Clinical Laboratory Science of Breast Cancer

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Introduction

The word cancer is itself so much dreaded by people that the very occurrence of the disease takes half of the life away from the patient and the relatives. The chances of getting cured stays away because the tendency to fight back is lacking among people encountering cancer. But the correct information about the disease and the ways to fight it coupled with positive attitude can work wonders and increase life expectancy, irrespective of the area affected by cancer including breast cancer, the most common cancer seen in women.

The most horrific moment a woman experiences when she knows that her mammogram has shown abnormalities suspected to be cancer or that a biopsy report has confirmed breast cancer. “Breast cancer accounts for 10.4% of all cancer causes in women all over the world and after lung cancer it stands as the second most common non – skin cancer” (Nicolini 436-471). In terms of causing cancer deaths this cancer stands fifth mainly taking toll on women between the ages 45 to 55. Breast cancer had caused 519,000 deaths in 2004. Though breast cancer is commonly a cause of concern in women, men do have breast cancer which is about 1% in occurrence. Poor detection is likely in the cases of male encountering breast cancer and that worsens the situation (Nicolini 436-471).

Breast cancer can be detected from abnormalities in mammogram, lumps and changed consistency of the breast tissues. The treatment of this disease involves surgery followed by drugs which interfere with the production of estrogen and progesterone. These drugs have strong side effects like impaired fertility.

“Sometimes treatment can be done with hormone therapy and radiation for cancers sensitive to hormones. The cancers which are not hormone sensitive or have spread to lymph nodes of armpits or have some genetic features are aggressive and they are treated aggressively as well” (Leach 17-27).

Structure of Breast

It is true that breast cancer is associated with the fears of death, surgery, loosing the shape of the body and sexuality but timely detection can lead to increased rate of survival and deal with many of those fears. Awareness plays a very vital role in early detection of breast cancer (Leach 17-27).

Medical Definition

Breast cancer, like any other cancer, is the result of “uncontrolled growth of cells in the breast” (Leach 17-27). It could be stated that “The term ‘breast cancer’ refers to a malignant tumor that has developed from cells in the breast” (breastcancer 1). It is necessary to know how the formation of cancers in the body from the cells takes place to understand breast cancer properly.

In every cell of the body there is a nucleus which is the control room of the cell and it contains the genetic matter. The genes carry the instructions to form a healthy human body. The cells of a human body divides in a regularly fashion through which older cells die and the new cells take their place to carry on with the regular activities. Certain genes need to be active and certain and genes need to stay inactive for a body to stay disease free. But certain incidents like mutations might change the genes abnormally and their functions become modified. The inactive genes become active whereas the active genes might get inactive. Because of this, cells start dividing and growing abnormally. The cell division and growth simply goes out of order and the uncontrolled growth ultimately results in a tumor (Nicolini 436-471).

Mammogram showing breast cancer

Tumors can be just a harmless lump of cells which pose no threat to the health and are known as benign tumors. These are slow growing cells generally similar looking to normal cells and never invade the cells and tissues of other parts of the body. These are non cancerous. But tumors which grow aggressively and invade tissues of the other body parts of organs beyond the boundary of the tumor itself are known as malignant tumors. These are potentially dangerous and are the causes of cancer when left unchecked.

Such a malignant tumor when is formed inside the breast it becomes the foundation of breast cancer. In common occurrences the breast cancer starts in the lobule or the ducts.

“The lobules are the milk producing glands and the ducts are the carriers of the milk from the lobules to the nipples. “Cancer can originate in the stromal tissue also, that is the fatty tissue and the fibrous connective tissues of the breast but that are rare in occurrence” (Hay 517-534).

With the advancement in the growth of the malignant tumor the cancerous cells start invading the healthy cells of the breast and cancer starts spreading beyond the point of its origin. Gradually the cancer spreads to the lymph nodes in the arm pits and from there it spreads to the other organs through the lymph. When the stage of the cancer in the breast is referred it is actually denoted that how far the cancer has spread beyond its point of origin (Hay 517-534).

Breast cancer has a deep relation with the genetic material of the human body and its abnormalities caused due to various reasons. The abnormality might be inherited from either of the parents which are about 5% to 10% in occurrence. Rest 90% genetic abnormalities occur either due to aging process or any other reason. According to Marisa Weiss M.D., president and founder, breast radiation oncologist, Philadelphia, PA,

“Just think about the many things that might cause the wear and tear that leads to abnormal cell growth—pollutants, hormones, pesticides, smoking, alcohol use, obesity, stress…. Or maybe your cells just made a mistake one day when they were making new genes to pass on to their baby cells. Perhaps there was a misprint in the genetic instruction manual that said switch growth on instead of growth off. This is a test” (breastcancer 1).

