Breast Cancer

Breast cancer is cancer that forms in the cells of the breasts. Breast cancer can occur in both men and women, but it is far more common in women. It is the most common cancer diagnosis among women in Jordan.

Substantial support for breast cancer awareness and research funding has helped created advances in the diagnosis and treatment of breast cancer. Breast cancer survival rates have increased, and the number of deaths associated with this disease is steadily declining, largely due to factors such as earlier detection, a new personalized approach to treatment, and a better understanding of the disease.

Signs and Symptoms

Signs and symptoms of breast cancer may include:
A breast lump or thickening that feels different from the surrounding tissue
Change in the size, shape or appearance of a breast
Changes to the skin over the breast, such as dimpling
A newly inverted nipple
Peeling, scaling, crusting or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin
Redness or pitting of the skin over your breast, like the skin of an orange.

When you need to see a doctor

If you find a lump or other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor for prompt evaluation.

Causes

Breast cancer occurs when some breast cells begin to grow abnormally. These cells divide more rapidly than healthy cells do and continue to accumulate, forming a lump or mass. Cells may spread (metastasize) through your breast to your lymph nodes or to other parts of your body.

Breast cancer most often begins with cells in the milk-producing ducts (invasive ductal carcinoma). Breast cancer may also begin in the glandular tissue called lobules (invasive lobular carcinoma) or in other cells or tissue within the breast.

Researchers have identified hormonal, lifestyle and environmental factors that may increase your risk of breast cancer, but it's not clear why some people who have no risk factors develop cancer, yet other people with risk factors never do. It's likely that breast cancer is caused by a complex interaction of your genetic makeup and your environment.

Inherited breast cancer

About 5–10% of breast cancers are linked to gene mutations passed through generations of a family.

A number of inherited mutated genes which can increase the likelihood of breast cancer have been identified. Published data had shown that 5–10% of breast cancer is hereditary and mostly related to BRCA1 or BRCA2 gene mutations. Efforts to identify such mutations are extremely important given the high penetrance rates among its carriers

Genetic testing of these genes may help guide treatment and management decisions. Identification of the causative variant will also guide testing and diagnosis of at-risk relatives. This test is specifically designed for inherited germline mutations.

At KHCC, we are currently using a cancer panel based on breast cancer and gynecology guidelines to analyze genes linked to an increased risk of breast, ovarian, uterine, fallopian and peritoneal cancer. Certain genes in this panel are also linked to an increased risk of other types of cancer. This panel includes the genes currently recommended by the National Comprehensive Cancer Network (NCCN) to improve surveillance and possible preventive measures.

Some patients who undergo test criteria will be referred to a genetic counseling clinic. Genetic counselors can review your family health history, assess your risk and order genetic testing for you. A genetic counselor can also discuss the benefits, risks, and limitations of genetic testing to help you make a joint decision.

Risk factors

A breast cancer risk factor is anything that makes it more likely to develop breast cancer. But having one or even several breast cancer risk factors doesn't necessarily mean that you will develop breast cancer. Many women who develop breast cancer have no known risk factors other than simply being women.

Factors that are associated with an increased risk of breast cancer include:

Being female, as women are much more likely than men are to develop breast cancer.
Increasing age, as the risk of breast cancer increases with age.
A personal history of breast conditions such as a breast biopsy that found lobular carcinoma in situ (LCIS) or atypical hyperplasia of the breast.
A personal history of breast cancer, such as breast cancer in one breast, which can put you at an increased risk of developing cancer in the other breast.
A family history of breast cancer. If sister or daughter was diagnosed with breast cancer, particularly at a young age, the risk of breast cancer is increased, though the majority of people diagnosed with breast cancer have no family history of the disease.
Inherited genes and certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most well-known gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don't make cancer inevitable.
Radiation exposure such as receiving radiation treatments to the chest as a child or young adult.
Obesity.
Beginning menstruation before age 12.
Beginning menopause at an older age.
Having your first child at an older age. Women who give birth to their first child after age 30 may have an increased risk of breast cancer.
Having never been pregnant. Women who have never been pregnant have a greater risk of breast cancer than do women who have had one or more pregnancies.
Postmenopausal hormone therapy. Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of breast cancer. The risk of breast cancer decreases when women stop taking these medications.
Drinking alcohol.

Prevention

Breast cancer risk reduction for women with an average risk:

Making changes in daily life may help reduce the risk of breast cancer.:

Conduct regular breast self-exams.
Get clinical breast exams and mammograms.
Avoid Alcohol.
Exercise most days of the week, aiming for at least 30 minutes of exercise on most days of the week.
Limit/avoid postmenopausal hormone therapy, as combination hormone therapy may increase the risk of breast cancer
Maintain a healthy weight.
Choose a healthy diet. Women who eat a Mediterranean diet supplemented with extra-virgin olive oil and mixed nuts may have a reduced risk of breast cancer.

Breast cancer risk reduction for women with a high risk

Preventive medications (chemoprevention). Estrogen-blocking medications such as selective estrogen receptor modulators and aromatase inhibitors, reduce the risk of breast cancer in women with a high risk of the disease. These medications carry a risk of side effects, so doctors reserve these medications for women who have a very high risk of breast cancer.
Preventive surgery. Women with a very high risk of breast cancer may choose to have their healthy breasts surgically removed (prophylactic mastectomy). They may also choose to have their healthy ovaries removed (prophylactic oophorectomy) to reduce the risk of both breast cancer and ovarian cancer.

Diagnosing breast cancer

Tests and procedures used to diagnose breast cancer include:

Breast exam. Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.
Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram
Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst.
Removing a sample of breast cells for testing (biopsy). A biopsy is the only definitive way to make a diagnosis of breast Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous.
A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options.
Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of the breast.

