BREAST CANCER

by Dr Pat Connelly MD

Approximately one in nine women will develop breast cancer sometime in her life. It is the most common cancer in women, excluding skin cancer, accounting for about 1/3 of all malignancies. It is the second leading cause of cancer deaths in women. Breast cancer is responsible for 18% of cancer deaths in women. These are sobering statistics which can be downright scary. It is a significant health hazard which medicine hasn't been able to alter much. Breast cancer is different from other cancers in our society because it has been inextricably entwined with a woman's sexuality. Until recently this last aspect has been largely ignored by the medical community. However, currently, breast conserving surgery as well as breast reconstruction are an integral part of the management of female breast cancer. Prevention of breast cancer is a hot research topic. Breast cancer does occur in males but is much more uncommon.

How is breast cancer found?

The diagnosis of breast cancer is made in basically made two ways - physical exam or mammography. The patient or physician feels an abnormality in one of the breasts. It may be a firm lump, something different compared to the other breast, or just something new. This is why self examination is so important. A woman who once a month examines her own breasts is going to recognize an abnormality sooner. I have heard various objections from women concerning self-examination. "I never know what I am feeling." You will easily learn how your breasts normally feel. Something different will show up immediately. You will know better than your Doctor if something is different in your breasts. If it persists for more than a month or into the next menstrual cycle, the breast should be examined by a physician. Also a woman should have a yearly breast exam by a physician when she has her PAP smear taken. Don't let your gynecologist skip the breast exam or perform one too hurriedly. More uncommonly, some other symptom may be the first sign of breast cancer.

Mammography (see picture above) is the second method for diagnosing breast cancer. Mammography is a efficacious proven tool for diagnosing breast cancer for women over 50 years of age. For women 40 to 50 years old, it is more controversial. If I had other risk factors, I would undergo regular mammographic screening before age 50. A baseline mammogram around age 40 is appropriate. Though I have never had a mammogram, I am told they are relatively painless if performed by an experienced mammography technician. The most useful tool we have for fighting breast cancer is early detection. Breast cancer is curable when found early.

What happens next?

An abnormality is found by physical examination or mammography. Another non-invasive test is ultrasound. Ultrasound helps determine if a mass is solid or cystic. Cysts can also be diagnosed by needle aspiration. Cystic lesions are generally benign but may be confirmed by needle aspiration. Needle aspiration of cysts is different from needle biopsy of solid masses. Any physician can aspirate a cyst, but only physicians who are experienced with the procedure should perform needle biopsy of solid masses. Palpable, able to be felt, suspicious masses should have some sort of tissue biopsy. Fine needle aspiration biopsy (FNAB) is simple, quick, accurate, and painless when performed properly. When combined with mammography and physical exam, it is 98 to 99% sensitive in detecting breast cancer. An alternative to FNAB is open surgical biopsy. These may be performed with local anesthesia (you don't have to be put to sleep). If the lesion is large enough, a frozen section can be done by the pathologist with a preliminary answer at the time of surgery. However, many lesions are quite small and a frozen section should not be performed. Frozen section damages the tissue and is not as accurate as routine pathological exam. The answer is usually available within 24 to 48 hrs.

If the lesion is detected by mammography and is not palpable, a relatively new biopsy procedure is available. It is called stereotactic needle biopsy. This biopsy procedure is performed with the help of a special mammographic biopsy table. The alternative is open surgical biopsy with prior needle localization (see above diagram). The patient has a mammogram immediately before surgery with placement of a fine localization wire. The wire tells the surgeon what breast tissue to remove. The wire and biopsy specimen (15kb photo) are x-rayed after removal from the patient to be sure the abnormal area has been removed. Frozen section should not be done on most mammographically detected lesions.

The pathologist exams the biopsy and determines if it is malignant (cancer), premalignant (high risk of becoming cancer), or is benign (harmless). If it is benign, then the whole scary story is over. If it is malignant or premalignant, the patient then discusses what else needs to be done with her surgeon. Usually, if the cancer has not been completely removed surgically, additional surgery is indicated. The additional surgery also adds more information that is needed to choose optimal treatment. Depending on the histology (type of cancer), grade (how aggressive it looks under the microscope), stage (how big the cancer is as well as how far it has spread), and additional prognostic ( predictive of how patients do) factors, additional radiation therapy or chemotherapy is indicated. All of this information should be found in the Pathology Report. This is a complex issue which demands the cooperation of various doctors including the surgeon, pathologist, radiotherapist, and oncologist. The patient should listen to recommendations from all of these professionals before deciding on her course of action.

Breast cancer, as well as other cancers, is a complex disease which requires the interactions of various physicians. All patients should understand their disease in as much detail as they would like. They should be comfortable with their physicians as well as their diagnosis. Acquiring a second opinion is sometimes useful if for nothing more than peace of mind. Ultimately, patients should be in control of the whole process.

Breast cancer