Cancer  in Females
Breast Cancer
 
Definition of breast cancer: Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare.
The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.
Age and health history can affect the risk of developing breast cancer.
Anything that increases your chance of getting a disease is called a risk factor. Risk factors for breast cancer include the following:
·                   Older age.
·                   Menstruating at an early age.
·                   Older age at first birth or never having given birth.
·                   A personal history of breast cancer or benign (noncancer) breast disease.
·                   A mother or sister with breast cancer.
·                   Treatment with radiation therapy to the breast/chest.
·                   Breast tissue that is dense on a mammogram.
·                   Taking hormones such as estrogen and progesterone.
·                   Drinking alcoholic beverages.
·                   Being white.
Breast cancer is sometimes caused by inherited gene mutations (changes).
The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up approximately 5% to 10% of all breast cancer. Some altered genes related to breast cancer are more common in certain ethnic groups.
Women who have an altered gene related to breast cancer and who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of developing ovarian cancer, and may have an increased risk of developing other cancers. Men who have an altered gene related to breast cancer also have an increased risk of developing this disease.
Tests that examine the breasts are used to detect (find) and diagnose breast cancer.
A doctor should be seen if changes in the breast are noticed. The following tests and procedures may be used:
·    Mammogram: An x-ray of the breast.
·   Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, the doctor may need to remove a small piece of the lump. Four types of biopsies are as follows:
·    Excisional biopsy: The removal of an entire lump of tissue.
·    Incisional biopsy: The removal of part of a lump or a sample of tissue.
·    Core biopsy: The removal of tissue using a wide needle.
·    Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.
·         Estrogen and progesterone receptor test: A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If cancer is found in the breast, tissue from the tumor is checked in the laboratory to find out whether estrogen and progesterone could affect the way cancer grows. The test results show whether hormone therapy may stop the cancer from growing.
·          MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options depend on the following:
·      The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
·                   The type of breast cancer.
·                   Estrogen-receptor and progesterone-receptor levels in the tumor tissue.
·                   Whether the cells have high levels of human epidermal growth factor type 2 receptors (HER2/neu).
·                   How fast the tumor is growing.
·                   A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
·                   Whether the cancer has just been diagnosed or has recurred (come back).
After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.
The process used to find out whether the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.
There are three ways that cancer spreads in the body.
·                   Through tissue. Cancer invades the surrounding normal tissue.
·                   Through the lymph system

• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

The following stages are used for breast cancer:
Stage 0 (carcinoma in situ)
There are 2 types of breast carcinoma in situ:
Ductal carcinoma in situ (DCIS)
 
Lobular carcinoma in situ (LCIS)
 
Stage I
In stage I, cancer has formed. The tumor is 2 centimeters or smaller and has not spread outside the breast.
Stage IIA
In stage IIA:
·                   no tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
·                   the tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
·                   the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB
In stage IIB, the tumor is either:
·                   larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
·                   larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA
In stage IIIA:
·                   no tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
·                   the tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
·                   the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
·                   the tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Stage IIIB
In stage IIIB, the tumor may be any size and cancer:
·                   has spread to the chest wall and/or the skin of the breast; and
·                   may have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.
Stage IIIC
In stage IIIC, there may be no sign of cancer in the breast or the tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:
·                   has spread to lymph nodes above or below the collarbone; and
·                   may have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.
Stage IIIC breast cancer is divided into operable and inoperable stage IIIC.
In operable stage IIIC, the cancer:
·                   is found in ten or more axillary lymph nodes; or
·                   is found in lymph nodes below the collarbone; or
·                   is found in axillary lymph nodes and in lymph nodes near the breastbone.
In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone.
Stage IV
In stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.
Four types of standard treatment are used:
Surgery
Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.
Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:
·                   Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
·                   Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.
Other types of surgery include the following:
·                   Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.
Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.
·                   Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy.
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, or hormone therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy
Radiation therapy
 
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body
Hormone therapy
Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing.
The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.
Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer
Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone-dependent breast cancer.
New types of treatment are being tested in clinical trials.
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Breast cancer

The incidence of breast cancer in India is on the rise and is rapidly becoming the number one cancer in females pushing the cervical cancer to the second spot. The seriousness of the situation is apparent after going through recent data from Indian Council of Medical Research (ICMR).

The rise is being documented mainly in the metros, but it can be safely said that many cases in rural areas go unnoticed. It is reported that one in 22 women in India is likely to suffer from breast cancer during her lifetime, while the figure is definitely more in America with one in eight being a victim of this deadly cancer.
 
Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.
The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.
Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels lead to organs called lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter lymph and store white blood cells that help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.
 
