Breast Cancer is the most common cancer diagnosed in women, and is the leading cause of cancer death in women. The incidence is increasing worldwide, and increases with age. 

Age,

 Family history

 BRCA 1 or 2 mutation

 Hormonal factors (early onset of menstruation, late menopause, late or no pregnancies, combined hormone replacement therapy)

Lifestyle: sedentary lifestyle, obesity, smoking, more that 2 alcoholic drinks daily

Breast density 

History of chest radiation before the age of 30

There is clear survival benefit to annual screening between the ages of 50-74. There is some controversy and conflicting recommendations for the age group of 40-50 for women with average risk. In general, it is because younger breast tissue is denser, and small cancers are difficult to detect in this age group. Hence, all studies do not show the clear benefit of lives saved per mammogram done. However, it is still recommended for women with greater than average risk. And self-examination is always a good idea; it’s painless and free. It won’t pick up microscopic disease, but sometimes lumps show up between mammograms. Unless you examine them regularly, you won’t find them.

In the older age group, again the long term benefit of screening is clouded by life expectancy limited by other diseases. In general, if the overall life expectancy is less than 5 years, screening does not add benefit. 

This is usually done by putting needle into the lump visualized by mammograms, and extracting some tissue for the pathologist. Then the pathologist defines

 The nature of the cell

The presence of estrogen and progesterone receptors: helps to determine sensitivity to hormone therapy

The expression of her-2 neu protein: determines need for a targeted treatment against it.

Oncotype Dx score: this helps in predicting recurrence risk, and benefit of chemotherapy

Staging: will include 

The size of the primary tumor (T),

The presence of involved lymph nodes (N): these are sampled by a technique called Sentinel Node biopsy, in which only the unique lymph node draining the tumor bed is removed. If cancer cells are found, additional lymph nodes are removed for examination.

Scans: to detect distant disease. These are done only if the primary tumor is advanced, or if lymph nodes are involved. For small tumors, scans mainly find false positives, which lead to unnecessary anxiety and needless biopsies. 

Next step: deciding a treatment plan: depends upon stage.

Surgery: either a modified mastectomy to remove the entire breast tissue, and a sampling of lymph nodes from under the armpit. OR a lumpectomy with lymph node sampling. The lumpectomy has to be followed by radiation to complete the local treatment. Sometimes, if the tumor size is large, or more than 4 lymph nodes are involved, radiation is required even with a mastectomy. 

Radiation therapy:  is a delivery of a daily controlled dose to the tumor bed. This is delivered after a lumpectomy or mastectomy to eradicate any hidden cancer cells and prevent local recurrence. It does not circulate in the body, so the side effects are limited to the local area. The treatment takes several weeks to reach the desired total dose, although clinical trials to study the efficacy of a short course of treatment to a small tumor have been done. There is a lifetime dose limit to any tissue, so re-irradiation to the same site is limited. Recurrences will require a mastectomy, if a lumpectomy + radiation has been previously done. 

Chemotherapy: is delivered either

 After surgery, if a large tumor, or multiple lymph nodes are involved. 

Before surgery, to shrink the tumor, and enable a clean cancer operation.

This is usually a combination of at least 2 drugs, given intravenously, at intervals of 2-3 weeks, for a total of 4-8 treatments. 

Combinations commonly used are Cytoxan- Adriamycin, (C A); C A + Taxol (C A + T); 5 FluoroUracil-Adriamycin-Cytoxan (FAC); Taxotere-Adriamycin-Cytoxan (TAC);Cytoxan-Methotrexate-5FU (CMF).  The combination is chosen depending on the stage of the cancer, and local experience. 

Targeted therapy: is used against specific proteins or receptors. E.g. Trastuzumab (Herceptin) is combined with AC+T for her-2 neu overexpressing tumors.

Hormone therapy: is given after completion of the primary treatment. This is oral therapy, and is taken for 5 years. Only tumors that express Estrogen or Progesterone Receptors (ER and PR) provide a handle for these drugs to work. The choice of drugs will depend on menopausal state, and other medical conditions. Sometimes, there is benefit to suppressing gonadal function and making the premenopausal woman, post menopausal. 

Breast Cancer commonly spreads to the Lungs, Liver, Bones and Brain. Treatment choices depend on the location, and extent of disease, the hormone receptor and her-2 neu expression, and overall medical condition of the person. 

Radiation would be required for brain disease or painful bone disease

Hormone therapy: for limited disease volume, hormone responsive cancer cells, or older patients

Chemotherapy: for more extensive disease, in younger patients, or disease not responsive to hormonal manipulation.

Targeted agents: against the her-2 neu receptor, in combination with chemotherapy or hormonal intervention. Newer agents are being tested against other cell signaling pathways.

 

Bisphosphonates: are used to decrease bone pain or bone fractures related to bone metastases.

The goal of treatment in metastatic disease is shrinking the disease, prolonging life, and improving symptoms. The treatment is usually continued as long as it works. When the disease breaks through and starts growing again, the next line of therapies can be used. These decisions are made on a case by case basis, depending on the patient’s condition and available treatments.