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Figures and shows the anatomy of the breast. Firstly, the breast consists of three types of tissue which are glandular, fibrous connective, and adipose fat bontranger. Besides, the breast consists of lobes which are organized into 15-20 sections. Each lobe has smaller structures that produce milk, called lobules. Projecting from the lobules is the tiny tube or the duct that allow the passage of milk. All the duct is connect and form the larger duct that eventually exits the skin in the nipple. Nipple is the dark area that surrounded the skin. It is also called areola. The breast also consists of connective tissue and ligament which give the shape to the breast and provide support to it. There are also nerves in the breast to provide sensation. On the other hand, blood vessels, lymph vessels, and lymph nodes also included in the breast (webMD). Although breast has no muscle, but the muscle under the breast is present to provide support and cover the ribs. There are fat that fills the space between the lobules and duct (medical center).
Breast cancer is the cancer that starts in the tissues of the breast. Lobular carcinoma and ductal carcinoma are the most common types of breast cancer but majority of breast cancer found is ductal carcinoma. However, breast cancer also can start in other areas of the breast. It can be invasive or noninvasive. Invasive means it has spread from the lobule to the other tissues in the breast. In contrast, noninvasive, is called 'in-situ' as it has not yet invaded other breast tissues (ADAM). Both invasive ductal carcinoma and invasive lobular carcinoma invades deeper into the breast and have a potential to spread to other areas of the body called metastasize (webMD). On the other hand, ductal carcinoma in situ (DCIS) or intraductal carcinoma is breast cancer in the lining of the milk duct that has not yet invaded nearby tissues and it may progress to invasive cancer if untreated (ADAM). However, women diagnosed with DCIS have a high likelihood of being cured. In contrast, lobular carcinoma in situ (LCIS) is not a true cancer as it does not invade or spread to other tissue but the women who have this type of cancer have increase risk of developing invasive breast cancer in the future (webMD).
Breast cancer is believed to be caused by several factors. The most common factors are age and gender. Breast cancers are likely to develop as the age got increases and it can be found more in women than in men. Besides, breast cancers are easily to develop in women that have family history of breast cancer and other cancer such as uterine, ovarian, or colon cancer. Besides, BRCA1 and BRCA2 are the most common gene defect that can develop into breast cancer. So, women who inherit these defective genes from their parents have up to 80% chance of getting breast cancer in their lifetime. Women also have an increase risk of breast cancer if they got their periods early (before age 12) or went through menopause late (after age 55). Exposure to the radiation will increase risk of developing breast cancer. For example, if women received radiation therapy to treat cancer of the chest area during childhood or during breast developments, they might get breast cancer when they were adults (ADAM). Furthermore, the women may have a higher risk of developing breast cancer again if they have previous diagnosis of breast cancer. It is because maybe an early non-invasive cancer cells are still remain in the breast's duct or lobules have invade the other breast or on the same breast again. Lastly, breast density also can be the cause of the breast cancer. It is because the denser the breast, the higher the concentration of breast cell, thus the more cells that can become cancerous (nhs).
According to the data from National Cancer Registry of Malaysia for 2004, shows that approximately 1 in 20 women in the country have been diagnosed with breast cancer in their lifetime as it provide an age-standardize incidence rate (ASR) of 46.2 per 100,000 women. However, the rate are differs between three main races which are Malays, Chinese and Indians. Chinese shows the highest age standardize incidence rate with 59.7 per 100,000, followed by the Indians at 55.8 per 100,000. The Malays shows the lowest incidence which is 33.9 per 100,000. It can be translated into 1 in 16 Chinese, 1 in 16 Indian and 1 in 28 Malay women developing breast cancer at some stage in their lives. The commonest age of the women reported with breast cancer is between 40-49 years, with just over 50% of the cases under age of 50 years, 16.8% below 40, and 2% under 30 (pubMed). Compared to the other countries, North Europe and North America shows the highest incidence, followed by Mediterranean countries and South America and the lowest are Asia and Africa. The patient's ages that have been reported with breast cancer is 50 years in developing countries compared to 60 years in Western countries (radiomal). Moreover, white women are less likely to get breast cancer than African-American women. However, in women below 45, breast cancer is commonly in African-American women than white women but African-American women are always found to be dying from breast cancer. In contrast, Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer (US statistic). In other words, it can be describe that one woman is diagnosed with breast cancer in every 3 minutes in USA. Meanwhile, every 11 minutes, one woman will die from breast cancer in USA and lastly 30,000 women and 200 men are diagnosed with breast cancer in UK every year (radmal).