Breast cancer is the second most common type of cancer in American women.
Women in the United States get breast cancer more than any other type of cancer except skin cancer. The number of new cases has increased every year over the last 30 years. Breast cancer is second to lung cancer as a cause of cancer death in American women. However, deaths from breast cancer have decreased a little bit every year for the past several years. Breast cancer also occurs in men, but the number of new cases is small.
Avoiding risk factors and increasing protective factors may help prevent cancer.
Avoiding cancer risk factors such as smoking, being overweight, and lack of exercise may help prevent certain cancers. Increasing protective factors such as quitting smoking, eating a healthy diet, and exercising may also help prevent some cancers. Talk to your doctor or other health care professional about how you might lower your risk of cancer.
 
Finding and treating breast cancer early may prevent death from breast cancer.
The following risk factors may increase the risk of breast cancer:
Estrogen (endogenous)
 A woman's exposure to estrogen is increased in the following ways:
·         Early menstruation: Beginning to have menstrual periods at age 11 or younger increases the number of years the breast tissue is exposed to estrogen.
·         Late menopause: The more years a woman menstruates, the longer her breast tissue is exposed to estrogen.
·         Late pregnancy or never being pregnant: Because estrogen levels are lower during pregnancy, breast tissue is exposed to more estrogen in women who become pregnant for the first time after age 35 or who never become pregnant.
Hormone replacement therapy/Hormone therapy
 
·         Combination HRT/HT is estrogen combined with progesterone or progestin. This type of HRT/HT increases the risk of developing breast cancer.
·        Estrogen-only therapy may be given to women who have had a hysterectomy. It is not known if this type of HRT/HT increases the risk of breast cancer.
 
Exposure to Radiation
Radiation therapy to the chest for the treatment of cancers increases the risk of breast cancer, starting 10 years after treatment and lasting for a lifetime. The risk of developing breast cancer depends on the dose of radiation and the age at which it is given. The risk is highest if radiation treatment was used during puberty. For example, radiation therapy used to treat Hodgkin disease by age 16, especially radiation to the chest and neck, increases the risk of breast cancer.
Radiation therapy to treat cancer in one breast does not appear to increase the risk of developing cancer in the other breast.
For women who are at risk of breast cancer due to inherited changes in the BRCA1 and BRCA2 genes, exposure to radiation, such as that from chest x-rays, may further increase the risk of breast cancer, especially in women who were x-rayed before 20 years of age.
Obesity
Obesity increases the risk of breast cancer .
Alcohal
Drinking alcohol increases the risk of breast cancer. The level of risk rises as the amount of alcohol consumed rises.
Inherited Risk
Women who have inherited certain changes in the BRCA1 and BRCA2 genes have a higher risk of breast cancer, and the breast cancer may develop at a younger age.
The following protective factors may decrease the risk of breast cancer:
Exercise
Exercising four or more hours a week may decrease hormone levels and help lower breast cancer risk..
Estrogen (decreased exposure)
Decreasing the length of time a woman's breast tissue is exposed to estrogen may help prevent breast cancer. Exposure to estrogen is reduced in the following ways:
 
·                 Pregnancy: Estrogen levels are lower during pregnancy. The risk of breast cancer appears to be lower if a woman has her first full-term pregnancy before she is 20 years old.
·                 Breast-feeding
·                 Ovarian ablation: The amount of estrogen made by the body can be greatly reduced by removing one or both ovaries, which make estrogen. Also, drugs may be taken to lower the amount of estrogen made by the ovaries.
·                 Late menstruation: Beginning to have menstrual periods at age 14 or older decreases the number of years the breast tissue is exposed to estrogen.
·                 Early menopause: The fewer years a woman menstruates, the shorter the time her breast tissue is exposed to estrogen.
 
Selective estrogen receptor modulators
Selective estrogen receptor modulators (SERMs) are drugs that act like estrogen on some tissues in the body, but block the effect of estrogen on other tissues. Tamoxifen is a SERM that belongs to the family of drugs called antiestrogens. Antiestrogens block the effects of the hormone estrogen in the body. Tamoxifen lowers the risk of breast cancer in women who are at high risk for the disease. This effect lasts for several years after drug treatment is stopped.
Taking tamoxifen increases the risk of developing other serious conditions, including endometrial cancer, stroke, cataracts, and blood clots, especially in the lungs and legs. The risk of developing these conditions increases with age. Women younger than 50 years who have a high risk of breast cancer may benefit the most from taking tamoxifen. Raloxifene is another SERM that helps prevent breast cancer. In postmenopausal women with osteoporosis (decreased bone density), raloxifene lowers the risk of breast cancer for women at both high risk and low risk of developing the disease. It is not known if raloxifene would have the same effect in women who do not have osteoporosis .Raloxifene may increase the risk of blood clots, especially in the lungs and legs, but does not appear to increase the risk of endometrial cancer.
Aromatase inhibitors Aromatase inhibitors lower the risk of new breast cancers in postmenopausal women with a history of breast cancer. In postmenopausal women, taking aromatase inhibitors decreases the amount of estrogen made by the body. Before menopause, estrogen is made by the ovaries and other tissues in a woman's body, including the brain, fat tissue, and skin.
 
