis
Detection of breast cancer is defined as the use of screening tests in symptomatic women at periodic intervals to discover breast malignancy. Women should be taught the technique of breast self-examination. Clinical examination of the breast is recommended at annual check-ups. Radiological screening (see also mammography) can detect breast cancer at an early stage and is recommended, where available, on an annual basis for women over the age of 40. Various studies have shown that screening programs effectively reduce mortality rates related to breast cancer. However, the frequency of screening and the degree of compliance are key factors affecting the success of breast cancer screening.
[edit] Biopsy and Surgical Procedures
If screening procedures discover a suspicious lump or thickening in a breast, action must be taken to determine whether it is malignant and to perform the recommended surgery. There are several ways to obtain cells from a lump that has been detected for diagnosis at the pathology laboratory. If the lump contains fluid, a fine needle can be inserted into it and a little fluid is drawn in an almost painless procedure. When the tumor is solid, a wide biopsy needle can be inserted. In some cases, the whole lump or some part of it is removed in an operating room.
If there is concern that the breast malignancy may have already spread to other tissues, further testing procedures, including x-ray evaluations and a bone scan, are necessary. The extent of preoperative investigation procedures should be decided by an experienced specialist.
A woman confronting these tests should be aware of all options available to her and discuss them with a specialist. The different operations performed today for breast cancer, the extent of the operation proposed and the postoperative consequences should be discussed in detail ahead of time. Treatment for breast cancer may involve the expertise not only of a surgeon, but of a radiotherapist and an oncologist as well. At present, the major surgical alternatives available to women suffering from breast cancer can be classified as follows (all involve removal of the breast to insure excision of all cancerous tissue):
[edit] Radical Mastectomy
This operation was first described in 1891. All breast tissue, pectorial muscles (the muscles beneath the breast), and axillary lymph nodes are removed.
[edit] Extended Radical Mastectomy
Though rarely done, in this operation the internal mammary lymph-nodes are removed in addition to all of the other procedures performed in a radical mastectomy. To do so it is sometimes necessary to remove a section of the ribs.
[edit] Modified Radical Mastectomy
The entire breast and the axillary lymph nodes are removed.
[edit] Total Simple Mastectomy
The whole breast is removed. The axillary (armpit) area and pectoral muscles are left intact. Recently there has been increasing support for conservative surgery—surgery that does not require removal of the breast—combined with radiotherapy for women with early breast cancer. Conservative surgery implies removal of just the tumor and some surrounding normal breast tissue. Quadrantectomy implies removal of the tumor plus the whole quadrant of internal breast tissue surrounding it. The terms lumpectomy and segmental mastectomy, sometimes used for these procedures, are imprecise. These operations are combined with axillary lymph node dissection and radiotherapy. The principal advantage of the conservative treatment is cosmetic. Thus, the major criterion for the patient is the ability to adequately remove the primary tumor with controlled cosmetic deformity. Nowadays it is also common to have breast reconstruction following a mastectomy.
Early diagnosis is the major factor influencing mortality from breast cancer. When cancer is diagnosed in its early stages, curability rates are higher than 90 percent for five years. If the lesions are one centimeter or less and lymph nodes are not infected, the twenty-year survival rate is also about 90 percent. In advanced breast cancer, which now constitutes only a minority of cases, the prognosis is much worse—about 20 percent survival at five years. Therefore, patients who regularly practice self-examination and have annual breast examinations by a physician detect lesions far smaller than those found in women who examine themselves infrequently or not at all. The risk of death among women who are screened is much lower than the risk among women who are not screened.