MORTALITY AND MORBIDITY
Mortality and morbidity rates following BCS in women are low, limiting their value in assessing quality of care. Surgical is the major option of breast cancer management. The complication rate is higher in mastectomy compared to 1-ANP with wound infection being the most common. The complication rate following breast surgical procedure is considered to be low and the mortality of breast surgical procedures is reportedly less than 1% (national). However, many of the patients live much longer than 5 years after diagnosis and the patient who dies may be the cause by cancer other than breast (mortality). In addition, breast cancer deaths rates in US are higher than other cancer, besides lung cancer and there are also 2.6 milion breast cancer survivor in 2011 (2013 BC).
SIGN AND SYMPTOMS
The first symptoms that can easily be noticed by women are the presence of lump or an area of thickened tissue in their breast. 90% of lumps are not cancerous, but it is better for them to see the doctor for further examination. Besides, the lump also can be present in either of the armpit as well as dimpling skin and a change in the size or shape or size of one or both breast. There is also a change on the appearance of the nipple which it is sunken into the breast (nhs). It is also a change in the texture of the skin and the pore is enlarges that mimicking orange peel's texture (national bc). Moreover, the breast also reddened, itchy, and sore which means that the skin is rashy or hot when it has been touched. Upper back pain also can be felt as the cancer that grow in the glandular tissue of the breast pushes backward the ribs and spine. So, that why the pain is felt in the back rather than in the breast (msn). In addition, the discharge of the fluid from the nipple is also the symptom of breast cancer. This fluid maybe bloody, clear to yellow, green, and look like a pus (ADAM).
The histopathologic classification is based on characteristic that can be seen on light microscopy of biopsy specimen (wiki). The most common histopathological types are invasive ductal carcinoma, ductal carcinoma in situ and invasive lobular carcinoma (wiki). To determine whether cancer cells are in situ or not, it is depends on the invasion of cancer cells through the basement membrane (assess medicine). However, majority of breast cancer are derived from the epithelium lining the duct or lobules which is classified as mammary ductal carcinoma. Meanwhile, carcinoma in situ is derived from epithelial tissues and it does not invade to the other tissues. In contrast, invasive carcinoma invades the surrounding tissues (wiki). A biopsy sample is then been taken from the lesion after a suspicious breast lesion appears on mammography or ultrasound. So, the pathologist will analyze the sample whether it is positive or negative (steven).
All the cells in our body have a nucleus that control cell cycle including cell growth, maturity, division and death. The cells are quickly divides during childhood to grow while it is divide to replace the dead cell and repair damage in adult (Dr.Ananya). Like other cancer, breast cancer also occurs because of the interaction between environment and defective gene. The cells become cancerous when the mutations stop them from dividing (docbig). It is because the DNA in the nucleus was damage and this damage cell will either repair or die. However, in cancer cells, the damage DNA is not repair and continues to grow the abnormal cells as cancer cells have longer life spans instead of dying. Cancer cells can also invade other tissue that is called metastasis and grows into tumors that are supplied by a network of blood vessels (dr.ananya).
In detecting breast cancer, there are various imaging modalities used such as mammography, ultrasonography, Magnetic Resonance Imaging (MRI) and nuclear medicine. There is also another imaging modality used in breast cancer imaging which is Computed Tomography (CT). However, this modality is not recommended as it gives high radiation dose to the patient. It is commonly used in regional staging of small breast cancer before breast conserving surgery. Until now, mammography still accepted as gold standard for both screening and diagnosis of breast cancer. Here, the elaborations for each of the modalities are cited:
A mammogram is a radiographic x-ray of the breast. Screening mammogram is used to check for breast cancer in women who have no signs or symptoms of the disease. It usually involved two projection of each of the breast and can detect tumor that cannot be felt. It also can visualize microcalcification (tiny deposits of calcium) that sometimes indicate the presence of breast cancer. Meanwhile, diagnostic mammogram is used to check for breast cancer after a lump or other sign or symptom of the disease has been found. Diagnostic mammogram also can be used to visualize changes found during a screening mammogram when there is a presence of breast implants that are difficult to view breast tissue (cancertopic).