Prophylactic mastectomy
Some women who have a high risk of breast cancer may choose to have a prophylactic mastectomy (the removal of both breasts when there are no signs of cancer). The risk of breast cancer is lowered in these women. However, it is very important to have a cancer risk assessment and counseling about all options for possible prevention before making this decision. prophylactic mastectomy may cause anxiety, depression, and concerns about body image.
Prophylactic oophorectomy
Some women who have a high risk of breast cancer may choose to have a prophylactic oophorectomy (the removal of both ovaries when there are no signs of cancer). This decreases the amount of estrogen made by the body and lowers the risk of breast cancer.
 
Fenretinide
Fenretinide is a type of vitamin A called a retinoid. When given to premenopausal women who have a history of breast cancer, fenretinide may lower the risk of forming a new breast cancer. Taken over time, fenretinide may cause night blindness and skin disorders. Women must avoid pregnancy while taking this drug because it could harm a developing fetus.
 
The following have been proven not to be risk factors for breast cancer or their effects on breast cancer risk are not known:
Abortion
Oral Contraceptives
Taking oral contraceptives ("the pill") may slightly increase the risk of breast cancer in current users. This risk decreases over time.
Progestin-only contraceptives that are injected or implanted do not appear to increase the risk of breast cancer.
 
Environment
Certain substances in the environment (such as chemicals, metals, dust, and pollution) increases the risk of breast cancer.
Diet
 It is not proven that a diet low in fat or high in fruits and vegetables will prevent breast cancer..
Active and passive cigarette smoking
It has not been proven that either active cigarette smoking or passive smoking (inhaling secondhand smoke) increases the risk of developing breast cancer.
Statins
Studies have not found that taking statins (cholesterol -lowering drugs) affects the risk of breast cancer.
Cancer prevention clinical trials are used to study ways to prevent cancer.
New ways to prevent breast cancer are being studied in clinical trials.

• Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.
• Clinical breast exam (CBE) should be part of a periodic health exam, about every 3 years for women in their 20s and 30s and every year for women 40 and over.
• Women should know how their breasts normally feel and report any breast change promptly to their health care providers. Breast self-exam (BSE) is an option for women starting in their 20s.
• Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

 
 
Three tests are commonly used to screen for breast cancer:
Mammogram
A mammogram is an x-ray of the breast. This test may find tumors that are too small to feel. A mammogram may also find ductal carcinoma in situ, abnormal cells in the lining of a breast duct, which may become invasive cancer in some women. The ability of a mammogram to find breast cancer may depend on the size of the tumor, the density of the breast tissue, and the skill of the radiologist.
Clinical breast exam (CBE)
A clinical breast exam is an exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual.
Breast self-exam (BSE)
Breast self-exam is an exam to check your own breasts for lumps or anything else that seems unusual.
If a lump or other abnormality is found using one of these 3 tests, ultrasound may be used to learn more. It is not used by itself as a screening test for breast cancer. Ultrasound is a procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
New screening tests are being studied in clinical trials.
MRI (magnetic resonance imaging)
MRI is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). MRI does not use any x-rays.
In women with a high inherited risk of breast cancer, screening trials of MRI breast scans have shown that MRI is more sensitive than mammography for finding breast tumors. It is common for MRI breast scan results to appear abnormal even though no cancer is present. Screening studies of breast MRI in women at high inherited risk are ongoing.
In women at average risk for breast cancer, MRI scans may be done to help with diagnosis. MRI may be used to:
·                 Study lumps in the breast that remain after surgery or radiation therapy.
·                 Study breast lumps or enlarged lymph nodes found during a clinical breast exam or a breast self-exam that were not seen on mammography or ultrasound.
·                 Plan surgery for patients with known breast cancer.
Tissue sampling
Breast tissue sampling is taking cells from breast tissue to examine under a microscope. Abnormal cells in breast fluid have been linked to an increased risk of breast cancer in some studies. Scientists are studying whether breast tissue sampling can be used to find breast cancer at an early stage or predict the risk of developing breast cancer. Three methods of tissue sampling are under study:
·                 Fine-needle aspiration: A thin needle is inserted into the breast tissue around the areola (darkened area around the nipple) to withdraw cells and fluid.
·                 Nipple aspiration: The use of gentle suction to collect fluid through the nipple. This is done with a device similar to the breast pumps used by nursing women.
·                 Ductal lavage: A hair-size catheter (tube) is inserted into the nipple and a small amount of salt water is released into the duct. The water picks up breast cells .
 
 
Recommendations for Breast Cancer Screening

 Age

 Screening

 20-39

 40-49

 50-75

 75+

Breast self-exam

Monthly

Monthly

Monthly

Monthly

Clinical breast exam by a doctor

Every 3 years

Yearly

Yearly

Yearly

Mammogram

 —

Yearly, depending on your health history or preference

Yearly

Determined by patient and doctor preference