Classification of breast cancer can be done from various angles Viz. “Stage of the cancer, pathology, grade, status of the receptor and presence of genetic matter in the cancer cells” (Pandey 386-392).

Stage measures the size or advancement of the cancer that is how big the tumor has grown, has it advanced to the lymph nodes of the arm pits or not or whether it has metastasized or not. A stage 0 represents the in situ condition that is before the tumor spreading anywhere. Next stages from 1 to 3 represents early cancer where there are chances to get cured. The 4^th stage is the most advanced stage and is not curable. The higher the stage the more is the danger.

Pathology of the cancer determines whether the origin of the cancer is from the epithelial layers or other tissues, whether it is invasive or not. More rapidly growing and invasive carcinomas are more dangerous. Cell growth is measured by Ki67 protein which also can give some idea of the treatment the cancer is going t response to.

Grade indicates the extent of disruption the cancer cells have caused to the normal milk duct cells. Cancer cells generally cause the duct cell nuclei to become irregular and cells fail to differentiate properly. High grade cancer refers to undifferentiated cells and well differentiated cells represent lower grade of cancer. There is an intermediate grade also (Nicolini 436-471).

Presence of certain receptors in the cytoplasm and nuclei of the cancer cells indicate whether there is need of certain hormones for the growth of these cancer cells. Generally these receptors are

“identified by immunohistochemistry and are classified as the Estrogen Receptor (ER), Progesterone Receptor (PR) and HER2/neu. Based upon the presence and absence of these receptors a cancer cell is called positive or negative” (Nicolini 436-471).

ER+ cells have receptors for Estrogen and are generally treatable with the administration of drugs that interfere with the production of Estrogen in the body like tamoxifen. The HER2+ cancer cells are harder to treat and are treated with chemotherapy combined with monoclonal antibody drugs like trastuzumab. The triple negative cancer cells that do not have any kind of receptors for any hormone are the most difficult to treat with and have poor chance of recovery. Actually the receptor status is of great help to determine the treatment to be pursued and to figure out the chances of success in recovery.

Presence or absence of genetic material in the cancer cells and their difference in gene with the normal cells of breast can be determined through various tests. There have been evidences of differences but how much significance that has in the process of treatment is questionable.

“Tests like Oncotype DX which is supported by level II evidence is approved by the American Society of Clinical Oncology but not by Food and Drug Administration (FDA). FDA on the other hand approved MammaPrint which is supported by Level III evidences. Other tests are also available which are supported by Level III evidences like Theros and MapQuant Dx, but no test is supported by the Level I evidences” (Pandey 386-392).

Breast cancer when identified from histological point of view can be of two types basically, firstly, Ductal Carcinoma and secondly Lobular carcinoma.

Ductal Carcinoma – “the cancer which starts in the lining of milk ducts in the breast below the areola and nipple is called the ductal carcinoma” (Pandey 386-392). Ductal carcinoma ranges between 85 – 90% among all cancer cases. A ductal carcinoma can be treated successfully when it is a Ductal Carcinoma in Situ (DCIS), that is non invasive in nature. It can be removed surgically using lumpectomy and then treated with radiation when the tumor margins show no trace of cancer. But is a tumor is invasive and spreads to healthier tissue around, a mastectomy becomes a must and that generally is followed by chemotherapy.

Lobular Carcinoma – “the cancer which starts in the lobules that is the milk producing glands located beneath the ducts is called the lobular carcinoma” (Liu 283-291). Lobular carcinoma accounts for about 8% of all the cancer cases. “Like ductal carcinoma when the lobular carcinoma is not invasive and of LCIS that Lobular Carcinoma in Situ type the tumor is removed by lumpectomy and then followed by radiation” (Liu 283-291). But if it becomes invasive and spreads to other breast tissues then a mastectomy would be conducted followed by chemotherapy.

Another group of breast cancer is “Invasive or Infiltrating Breast cancer” (Eun 84-91). This type of cancer generally spreads to other parts of the breast and body beyond the margin of the original tumor. There are many subtypes of this type of breast cancer.

Rare in occurrence but highest in aggressiveness is “Inflammatory Breast Cancer” (Eun 84-91) where there is no lump formation. Instead nests of cancer cells are found. This cancer appears either on the skin or in the soft tissue of the breast beneath the skin. This type of cancer can also be treated to increase the survival rate if detected early. In this case the treatment is chemotherapy first and then surgery.

