Treatment Information - Breast Cancer

A malignant tumor can invade surrounding tissue and destroy it and also send bacteria into the blood stream infecting other areas. This is how cancer spreads within the body. When breast cancer spreads outside the breast, cancer cells often are found in the lymph nodes under the arm. Cancer cells may spread beyond the breast such as to other lymph nodes, the bones, liver, or lungs (Although it is not common, some patients whose underarm lymph nodes are clear of breast cancer may still have cancer cells which have spread to other parts of the body).
When breast cancer spreads, it is called metastatic breast cancer even though it is found in another part of the body. For example, breast cancer that has spread to the bones is called metastatic breast cancer, not bone cancer.

Medical researchers are learning about what happens inside cells that may cause cancer. They have identified changes in certain genes within breast cells that can be linked to a higher risk for breast cancer. Breast cells contain a variety of genes that normally work cooperatively with a woman's natural hormones, diet, and environment to keep her breasts healthy. Certain genes routinely keep breast cells from dividing and growing out of control and forming tumors. When these genes become altered, changes occur and a cell no longer can grow correctly.

Genetic changes may be inherited from a parent or may accumulate throughout a person's lifetime. Breast cancer usually begins in a single cell that changes from normal to malignant over a period of time. Presently, no one can predict exactly when cancer will occur or how it will progress. When breast cancer is diagnosed - even if detected at the earliest stage - it is not yet possible to predict which cancer cells will be treated successfully and which will continue to grow and spread quickly to other parts of the body.

Are All Breast Cancers Alike?
Breast cancer is a complex disease. All cases are not the same. Once breast cancer has been found, more tests will be done to find out the specific pattern (description) of your disease. This important step is called staging. Knowing the exact stage of your disease will help your doctor plan your treatment.

Your doctor will want to know:

·1	The size of the tumor and exactly where it is in your breast.

·2	If the cancer has spread within your breast.

·3	If cancer is present in your lymph nodes under your arm.

·4	If cancer is present in other parts of your body.

Many breast cancers being found are very early cancers known as breast cancer in situ or noninvasive cancer. Most of these cancers are found by mammography. These very early cell changes may become invasive breast cancer.

Two types of breast cancer in situ are:

·1

DCIS (ductal carcinoma in situ), which means that abnormal cells are found only in the lining of a milk duct of the breast. These abnormal cells have not spread outside the duct. They have not spread within the breast, beyond the breast, to the lymph nodes under the arm, or to other parts of the body. There are several types of DCIS. If not removed, some types may change over time and become invasive cancers. Some may never become invasive cancers. (DCIS is sometimes called intraductal carcinoma.)

·2

LCIS (lobular carcinoma in situ), which means that abnormal cells are found in the lining of a milk lobule. Although LCIS is not considered to be actual breast cancer at this noninvasive stage, it is a warning sign of increased risk of developing invasive cancer. LCIS is sometimes found when a biopsy is done for another lump or unusual change that is found on a mammogram. Patients with LCIS have a 25 percent chance of developing breast cancer in either breast during the next 25 years.

Microcalcifications are very small specks of calcium that can't be felt, but can be seen on a mammogram. They are formed by rapidly dividing cells. When they are clustered in one area of the breast, this could be an early sign of breast cancer in situ. About half of the breast cancers found by mammography appear as clusters of microcalcifications. The other half appear as lumps.

To be sure that you have a correct diagnosis if breast cancer in situ is detected, an experienced pathologist should examine your biopsy slides. You may want to have your slides examined also by a second pathologist at a university hospital, cancer center, or breast clinic. This is important because it is sometimes difficult to make an accurate diagnosis. The pathologist needs to determine the types of cells that are present in the tissue sample, how fast the cells are changing, and whether it is likely to become invasive cancer. The diagnosis will help your doctor decide on the appropriate treatment from a wide range of choices. The decision could be to have frequent follow-up exams to watch the suspicious area, or surgery to remove only the affected tissue, or surgery to remove one or both breasts. Surgery removing only the affected area is sometimes followed by radiation therapy to the breast.

Breast lumps

Seven out of eight breast lumps are benign and are not cancers. Common causes of benign breast lumps are cysts (sacs of fluid which build up in the breast tissue) or fibroadenomas (solid tumors made up of fibrous and glandular tissue). Benign breast lumps are easily treated.
If you do notice a lump or are aware of any new change in your breast visit your doctor straight away.
Any different or unusual change in the breast should always be examined, because even though most breast lumps are benign, they still need to be checked carefully to rule out the possibility of cancer. Also, if it is cancer, the earlier the treatment is given, the more likely it is to be successful.

Certain women do seem to be at a higher risk of developing the disease. The risk of developing breast cancer increases as women get older. More than half of breast cancers occurs in women over the age of 65.

A very small number (less than 5 in 100) of breast cancer cases are caused by an inherited faulty gene. The abnormal genes, which lead to an increased chance of developing breast cancer, include BRCA1 and BRCA2. The following factors might indicate the possible presence of an inherited faulty gene within a family:

·1	Breast cancer in several close members of the same family.