The first advantage of using mammogram as a breast cancer imaging is it can improve physician's ability to detect small tumor. So, the woman has more treatment options when the cancers are small. For example, in the screening of ductal carcinoma in situ (DCIS), mammography can increase the detection of small abnormal tissue growths that confined to the milk ducts in the breast. It is because when the tumor is removed at this stage, it will not harm the patient and mammography is the only proven method that can reliably detect these tumors. Moreover, mammogram also can detect the other types of breast cancer including invasive ductal and invasive lobular cancer. In addition, x-rays usually does not have side effects in the typical diagnostic range for this exam and the radiation is not remains in the patient's body after an examination (radioinfo).
On the other hand, mammography also has its limitation. For example, initial mammographic images themselves are not usually enough to determine the existence of a benign or maglinant tumor with certainty. The radiologist may recommend further diagnostic studies if a finding or spot seems suspicious. It is because, the compositions of the normal breast for each woman are different and it is difficult to interpret a mammographic images. Furthermore, the radiologist also may misdiagnose an image if there is powder or deodorant on the breast during procedure or if the patients have undergone breast surgery. The radiologist also may compare the image with previous examination as some breast cancers are hard to visualize. In a nutshell, not all the breast cancer can be visualize with mammography. Besides, breast implants also can prevent accurate mammogram reading. It is because the implants contain both silicone and saline which are radiopaque in mammogram image that can obscure the tissue behind them, especially if the implants have been placed in front of the chest muscle rather than beneath it. However, the experience radiologist and technologist know how to carefully compress the breast without rupturing the implants. So, when making an appointment, the patient with implants should ask if the special technique design is used to accommodate them and they also should ensure that only radiologists who are experience in performing mammography can do the examination (radiologyinfo).
Ultrasound imaging, also called ultrasound scanning or sonography, involve the use of a small transducer (probe) and ultrasound gel to expose the body to high-frequency sound waves. Ultrasound uses the sound waves instead of ionizing radiation (x-ray) to produce a picture inside the patient's body and it is safe and painless. It also can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels as ultrasound images are captured in real-time (radiology info). A breast ultrasound examination is not considered a screening test but it is used after doing a mammogram and clinical breast exam as these examinations does not give enough diagnostic value for radiologist to access. It is also can be used if mammogram shows a vague mass, or if a lump can be easily felt during a clinical breast exam. Ultrasound produces sharp, high contrast images although in a dense breast tissue which can create an image that often allows a doctor to distinguish between a fluid-filled cyst and a solid mass (pam.stephen). Meanwhile, Doppler ultrasound is special ultrasound technique that will visualize the blood flow through blood vessels such as major arteries and vein in the abdomen, arm, legs and neck. During the examination, the radiologist will perform the test using the doppler technique to evaluate blood flow or lack of flow in any breast mass. Sometimes, it will provide additional information such as the cause of the mass (radioinfo).
On the other hands, the advantages of using ultrasound as the modalities for breast cancer are no needles or injection used. It means that the ultrasound scanning is noninvasive although it may be temporarily uncomfortable, but it almost never painful. Moreover, ultrasound is widely available which is it easy to use and less expensive compared to other imaging methods. It is also does not used ionizing radiation and this make it safe to the patient to do the examination while give a clear image of soft tissues that less visualize on x-ray images. Furthermore, it is a good tool for guiding minimally invasive procedures such as needle biopsies and needle aspiration as it provides real-time imaging. Ultrasound able to detect and classify breast lesion that cannot be visualized using mammography as well as woman with dense breast. Besides, radiologists are able to distinguish between normal tissue (fat lobules) and benign cyst by using ultrasound. Sometimes, mammogram will be used together with ultrasound for most women 30 years old and older but for women under age 30, ultrasound alone is often sufficient to determine whether an area of concern needs a biopsy or not.