The least common type of breast cancer is the “Paget’s disease of the Nipple or areola” (Eun 84-91). This is a rare cancer where the skin appears like having some itchy skin rashes or eczema. In this type of cancer the cancer generally invades the nipple, areola and the ducts and ultimately reaches the skin just before breaking through. A mastectomy is a must for this type of cancer (Makrigiannakis 534-542).

Stages of Breast Cancer are referred to as Stage 0, I, IIA, IIB, IIIA, IIIB, IIIC and IV according to either the size of the tumor or the invasion made by the cancer cells in the healthier breast tissues or outside.

Stage 0: The stage which indicates that the tumor is still at the point of its origin and has not invaded the adjacent healthier tissues.
Stage I: This stage indicate that the tumor has grown up to 2 centimeters or less but has not made advance outside the breast and has not reached the lymph nodes (Makrigiannakis 534-542).
Stage IIA: This is a very important stage of the ailment.

“This stage either indicates the arm pit lymph nodes that is the axillary lymph nodes showing presence of cancer cells but no tumor in the breast can be found, or a tumor up to or less than 2 centimeters is found in the breast which has affected the axillary lymph node, or the size of the tumor has grown between 2 to 5 centimeters without affecting the lymph node in the arm pit” (Khan 677-686).

Stage IIB: This is a stage when the tumor either grows more than 5 centimeters in size but does not affect the axillary lymph node or it indicated that the tumor has not grown beyond 5 centimeters bur has already affected the axillary lymph node and this stage could be considered as a break-even point of the ailment that can increase the risk in the future.
Stage IIIA: The tumor in this stage might be of any size or there might not be any tumor in the breast and the cancer cells reach the lymph nodes of arm pit and the lymph nodes near the breast bone. The cells might stick together or to the other organs.
Stage IIIB: “At this stage generally the tumor reaches the skin of the breast or the wall of the chest and affects the lymph nodes of arm pit and lymph nodes near the breast bone” (Makrigiannakis 534-542). The cells might stick to each other or to other organs.
Stage IIIC: The next stage is of extreme importance.

“Tumor of any size might be found inside the breast or no tumor might be found and the cancer cells already reach the breast skin or chest wall, the axillary lymph nodes and the lymph nodes near the breast bone. Along with that the cancer also reaches the lymph nodes of collar bone, either above or below” (Khan 677-686).

Stage IV: This is the final stage when the cancer has already spread to the other body parts or metastasized (Makrigiannakis 534-542).

The success in the treatment of cancer depends greatly on the stage in which it is detected as that dictates the possibilities of cancer cells being controlled by drugs or radiation.

Medical History

In the history of tumors causing cancers breast cancer is possibly the earliest known disease found in history. Instances of breast cancer had been found long back in 1600 BC in Egypt and were described in the Edwin Smith Papyrus. Cases of breast tumors and ulcers were depicted there and though treated by cauterization the diseases were described to be having no treatment. The disease was very less understood and for long it was only referred to as some untreatable disease by physicians.

A little step forward was taken after the understanding of the fact that there is a relation between the axillary lymph node that is the lymph node in the arm pit and spreading of breast cancer. This understanding was possible after the better acquisition of knowledge on the circulatory system and its functions in the 17^th century.

“The first successful surgery was conducted on breast to remove the lymph node, parts of the breast tissue and parts of chest muscle by French Surgeon Jean Louis Petit (1674–1750) who was followed by Scottish surgeon Benjamin Bell (1749–1806)” (Ogura 46-53).

Mastectomy surgery is of extreme importance in this stage.

“Mastectomy surgery was started by William Stewart Halsted in 1882 who ahcieved success in performing radical mastectomies. Radical mastectomy involed removal of one or both the breasts, lymph nodes and chest muscles and was the only way to treat cancer and to stop it from recurring” (Metodiev 181-194).

The extent of pain resulting from the mastectomy was quite high though and it caused disability also but it remained as the only treatment of breast cancer till 1970s. In 1970s the phenomenon of metastasis was quite researched upon and new facts came out. Better understanding of breast cancer was achieved and both its localized and metastasized forms were better explored. This helped in evolution of other methods of surgery which were less severe with equally effectively (Khan 677-686).

Incidence

Breast cancer incidents are found all over and it accounts for 16% of all the female cancer cases.

