Worldwide, breast cancer is the most common invasive cancer in women. Breast cancer comprises 22.9% of invasive cancers in womenand 16% of all female cancers. In 2008, breast cancer caused 458,503 deaths worldwide
Risk factors for developing breast cancer
The risk of developing breast cancer is predominantly determined genetically. Therefore, the risk for any individual increases rapidly if two or more first-degree relatives have had breast cancer. Other risk factors are late age of first pregnancy, obesity, history of cancer in the contralateral breast, endometrial and ovarian cancer, old age, nulliparity, menarche <12years; menopause >55years, excessive alcohol intake, high fat diet and a history of low-dose irradiation
Radiographic screening
It is important to offer screening tests to woman with an increased risk of developing breast cancer. Mammography is the most commonly used screening test, with the aim of detecting breast tumours before they are even clinically palpable. Mammography should be repeated two-yearly in high risk patients from age forty, and annually after age fifty. Woman with a low risk also benefit from mammography. An initial test should be performed at age fifty with follow-up tests performed every 2-5years.
Signs and symptoms
The most common presenting symptom in breast cancer is a palpable breast lump, mostly discovered by the patient herself. Other symptoms of breast cancer include blood stained nipple discharge, skin or nipple retraction, skin oedema, hardness and shrinkage of the breast.
It is important to educate woman about breast self-examination and awareness, as this may lead to earlier recognition of possible signs of breast cancer.
The technique of breast self-examination
Breast self examination is best performed after the menstrual period when the breasts are soft. The breast tissue tends to be more nodular and painful in the premenstrual phase making the assessment more difficult. The technique consists of a thorough inspection, followed by systemic palpation of the breast tissue.
Inspection is best performed in the upright position in front of a mirror or a family member. The shape, size and skin of each breast should be inspected with care. Important signs to look for are nipple retraction, skin retraction, nipple discharge and discoloration of the skin.
Palpation of the breasts is done with the opposite hand while lying down. Breast tissue is systematically palpated between flat fingers and the chest wall. To ensure palpation of the entire breast, it should roughly be divided into quadrants, where after each quadrant, including the area under the areola, should be examined.
Breast lumps
It is important to remember that nine out ten breast lumps felt on examination are non-cancerous. Many diseases can cause a lump in the breast, of which fibrocystic disease is the most common. It is a condition of women in the later reproductive years and is caused by the effect of hormones on the breast. Patients may present with pain in the breasts, which may by cyclical or may even bring about discomfort on a daily basis. On palpation of the breasts, tender often multiple nodules can be detected in both breasts. These nodules are movable and varying in size.
Fibroadenoma is a benign tumour which occurs in young women as a palpable round, firm, mobile and non-tender mass. Excision biopsy is recommended in these patients, not only to prevent discomfort, but to exclude carcinoma.
When a solitary hard irregular nodule is detected on palpation of the breasts, one gets suspicious of carcinoma, especially if it feels immobile. Although a clinical suspicion of malignancy is important, carcinoma of the breast is diagnosed with biopsy or in certain instances by fine needle aspiration of a lump.
Treatment of breast cancer
There are several different types of breast cancer, the most common being infiltrating ductal carcinoma. The exact pathological type does not strongly predict the outcome of the disease, although infiltrating ductal carcinoma tends to have a poorer outcome with treatment.
Histological grading of the tumour is important, as this directly influences the prognosis of the disease for e.g. a poorly defined tumour, measuring more than 5 cm, with metastasis is known as a grade 4 tumour. It has a poorer prognosis compared to a localised cancer with a diameter of less than 2 cm, which is a grade 1 tumour.
The aim of breast cancer treatment is to get local control and prevent metastases. This is classically obtained through mastectomy and dissection of the axillary lymph nodes. In early stages, some patients qualify for breast-sparing operations. In these procedures, the tumour is excised locally with wide margins, together with lymph node dissection where after the remaining breast tissue is treated with radiotherapy.
Depending on the histological staging post-operatively, patients might have to undergo chemotherapy or hormonal therapy.
Conclusion
The prognosis and survival rate varies greatly depending on cancer type and staging. With best treatment and dependent on staging, five year relative survival varies from 98% to 23%, with an overall survival rate of 85%.
www.mybreast.org.za; www.cansa.org.za
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