Staging breast cancer

Once the patient is diagnosed with breast cancer, the medical team works to establish the extent (stage) of your cancer. The cancer's stage helps determine your prognosis and the best treatment options. However, complete information about cancer's stage may not be available until after you undergo breast cancer surgery.

Tests and procedures used to stage breast cancer may include:

Blood tests, such as a complete blood count (CBC)
Mammogram of the other breast to look for signs of cancer
Breast MRI
Bone scan
CT scan
PET scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances and taking into account your symptoms.

Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Breast cancer staging also takes into account your cancer's grade, the presence of tumor markers such as receptors for estrogen, progesterone and HER2, and proliferation factors.

Treatment

Breast cancer treatment options are determined based on the type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones, as well as the overall health of the patient and their preferences.

Most women undergo surgery for breast cancer and many also receive additional treatment after surgery such as chemotherapy, hormone therapy or radiation.

Chemotherapy might also be used before surgery in certain situations.

Breast cancer surgery:

Lumpectomy
Mastectomy
Sentinel node biopsy
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Radiation therapy

Operations used to treat breast cancer include:

Removing the breast cancer (lumpectomy). During a lumpectomy, which may be referred to as breast-conserving surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. A lumpectomy may be recommended for removing smaller tumors. Some people with larger tumors may undergo chemotherapy before surgery to shrink a tumor and make it possible to remove completely with a lumpectomy procedure.
Removing the entire breast (mastectomy). A mastectomy is an operation to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (total or simple mastectomy). Newer surgical techniques may be an option in selected cases in order to improve the appearance of the breast. Skin-sparing mastectomy and nipple-sparing mastectomy are increasingly common operations for breast cancer.
Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that are the first to receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.
Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel lymph nodes, your surgeon will discuss with you the role of removing additional lymph nodes in your armpit.
Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast because of a genetic predisposition or strong family history. Most women with breast cancer in one breast will never develop cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure.

Complications of breast cancer surgery depend on the procedures you choose. Breast cancer surgery carries a risk of pain, bleeding, infection and arm swelling (lymphedema). The options may include reconstruction with a breast implant (silicone or water) or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

Radiation therapy

Your doctors might recommend radiotherapy after surgery and/or chemotherapy depending on the type of surgery and the extent of the disease. Radiation therapy uses high-energy X-rays to kill cancer cells. This reduces the risk of cancer recurrence locally and regionally.

You will be first evaluated at the radiation oncology clinic to decide the number of required sessions and the area to be treated. Radiotherapy is usually directed to the breast/chest wall and sometimes to the draining lymph nodes in the lower neck and armpit.

Radiotherapy is sometimes given to other areas of the body if the tumor has spread outside the breast. In these cases, usually short courses of radiotherapy are delivered to alleviate symptoms.

You will have a CT simulation scan in preparation for treatment. During the scan, you need to lie in the position that you will be in for your radiotherapy treatment. You may have some small, permanent markings made on your skin. The marks are about the size of a pinpoint.

Radiation therapy is delivered using a large machine that aims the energy beams at your body (external beam radiation). Radiotherapy sessions are delivered on daily basis (except weekends) over few weeks.

Immediate side effects of radiotherapy include fatigue, skin irritation in the form of redness and peeling, feeling of breast heaviness, and mild local pain. Your doctor will explain to you any possible long-term side effects depending on your condition. During the course of your treatment, your doctor will monitor you weekly in clinic.

Smoking can make your skin reaction worse, therefore, it is recommended to abstain from smoking during radiotherapy.

It is extremely important that you do not become pregnant during the course of radiotherapy as this may harm the unborn fetus. External radiotherapy does not make you radioactive. It is safe for you to be with other people, including children, after your treatment.

Chemotherapy

Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery.

Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing an infection. Other side effects can include premature menopause, infertility (if premenopausal), damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.

Hormone therapy

Hormone therapy — perhaps more properly termed hormone-blocking therapy — is used to treat breast cancers that are sensitive to hormones such as estrogen receptor positive (ER positive) and/or progesterone receptor positive (PR positive) cancers. Hormone therapy can be used before or after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Treatments that can be used in hormone therapy include:

Medications that block hormones from attaching to cancer cells (selective estrogen receptor modulators)
Medications that stop the body from making estrogen after menopause (aromatase inhibitors)
Surgery or medications to stop hormone production in the ovaries

Hormone therapy side effects depend on the specific type of treatment, but may include hot flashes, night sweats and vaginal dryness. More serious side effects include a risk of bone thinning and blood clots.

Targeted therapy drugs

Targeted drug treatments attack specific abnormalities within cancer cells. For example, several targeted therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal growth factor receptor 2 (HER2). The protein helps breast cancer cells grow and survive. By targeting cells that make too much HER2, the drugs can damage cancer cells while sparing healthy cells.

Targeted therapy drugs that focus on other abnormalities within cancer cells are available. And targeted therapy is an active area of cancer research. Cancer cells may be tested to see whether you might benefit from targeted therapy drugs. Some medications are used after surgery to reduce the risk that the cancer will return. Others are used in cases of advanced breast cancer to slow the growth of the tumor.

Immunotherapy

Immunotherapy uses your immune system to fight cancer. The body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that blind the immune system cells. Immunotherapy works by interfering with that process.

Immunotherapy might be an option if you have triple-negative breast cancer, which means that the cancer cells don't have receptors for estrogen, progesterone or HER2. For triple-negative breast cancer, immunotherapy is combined with chemotherapy to treat advanced cancer that has spread to other parts of the body.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with the patient, family and other medical teams to provide an extra layer of support that complements patient ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with other appropriate treatments, people with cancer may feel better and live longer. Palliative care is provided by a team of doctors, nurses and other specially trained professionals to improve the quality of life for people with cancer and their families.