“After skin cancer it is the highest common cancer in women. The wide spread occurrence of this cancer can be guessed from the fact that breast cancer is found twice in number than the colorectal cancer and cervical cancer and the number is three times than the number of lung cancer” (Metodiev 181-194).

Number of breast cancer occurrences has phenomenally increased compared to that of 1970s due to the various reasons imparting adverse effect on women’s health in recent times including lifestyle and deaths caused by breast cancer is 25% greater in number than the deaths caused by lung cancer (Ogura 46-53).

The studies worldwide show that age plays a vital role in the development of breast cancer. Mostly women over 40 are susceptible to breast cancer, but in 5% cases younger women can become victims. If a woman has a family history of breast cancer in her first degree relatives that is mother or sister then there is almost twice possibility of getting breast cancer by her. Cancer occurrences are generally the results of inheritance of mutated genes from either of the parents. “The mutated BRCA1 and BRCA2 genes cause breast cancer most commonly” (Metodiev 181-194). It has been reported by Ogura that,

“Women with mutated BRCA1 genes are exposed to 80% risk of developing breast cancer and that too before the age of 50. Men also are exposed to the risk of developing breast cancer in the same situation but the risk involved is only 1% and that is generally by the age of 70. In case there is a mutated BRCA2 gene the risk for men goes up to 6%” (Ogura 46-53).

All these indicate that more than heredity the cause of breast cancer can be blamed on the abnormalities arising in the genes due to the aging process. Gender is also a factor along with age as women are almost 100 times more susceptible to breast cancer.

The frequencies of incidents though are not equal worldwide. Generally more number of breast cancer cases surface in the more developed countries whereas the number of breast cancer cases surfacing in the less developed and the developing countries are lesser in number. Age standardized studies around the world on breast cancer shows varied results in twelve world regions concerning the number of breast cancer cases per 100,000 women. North America topped the figures with 90 cases and Eastern Asia showed the least number with 18 cases. South Central, South Eastern and Western Asia scored 22, 26 and 28 respectively whereas sub Saharan and North Africa scored 22 and 28 respectively (Ogura 46-53). Among Europe, Eastern, Southern and Northern Europe scored from moderate towards the higher end with 49, 56 and 73 respectively and Oceania was also on the higher side scoring 74. The score of Western Europe was alarmingly high with 78 cases and South & Central America scored a moderate 42 cases (Metodiev 181-194).

In United States

Previous studies showed that out of every 8 cases 1 woman in likely to encounter breast cancer in United States a death chances are one out of every 35 cases. But recent studies have cut that figure down to only 6%. “The rate of incidence is highest in the United States in the world as 128. 6 cases are found in every 100,000 white women and 112. 6 cases of breast cancer are found in 100,000 African Americans” (Fetscth 319-328). It is reported that “the second most common cancer and also the cause of death after skein and lung cancers respectively” (Fetscth 319-328). It has been further reported by Fetscth that “450 – 500 male deaths were also there among the 40,910 death cases in 2007 which is 2% of all the deaths and 7% of all cancer deaths” (Fetscth 319-328).

In 2009 the number of cases of invasive breast cancer detected in the United States was 192, 370 and the cases of non invasive breast cancer was 62, 280. in 2008, 1990 cases of breast cancer was reported among men. It is a good thing that the incidence rate of breast cancer has reduced by almost 2% within the span of years from 1999 to 2006, including the Native Americans and Alaskan Natives. Studies say that this reduction is due to the reduction in the number of women going for Hormone Replacement Therapy (HRT). This indicates that there is a relation between HRT and breast cancer. Though 40,170 women suffering from breast cancer were facing death in 2009 there has been a notable decrease in the death rate as well. Rapidly increasing awareness and advancement in the treatment of breast cancer has succeeded to increase the survival rate. In 2008, the number of women surviving breast cancer went up to 2.5 million (Eun 84-91).

“The African American women get breast cancer less than the white women of America, but the white women die in lesser number than the African American women” (Eun 84-91). That might be is because the African American women get more aggressive type of tumor when they get cancer. The biological factor that controls this kind of distinction is not known till today. Might be the formation of estrogen receptor negative cancer cells render the treatment difficult as they do not respond to the hormone treatment, which is quite effective for the white women. But there is a lot of disparity in the treatment even when the cancer has been diagnosed. Lack of access to proper screening and advanced treatment contribute a lot in this high death rate of the African American women (Szabo 197-208).

Incidence Rate in Other Countries

Among the other developed countries the United Kingdom encounters about 45,000 cases of breast cancer every year. Death rate is 12,500 annually among those cases getting diagnosed with cancer. “Treatment mainly is done with Tamoxifen which again becomes ineffective in almost 35% cases” (Eun 84-91).

