Local Health Column: From early diagnosis to cure

Breast cancer affects about 200,000 women each year in the United States, or one of every eight American women.

Although there are a number of risk factors for developing breast cancer, most patients have no identifiable cause to contribute to this disease. A woman who had cancer in one breast is at increased risk of developing cancer in the other breast at a rate of 1-2 percent per year. A woman with uterine cancer has a significantly higher risk of developing breast cancer than women in the general population, and vice versa. Family history of breast cancer (in first-degree family members, especially at younger ages before menopause or if it is bilateral) is a well known risk factor.

Hormonal replacement therapy for menopausal women is among the most common risk factors for breast cancer, especially if conjugated estrogen and progesterone pills are used. Oral contraceptive pills that contain low-dose estrogen do not appear to increase the risk of breast cancer compared to the higher-dose pills that were available many years ago. Early menarche (under the age of 12) and late menopause (after 50), women who never got pregnant (nulliparous), and women with their first full-term pregnancy after the age of 35 are at higher risk. Women with some benign breast proliferative conditions (including fibrocystic breast, atypical epithelial hyperplasia, increased breast density on mammography) are high risk.

Some inherited conditions have been found to be associated with specific gene mutation (alteration). The most common is on chromosome 17 (BRCA 1 and 2 gene mutation) which predisposes to breast and ovarian cancer. Men with BRCA 2 gene mutation can develop breast and prostate cancer.

Early signs and symptoms include a palpable single non-tender, firm or hard, ill-defined margin lump in the breast, or an abnormal mammogram without a palpable mass. Late findings may include skin or nipple retraction, bloody discharge from the nipple, skin dimpling, peau d'orange (like orange skin), redness or pain in the overlying skin of the breast, palpable axillary mass, breast enlargement, and redness or pain.

The gold standard

Early diagnosis of breast cancer remains the gold standard for cure. Screening mammograms for women above the age of 40 are the most reliable means of detecting breast cancer by about two years before a mass can be palpable and before it has spread to the lymph nodes. Screening mammography has shown survival benefits for women due to the early stage of the cancer.

Self breast examination is important when performed appropriately, although its impact on survival is deemed questionable by the American Cancer Society.

After the diagnosis is made, usually by a biopsy, the patient should undergo primary surgery with either breast conservative surgery (BCS) or lumpectomy (removal of just the tumor) with radiation therapy or mastectomy (removal of the whole breast) depending on patient's specific factors (such as preference), as well as some tumor-specific factors such as relative tumor size.

The breast cancer cells are then examined for their hormonal receptor status, Estrogen Receptor (or ER) and Progesterone Receptor (or PR) in addition to other prognostic receptors called HER2 /Neu. We also examine the regional lymph nodes.

Upon analysis of these factors, we come up with a treatment algorithm based on each specific case. There are other factors to be considered in the decision for treatment, including age and menopausal status of the patient, how fast the cancer is growing (both clinically as well as biochemically by a test called Ki-67) and presence of any organ versus bone sites of spread, if any.

We can consider breast cancer a multifaceted disease, i.e. not a single disease. You cannot apply somebody else's experience with therapy to your own situation, since every case is different. Upon detailed review of several patient-specific situations, as well as tumor-specific features, the oncologist should design the best strategy for each individual case. Treatment may include endocrine therapy (anti-hormonal) using oral medicine without chemotherapy, chemotherapy, biological therapy (Anti-HER2 therapy such as Herceptin), radiation therapy, or combinations of all. Some patients may need no additional therapy at all. Chemotherapy may even be with oral medication Capecitabine (Xeloda) in particular patients.

With recent modalities of therapy of breast cancer, many patients are now totally cured of their cancer when discovered early, or they live their normal lives with their advanced or metastatic cancer.

If you have any questions related to breast cancer (or any other cancer), please email me at drmohtaseb@azcancerandblood.com, call (928) 681-1234, or visit our office at 1755 Airway Ave. and I will be glad to respond to you promptly.