Besides, there are also limitations when using ultrasound. The first one is many cancers are not visible on it and the radiologist need to do biopsy to determine if a suspicious abnormality is a cancer or not. Mostly, the suspicious findings on ultrasound that undergo biopsy are not cancers. In addition, many calcifications that can be seen on mammography cannot be seen on ultrasound and on mammography, some early breast cancers only show up as calcifications. The most important thing is, although ultrasound is one of the tools used in breast imaging, but it does not replace annual mammography and clinical breast examination (radiologyinfo).
Magnetic Resonance Imaging (MRI) is a noninvasive medical test that helps physicians diagnose and treat medical condition. In MRI, it uses a powerful magnetic field, radio frequency pulses and a computer to produce a picture of organs, soft tissues, bone and other internal organ with more detail. The images can be monitored on a computer, electronically transmitted, printed or copied to a CD. Like ultrasound, MRI also does not use ionizing radiation or x-rays and the physician can use the detail images of MRI to determine various part of the body and the presence of certain diseases. MRI of the breast offers diagnostic information about many breast condition that cannot be obtain by other imaging modalities like mammography and ultrasound (radioinfo).
One of the advantages of MRI is it has proven in diagnosis of many condition including detecting and staging breast cancer, especially when other imaging modalities such as mammography and ultrasound unable to provide enough information. MRI also able to visualize the abnormalities that might be obscure by bone when using other methods. In addition, the contrast media used in MRI give less allergic reaction compared to iodine-based contrast media used in conventional x-ray and CT scanning. MRI grows as an addition to traditional x-ray mammography in the early diagnosis of breast cancer. It is able to detect small lesions that are sometimes missed by mammography and also can imaged the dense breast especially in younger women, as well as breast implants, which are difficult to be done by mammography. Besides, MRI can provide guidance for biopsy if a suspicious lesion is seen with it is most useful in evaluating women at high risk of breast cancer (radioinfo).
However, there are also limitations of using MRI as imaging modality for breast cancer. Firstly, high-quality images are obtains only if the patients are remain stay still while the images are being recorded. It is difficult to lie still during imaging if the patient's are anxious, confuse, or in severe pain. Moreover, the patients who are large in size might not fit into the opening of certain types of MRI machines and it is also cannot visualize a clear images if there is a presence of an implants or metallic object in the breast area. This gives the same effect as patient movement. The pregnant women are advised not to have an MRI examination unless medically necessary although there is no prove that it's harm the fetus. Lastly, the fact about MRI is it is typically cost more and more time is needed to perform the examination compared to other imaging modalities (radiologyinfo).
Nuclear medicine or scintimammography is an examination that may be used to investigate the abnormalities in the breast that has seen discovered by mammography. It is also known as Breast Specific Gamma Imaging (BSGI). It use small amounts of radioactive material to diagnose and determine the severity or treat a variety of diseases such as cancers, heart disease, gastrointestinal, endocrine, neurological disorder and other abnormalities within the body. The procedure is noninvasive and involves the injection of a drug into the patient's body. This drug also called radiotracer and it will emit radioactivity. The physician will determine whether the cancer could be present or not as the radiotracer accumulate differently in different kind of tissue. So, it's help to determine whether a biopsy or additional follow-up is necessary. The radiotracer will accumulate in the breast after the injection and release energy in the form of gamma rays. Then, this energy will be detected by a device called gamma camera where it works with computer to measure the amount of radiotracer absorbed by the body. So, the computer will view a special picture on both the structure and function of organs and tissue with more detail (radioinfo).
The advantage of scintimammography is it can reduce unnecessary invasive procedure by helping physician determined whether a breast abnormality requires biopsy. Besides, BSGI also able to detect dense breast tissue as well as breast implants (radioinfo).
On the other hand, the limitations of scintimammography are it cannot replace the mammography or ultrasound as primary screening procedure for breast cancer and the procedure itself less accurate in assessment of abnormalities smaller than one centimeter. In addition, compared to other imaging modalities such as mammography and MRI, the image resolution produce by nuclear medicine are poor. However, it is more sensitive than other imaging technique for many indications where the information is cannot be gain from other imaging technique (radioinfo).