It is reported by Eun that “In the countries of South America like Argentina, Uruguay and Brazil breast cancer is a major concern relating women’s health” (Eun 84-91). The rate of mortality is also a matter of concern. The developing countries of the other part of the world also have become exposed to different practices harmful for the women’s health like the intake of alcohol, smoking, increased intake of oral contraceptive pills, lack of breastfeeding habit etc. These have in turn increased the rate of breast cancer and death rate related to that.

Researches and Experiments

As the issue of breast cancer has been a major health concern there has been significant amount of researches in the field of breast cancer to find a way to fight this disease. The understanding of breast cancer has increased over the time since the understanding of the functions of the circulatory system in the body. The researches have not been conducted from a single perspective but a number of angles have been taken into account at different times and inferences incurred from those researches regarding the behavior of the cancer cells in response to drugs.

Experiments with Breast Cancer Cell Lines

Both in vivo and in vitro studies have been conducted on the Breast Cancer Cell (BCC) Lines which have provided quite lot of information about the breast carcinomas. The BCC can be cultured in simple standard media as they are free from stromal cell contaminants, are homogenous and are self replicating in nature. It is reported by Quan that “Significant work has been conducted in this area to obtain permanent lines but after the first permanent cell line BT – 20 was described in 1958 not more than 100 cell lines could be obtained” (Quan 194-198). There had been a lot of technical difficulty in the field of extraction of viable Breast Cancer Cells from the surrounding cells of the stroma of the primary tumors and that hindered the success of culturing BCC from the tumors in the laboratory. “That is why the majority of BCC lines came from the metastatic tumors particularly the pleural effusions” (Quan 194-198). It is possible to extract viable breast cancer cells from the pleural effusions as they are dissociated there and are free fro fibroblasts and other stromal contamination of the tumor. In 1970s many cell lines were established and they are largely used in today’s experiments. The prominent cell lines are “MCF – 7, T – 47D, MDA – MB – 231 ETC” which have been mainly used in the studies of the breast cancer cell lines (Eun 84-91).

These cell lines are used to culture the breast cancer cells which in turn are experimented on to see the response of various drugs on them either individually or in combination with other drugs. Radiation and surgical techniques are also applied to the cell cultures to obtain information. The experimentation is done in randomized and controlled environments. These researches have helped and are still helping to evaluate the usefulness of certain drugs and also to compare the drugs. The research on breast cancer is an ongoing process and every year new results and outcomes are emerging.

“To keep the world updated with the most recent results the results are annually reported in the scientific meetings held by institutes like American Society of Clinical Oncology or the San Antonio Breast Cancer Symposium or the St. Gallen Oncology Conference in Switzerland” (Quan 194-198).

These reported results are then reviewed to form guidelines for specific treatments for specific risk groups and stages by the different organizations (Pockaj 447-455).

Causes

There is no single reason to which the occurrence of breast cancer can be blamed. There are several factors that work for individuals to different extent to cause varying degree of impact and result in breast cancer. These reasons include age, gender, lack of breastfeeding, elevated hormone levels and certain harmful practices like smoking. There are chances of getting breast cancer as a result of heredity but the percentage is 5% only.

The main causes of breast cancer can be jotted down as follows:

Age: the more the age, the greater is the chances of getting breast cancer. Actually the risk of a 50 year old woman getting breast cancer is almost 8 folds than a 30 year old woman. Generally deaths related to breast cancer is the highest among all cancer deaths of women in the age group of 40 to 45. Younger women are less likely to get breast cancer except in cases with family history of breast cancer.
Gender: Pockaj reports that “women are likely to get breast cancer 100 times more than men” (Pockaj 447-455). However, it should be noted that according to Pockaj, there are cases of male breast cancers occurring every year and annually deaths are also reported but this accounts for 1% only (Pockaj 447-455).
Previous occurrence of breast cancer: there are chances of developing a new cancer from a new location in a patient previously diagnosed with breast cancer. “This is a second or new cancer and never a recurrence of the previously treated one” (Pockaj 447-455). The risk of a woman getting a new cancer becomes 10% to 15% more after 20 years of being diagnosed with the previous cancer as the chance of a new cancer increases every year by 0.5% to 0.7%. “If the previous carcinoma was lobular the chances of the new cancer increases by 10% to 30% but in case of a previous ductal carcinoma the new cancer chances become 30% to 50% greater” (Quan 194-198).
History of family with breast cancer: It should be noted that “the chances of getting breast cancer as a result of family history are about 10% to 15%” (Pockaj 447-455). Generally a woman is more at risk (almost twice) of getting breast cancer when any of her first degree relatives like mother sister or daughter has been detected with breast cancer. If several generations of the family had that history or the first degree relative had a cancer before menopause or if it had involved both the breasts the chances increase quite significantly. Other inherited diseases like the La – Fraumeni Syndrome or the ataxia telangiectasia also increase the risk of getting breast cancer significantly (Eun 84-91).
Mutation in the genetic material: A prominent reason of getting breast cancer is mutation of genes in the cells of the individual. The two commonest genes studied as the reasons of breast cancer in their mutated forms are BRCA1 and BRCA2. It has been seen that in women with mutated BRCA1 the lifetime chances of getting breast cancer by the age of 50 increases by 90%. BRCA1 even stands as a cause of ovarian cancer as well. “There are many other genes that contribute to breast cancer like the HER – 2/neu oncogene, p53, AT, the GADD repair group and the RB suppressor gene” (Fobair 579-594). Some of these speeds up the metastasis and some are directly responsible for the occurrence of breast cancer.
Level of Hormones: Female sex hormone estrogen is responsible for female characters in a woman but prolonged exposure of the body to this hormone increases the chances of getting breast cancer. Prolonged exposure can occur to estrogen if a woman has very early onset of menstrual cycle, late menopause, late or no pregnancies at all or takes oral contraceptive pills for long that is more than 10 years. “Some older woman face the risk of breast cancer because of Estrogen Replacement or Hormone Replacement therapies used to relieve the menopausal symptoms” (Liu 283-291). This risk becomes minimized 5 years after stopping the therapy. Liu farther indicates that proper and measured exercise can reduce the estrogen level in the body by inhibiting ovulation and thus exercise may help to avoid breast cancer.
Body Fat: “Body fat manufactures aromatase, an enzyme having the capacity to synthesize estrogen from the steroid androstenedione released by the adrenal glands” (Liu 283-291). Therefore excess body fat might account for increased estrogen levels in post menopausal women thus increasing the risk of getting breast cancer (Makrigiannakis 534-542).
Other benign breast diseases: generally, “the benign breast diseases like the fibrocystic disease are only the temporary changes in the breast which come and go with the menstrual cycle and never are reasons or threat of cancer” (Liu 283-291). But there are some cases when there are risks of cancer because of the changes caused by the benign diseases in the breast. There are cases, provided by Liu, that indicate the principal and example of such cases establish that there are Fibroadenoma or tumor made of glandular tissue, Hyperplasia or unnatural increase in the number of cells and Atypia or cells with abnormal structure the chances of getting cancer increases mainly significantly in women with family history of breast cancer. Otherwise hyperplasia alone or coupled with atypia increases the chances of getting cancer almost 5 times (Liu 283-291).
Consumption of Alcohol: The chance of encountering breast cancer is higher in women who consume alcohol. Taking more than two drinks a day increases the estrogen level in the blood which subsequently increases the risk of breast cancer. If the number of drinks is more than 3 the risk of getting cancer becomes almost three times greater.
Exposure to radiation: any kind of radiation increases the chance of breast cancer greatly. “If there has been any reason for which the chest area has been exposed to radiation in the earlier ages, the chances of breast cancer increases” (Nicolini 436-471).
Exposure to Pollutant: some environmental pollutants like the pesticides of organochloride origin increase the risk of breast cancer (Pandey 386-392).
Smoking: though smoking does not have any direct impact on breast cancer it is advisable to quit smoking as smoking is the reason for many other cancers. More over smoking prevents certain types of reconstructive surgeries also.

Symptoms

Generally the first symptom of breast cancer is a small lump which can be felt distinctly from the other parts of breast. But that lump can be felt only when the cancer has advanced to some extent because the actual beginning of cancer does not cause any symptoms. Any lumps in the lymph node of the arm pits are also suggestive of probable breast cancer. The patient might feel it or the doctor can do that for her. Patient might feel the hardness of the painless lump and the irregular edges but those are not true always. Soft, rounded and tender lumps should not be neglected as cancers might form in that way also. Sometimes other non cancerous but serious breast infection or cysts might resemble cancer symptoms too. Therefore it is absolutely a must to check up any abnormality with the doctor. If there is a positive case of cancer it can be detected through mammogram (Nicolini 436-471).

The following symptoms are also found when there is a case of breast cancer apart from the lump.