·2	Other cancers, especially cancer of the ovary and colon, as well as breast cancer, in members of the same family.

·3	Breast cancer in a close relative when under the age of 40.

·4	Breast cancer in a close relative affecting both breasts.

What are the symptoms?
In most women, breast cancer is first noticed as a painless lump in the breast. There are, however, other signs to be aware of:
Breast:

·1	Change of size or shape

·2	Dimpling of the skin

·3	Lump or thickening

Nipple:

·1	Becomes inverted (turned in)

·2	Lump or thickening

·3	Bloodstained discharge (very rare)

Arm:

·1	Swelling or lump in armpit

Pain in the breast is not usually a symptom of breast cancer. In fact, many healthy women find their breasts feel lumpy and tender before a period, and some types of benign breast lumps are painful.

Early detection (screening)

The earlier a breast cancer is diagnosed and treated, the better the chance of successful treatment.

Breast self-awareness
Mammography can detect changes in the breast tissue before they develop into a lump large enough to be felt with the fingers. Nevertheless the majority of breast tumors are first detected by women themselves.
It is important to become familiar with how your breasts normally feel at different times of the month. You will then quickly be aware of any changes in your breasts that are not normal for you.
If you are concerned about anything unusual in your breasts, you should make an appointment to discuss this with your doctor.
If you feel uncomfortable or anxious about feeling your breasts, you may find it helpful to discuss your worries with your doctor or nurse, or the staff at a well woman clinic. They will be able to tell you about the changes you can normally expect to see in your breasts, and can advise you on the best way to become aware of how your breasts should look and feel.
Mammography
Mammograms (breast x-rays) can often detect cancer before it can be felt. The NHS offers mammograms to all women between the ages of 50 and 64, every three years, as part of a national breast-screening program. There are plans to extend the age of screening from 50 to 69. Women older than the upper age limit can have mammograms performed every three years on request.

Some women are concerned about having this type of regular screening, as each mammogram directly exposes the breasts to a small dose of x-rays. However, the tiny risk of these x-rays actually causing any harm is far outweighed by the benefits of detecting early breast cancer.

Women who are not in the national screening age group and who have a close relative with breast cancer can discuss with their doctor whether they should have regular screening before the age of 50.
It is important to remember that a small number of breast cancers don't show up on a mammogram. If you find a lump in your breast, despite recently having a mammogram which showed no cancer, it is important to have it seen by a doctor immediately.
How is it diagnosed?
You will probably begin by seeing your family doctor (general practitioner) who will examine you. Your GP may need to refer you to hospital for specialist advice or treatment.
At the hospital the doctor will take your medical history before carrying out a physical examination. They will examine your breasts and feel for any enlarged lymph glands under your arms and at the base of your neck. A chest x-ray and blood tests may also be taken to check your general health.
The following tests may be used in the diagnosis of cancer of the breast. You may have one or two of those listed, or a combination.
Mammography
This is a x-ray technique for examining the breast. It is especially useful for detecting early changes in the breast, which have not yet caused a lump. It is usually used for women over the age of 35, as in younger women the breast tissue is more dense and this can make it difficult to detect any changes on the mammogram. Some women find mammography uncomfortable or even painful because pressure is put on the breasts, but this only lasts a few seconds and is not harmful to the breasts.
Ultrasound
Ultrasound is used to see if a lump is solid or contains fluid a cyst. It is usually used in women under the age of 35.
A special gel is spread onto the breasts and a small device, which emits sound waves, is passed over the area. The echoes are converted into a picture of the breast tissue by a computer.
This test is painless and takes just a few minutes.
Fine needle aspiration
This is a quick, simple procedure, which is done in the outpatient clinic. Using a fine needle and syringe, the doctor takes a sample of cells from the breast lump and sends it to the laboratory to see if it contains any malignant cells. This technique may also be used to drain a benign cyst. As the breast is sensitive the needle aspiration can be quite uncomfortable.
Sometimes (especially if the lump is small) a needle aspiration may be carried out in the x-ray department. The doctor uses x-ray or ultrasound guidance to make sure that the exact area of the breast is sampled with a special

needle. Your doctor will discuss with you which type of needle aspiration you may have.
Needle (core) biopsy
This test uses a slightly larger needle than the one used for aspiration. It is done under a local anesthetic, which numbs the area and allows the doctor to take a biopsy (a small piece of tissue from the lump). The sample is examined in the laboratory to check for signs of cancer.
Colour Doppler
Certain types of ultrasound machine show the blood supply to the lump and this may help to distinguish between a cancer and a benign lump. The blood supply shows up as patches of red or blue color on the scan.
Blood tests
Samples of your blood will be taken to check your general health, the number of cells in your blood (blood count) and to see how well your kidneys and liver are working. Your blood may also be tested to see whether it contains particular chemicals (called markers) which are sometimes produced by cancer cells.
Excision biopsy
The whole lump is removed under a general or local anesthetic and sent to a laboratory for examination under a microscope. This may mean an overnight stay in hospital but is done as a day case in some hospitals.
If a lump is too small to be felt but has shown up on mammography or ultrasound, it may be necessary for the radiologist to mark the area for the surgeon. They do this by inserting a very small wire under local anesthetic, using x-ray or ultrasound guidance.
Some hospitals operate a special `one stop' breast cancer clinic, which means you will have all the necessary tests and some of the laboratory results on the same day. It may take longer in other hospitals for the results to come through.