The treatment of breast cancer can be divided into two categories which are early stage and advanced stage. Early stage treatment involves tumors that are confined to the breast while advanced stage treatment involves tumors that have spread beyond the breast to other region of the body. Normally, the option of the treatment are depends on the size of tumor, location, physical condition of patient, and stage of cancer (cancerquest). Below are the options that are used to treat breast cancer:
-Breast cancer surgery
There are four types of breast cancer surgery. Firstly, removing the breast cancer called lumpectomy. In this operation, the surgeon will removes the tumor and a small margin of surrounding healthy tissue. It is typically used for a smaller tumor that is easily separated from the surrounding tissue. Then, the second one is removing the entire breast which is called mastectomy. In this operation, the surgeon will removes the entire breast tissue of the patient. It includes the lobules, ducts, fatty tissue and some skin, including the nipple and areola. Mastectomy also can be radical. This means the underlying muscle of the chest wall is removed along with breast tissue and surrounding lymph nodes in the armpit. However, radical mastectomy is less commonly done today. Furthermore, removing one lymph nodes or sentinel biopsy is done to remove the lymph node. It is because breast cancer that spread to the lymph node may spread to other areas of the body. So, the surgeon will determine which lymph nodes near the patient's breast tumor receives the lymph drainage from the cancer. If no cancer is found, there is small chance to find cancer in any of the remaining lymph nodes and no other lymph nodes needs to be removes. Next, the last operation for breast cancer surgery is removing several lymph nodes or axillary lymph node dissection. Through this operation, the surgeon may remove additional lymph nodes in the armpit if the cancer is found in the sentinel node (mayoclinic).
In this treatment, it uses high-powered beams of energy such as x-rays to kill cancer cells. In this option, a large machine will be aims the energy beams at the body called external beam radiation. However, radiation can also be done by placing a radioactive material inside the body which is called brachytherapy or nuclear medicine. It is commonly used for early stage breast and also for larger breast cancer after lumpectomy. Unluckily, there are side effects of radiation therapy such as fatigue and red, sunburn-like rash where the radiation is aimed. Sometimes, more serious problem may occur like arm swelling (lymphedema), broken ribs, and damage to the lungs or nerves. On the other hand, in chemotherapy, the drug is used to destroy cancer cells. The doctor may recommend chemotherapy if the cancer has a high chance of returning or spreading to another part of the body. So, it will decrease the chance that the cancer will recur. Sometimes, chemotherapy is given before surgery in woman with larger breast tumor so that the tumor will shrink to a size where it is easier to remove with this surgery. Moreover, for a woman whose cancer has already spread to other parts of the body, chemotherapy is done to decrease any symptoms and to control the cancer. Chemotherapy side effects include hair loss, nausea, vomiting, fatigue, and a small risk of developing infection and it is depends on the drugs the patients receive (mayoclinic).
Hormone therapy is used to treat breast cancers that are sensitive to hormone. It is used to decrease the chance of the cancer returning after surgery and it also may shrink the cancer that has already spread. Treatments that can be used in hormone therapy include medications that block hormones from attaching to cancer cells, medications that stop the body from making estrogen after menopause, and surgery or medications to stop hormone production in the ovaries (mayoclinic).
In this treatment, the drugs will attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include Trastuzumab (Herceptin), Lapatinib (Tykerb), and Bevacizumab (Avastin). The side effects of targeted drugs depend on the drug the patients receive. It can be very expensive and aren't always covered by health insurance (mayoclinic).
The 5-year survival rate is used to determine the prognosis of patient who suffers from breast cancer. It is the percentage of patient who lives at least 5 years after being diagnosed with cancer and it shows that many of these patient lives much longer than five years after diagnosis (BC survival rate by stage). However, the prognosis of breast cancer is usually depends on its five stage with the 5-year survival shows that the survival rate is decreases as the stage of cancer increases (ca,monthly). In addition, the locations of the tumor also play a role in prognosis of breast cancer. It is because if the tumor developed outside the breast, the cancer is more serious than those that occur in the middle of the breast. For the good news, women are living longer with breast cancer due to treatment options. However, survivor must face some risk for complications from the treatment and also the uncertainties of possible recurrent cancer. Normally, recurrences of cancer are developed within 5 years of treatment (nytimes).