“Changes in the shape and size of the breast” (Nicolini 436-471).
Dimpling of the skin or skin irritation.
Pain in the breast or the in the nipple.
Inversion of the nipple.
Lump in the underarm.
A single nipple spontaneous discharge other than breast milk.
Symptoms of Inflammatory Breast Cancer include itchiness and redness of the breast, warmth, swelling, pain and the texture of the breast becomes like orange peel (Fobair 579-594).

The symptoms of Paget’s disease include increased tenderness, burning sensation, itchiness and sensitivity of the breast with eczema like skin along with the lump in the breast.
In the advanced stage when the cancer metastasizes there appear some non specific symptoms like jaundice, fever, chills, bone and joint pains and other neurological symptoms.

The presence of some of these symptoms might indicate breast cancer but sometimes they can indicate other benign breast diseases as well. The benign diseases should also be taken care of as there are always increased chances of getting breast cancer from some of these diseases.

Symptoms of Brest cancer (Source: nursingcrib.com)

Diagnosis

Breast cancer is mainly diagnosed with the help of screening and other confirmatory tests. The tests which are useful in detecting suspected breast cancer are as follows:

Screening test: Not only for cancer patients but screening tests are necessary for women apparently healthy also. These tests include yearly mammograms which can detect cancer at very early stage. If there is an early detection there can be a successful treatment also.
Diagnostic Tests: These tests are taken based on the result of the screening test suggestive of cancer or if there are any suspicions about the presence of cancer in the breast. These tests can determine the spread of cancer too away from the breasts and suggest the course of treatment (Khan 677-686).
Monitoring Tests: Monitoring tests can tell about the progress of the treatment that is currently going on with the breast cancer and they can also indicate any signs of recurrence.

Typically the clinical detection of breast cancer is a combination of three tests and is known as the ‘triple test’ (Eun 84-91). The three tests include the clinical, examination of the breast by the doctor, a mammography to screening the lump and a Fine Needle Aspiration Cytology (FNAC) done to draw a little fluid from the lump probably with a local anesthesia. The fluid obtained indicates probable absence of cancer if it is clear but bloody fluid has to be sent for further analysis as that might be suggestive of cancer.

The above three tests present quite a reliable tool for detection of cancer. There are options of several types of biopsy like the core biopsy where a small portion of the lump is taken out for examination and excision biopsy where the entire lump is taken away and inspected. One more option of biopsy is there called the Vacuum Assisted Breast Biopsy (VAB) which is used to diagnose cancer among women detected with cancer through mammography.

Whatever the test, biopsy or Breast MRI, waiting for results is no doubt painful. But it has to be taken care that there is no lack of motivation in ensuring good health of the breasts irrespective of the results and keep positive attitude (Ogura 46-53).

Preventive measures

Breast cancer is dreaded by so many people for its potentially fatal consequences. Therefore many who have encountered this disease and survived would never like to get it back ever in life and even those never had this disease want to stay clear of it irrespective of whether they are of high risk group or not. Like all other diseases for breast cancer also it is better to prevent than cure.

It is well known that breast cancer has some genetic relation to it. Therefore all the factors causing the cancer can’t be avoided, but many lifestyles related which tend to cause the breast cancer can be changed and care can be taken to ensure that the breasts are at their best healthy conditions. This can reduce the chances of getting breast cancer to great extent.

A regular screening of the breasts like the annual mammogram and the examination by the doctor annually helps to ensure best health for the breasts. If there is any instances of cancer it can be detected by regular screening at a very early stage and therefore can be treated successfully to increase the survival chances.
If someone has a habit of smoking it should be given away for the betterment of health. Smoking increases the complexity of already existing breast cancer and has the potentiality to make the blood clot after hormonal therapies. Reconstructive surgeries are not possible for women who smoke.
Regular exercise is helpful in preventing cancer as it lowers the estrogen level in the blood. Lowered estrogen level means lower cell division rate which in turn reduces the chances of getting breast cancer. Another benefit of exercise is the strengthened immune system to fight any kind of illnesses (Leach 17-27).
Maintaining a healthy weight by reducing fat intake and increasing exercise is necessary. Excess fat leads to excess estrogen production which is a cause of breast cancer.
Exposure to estrogen should be reduced by stopping hormone replacement therapies and going for safer and natural ways to relieve post menopausal symptoms instead (Hay 517-534).
Leaving alcohol consumption totally or limiting it to a great extent helps to cut down estrogen level in the blood and reduces chances of getting breast cancer.
“A full term pregnancy followed by breastfeeding” (Eun 84-91) has a definite effect on the reduction of chances to get breast cancer. Estrogen of blood is balanced by other hormones and the chances of getting breast cancer reduce drastically.
“Good food and nutrition habits” (Eun 84-91) are very necessary to keep cancer at bay. Decreased animal fat intake along with increased fruit vegetables and other dietary fibers should be considered while planning a diet to stay healthy.
Relief from stress and relaxation are must to stay healthy. Relaxation enhances immune system and provides better chances to fight any illness by preventing any imbalance in the hormonal system of the body.