Further tests

If the tests show that you have breast cancer your doctor may want to do some further tests to see if there has been any spread of the cancer. These help the doctor to decide on the best type of treatment for you. The tests will usually consist of a chest x-ray and some of the following:
Liver ultrasound scan
Depending on the results of blood tests you may be asked to have a liver ultrasound scan to check your liver. This is a painless test and only takes a few minutes. It will probably be done in the hospital-scanning department.
You will be asked to lie on a couch. A gel will be spread on your abdomen and a small device like a microphone will be passed over the area. The echoes are converted into a picture by a computer.
Bone scan
For this test a very small amount of a mildly radioactive liquid is injected into a vein, usually in your arm. A scan is then taken. As abnormal bone absorbs more of the radioactive substance than normal bone this shows up on the scan as highlighted areas.
Areas of previous injury or arthritis will also show up on the scan, and the doctors may ask you to have further x-rays of highlighted areas (known as `hot spots') to find the cause.
After the injection you will have to wait for up to three hours before the scan can be taken, so you may want to take a book or magazine with you, or a friend to keep you company.
This test does not make you radioactive and it is completely safe for you to be with other people after the scan, although it is advisable to avoid pregnant women or children for 24 hours. The radioactivity disappears from the body within a few hours.
Magnetic resonance imaging (MRI or NMR scan)
This test uses magnetism to build up cross-sectional pictures of your body. It can look at breast tissue, or other areas of the body.
During the test you will be asked to lie very still on a couch inside a long chamber for up to 30 minutes. This can be unpleasant if you don't like enclosed spaces; if so, it may help to mention this to the radiographer. The MRI scanner is also very noisy, but you will be given earplugs or headphones. You can usually take someone with you into the room to keep you company.
The chamber is a very powerful magnet, so before entering the room you should remove any metal belongings. People who have cardiac monitors, pacemakers or certain surgical clips should not have a MRI because of the magnetic fields.

There is some interesting information on cancer, which I am told is from a government white paper.

Presented to the secretary of state for health

By command of her majesty June 1991

Annex C
Cancers

Burdens

C1. After coronary heart disease, cancers are the most common cause of mortality. In 1989 cancers accounted for 25% of all deaths and 26% of the total life years lost under the age of 65 .Around 7% of all NHS expenditure goes on cancer treatment and prevention.

C2. Cancers include a large number of very different conditions. In men the most common are lung cancer (25%of total registrations in 1998) followed by skin cancer (other than melanoma)13%and cancer of the large intestine and rectum(11%)and lung cancer (10%) .In terms of deaths under 65, the most frequent causes are lung cancer in men and breast cancers in women.

C3 Overall rates of cancer incidence and mortality have changed little since the mid 1970s although death rates under 65 have declined particularly amongst males. There have also been changes in the balance between different cancers. Skin cancers have particularly increased while stomach cancers have decreased.

Objective
C4. To reduce death and ill health from cancers

Scope for meeting

This objective

C5. Cancers vary enormously and the scope for reducing the ill health and death thy cause varies commensurately. Some can be prevented and some cannot.
Early detection is valuable in some cases but not in others. Some cancers can be treated some as yet cannot.

(a)Prevention
c6 The causes of cancer are not fully understood .It is estimated that up to (85%of mortality is potentially avoidable. The most significant factor is undoubtedly tobacco. Tobacco accounts for 30%of all cancer deaths, including about 90%of the 32500 deaths in England from lung cancer each year.

Diet may contribute to a vary of cancers being responsible for at least 10%of the total. Current evidence suggests that less than 2%of cancer deaths are caused by environmental factors such as air pollution and ionizing radiation, which causes so much public concern.

(h) Screening and early detection
C7 There has been considerable effort in recent years to develop effective and cost effective methods of detecting cancers when they are curable. These include the introduction of screening programs for cancer of the breast and cervix.

(C) TREATMENT

C8 The standard methods of cancer treatment are surgery, radiotherapy and chemotherapy , singly and in combination. The effects have been estimated as

Cured by cancer alone 22%
Cured by radiotherapy alone 12%
Cured by a combination of surgery and radiotherapy 6%
Cured by chemotherapy alone 1.6 %
Cured by chemotherapy combined with other methods 2.5%
Hormone therapy is also increasingly used.

Conventional treatment

Apparently there is no telling just how a particular cancer drug will fare upon you as this depends it seems on the exact type of cancer cells being treated and how the body reacts to the treatment. Sometimes surgery can also be the first stage of treatment. Radiation therapy is used to shrink the tumor according to these sources.

Side effects from surgery are acute pain at the actual site of the incision which goes on for long periods after the treatment. Obviously acute stress is often caused to the body from the surgery and other medications.