These good practices related to lifestyle changes can prevent people from many other illnesses along with cancer. So though we don’t have control over the genetic mutations or heredity there is something we can do to minimize the risk of breast cancer as far as possible.

Range of medical treatments

The treatment of breast cancer includes surgery, radiation and chemotherapy. First the lump or tumor is removed surgically from the breast and then radiation or chemotherapy or both of them are applied. The strength and duration of treatment depends on the stage of the cancer, its aggressiveness and the possibility of its recurrence in future.

Early stage breast cancers like those in the stage I and also the Ductal Carcinoma in situ (DCIS) cancers have very good chances of healing. The tumor is generally removed by using lumpectomy surgery and radiation or chemotherapy may or may not follow. But if the cancer is “aggressive HER2+ then treatment might include Trastuzumab (Herceptin) administration” (Eun 84-91).

The moderately advanced stages 2 and 3 are considered to have greater recurrence chances. The surgery involves either lumpectomy or mastectomy and the lymph node might also be needed to be removed. Surgery is followed by radiation and chemotherapy along with Trastuzumab for the HER2+ breast cancer.

The most advanced stage of breast cancer is stage 4 when the cancer already metastasizes and spread outside the breast. Though efforts are made to treat the cancer with a combination of surgery, radiation and chemotherapy this stage is not curable; treatment can increase life expectancy of about 6 months.

Medication for breast cancer

Administration of drugs is generally done after the surgery. But sometimes chemotherapy can be done prior to surgery as well. There are three types of medicines used for treating breast cancer.

Hormone Blocking Therapy: The cancer cells having Estrogen or Progesterone receptors can be treated with drugs that interfere with the production of these hormones in the body. Example of such drug is Tamoxifen.

Chemotherapy: Chemotherapy, the non hormonal drugs can be used in all the stages of cancer from stage 1 to stage 4. The chemotherapy drugs are generally used in combination as in cyclophosphamide plus doxorubicin (Adriamycin) or cyclophosphamide, methotrexate, and fluorouracil (CMF). These drugs have massive side effects as they attack the normal healthy cells also with the DNA of the cancer cells and heart gets damage due to that.

Monoclonal Antibody: previously mentioned drug Trastuzumab is a monoclonal antibody which is used to treat breast cancers of aggressive HER2+ type. The drug interferes with the HER2+ receptors on the cells and prevents them from dividing. Though having massive side effects on heart and being expensive Trastuzumab has lesser side effect than the conventional chemotherapy (Leach 17-27).

RadiationTherapy

Radiation therapy is applied in the site of surgery to deal with the cancerous cell that could not be removed by surgery. Radiation can be given externally or internally. The chances of recurrences reduce to considerable extent due to radiation therapy if applied properly (Eun 84-91).

Conclusion

Breast cancer is associated with a lot of fears and that is natural. The disease which claims so many lives every year is no doubt creates panic in the minds of both who has got it and who has higher risks of getting it. Those who have not got the disease and are not at risk want to stay clear of the distant chances of getting breast cancer. Known for its common occurrence in women breast cancer occurs to men and takes lives of men too.

Though the disease is dreaded it is better to approach it logically and understand it better to launch a tough fight against it rather than getting panicked. The disease occurs due to defect in genetic material also. Breast cancer is inherited in about 5% to 10% cases where it is transmitted from either of the parents. But the aging process leads to a wear and tear in the genetic material which causes breast cancer is rest and majority of the cases. The hereditary factors cannot be prevented but the rest factors can be taken care of by ensuring good breast health through regular screening and examination and by making changes in the lifestyle to make healthy habits (Leach 17-27).

If unfortunately the disease occurs in spite of all the precautions then it is better to keep the attitude rather than to get depressed. Early detection can be cured through surgery, medication and radiation. In the latter stages also the life expectancy can be increased through proper treatments. We have very advanced treatments today which can increase survival rates drastically. So keeping a positive attitude is the first and foremost necessity.

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