| Breast cancer refers to the presence of abnormal (malignant) cells or a malignant lesion (neoplasm or tumor) in breast tissue. It is the most common cancer in women after skin cancer but occurs only rarely in men. Most breast cancers develop in the glandular tissue of the breast (adenocarcinoma), including the ducts that carry milk from the lobes of the breast to the nipple (ductal carcinoma), and the lobes themselves (lobular carcinoma). Malignant cells divide more rapidly than normal healthy cells (cellular proliferation) and may spread throughout breast tissue and into surrounding tissue or lymph glands (invasive cancer). Malignant cells that enter the lymphatic system through the lymph nodes under the arm can travel to distant organs (metastasize) such as reproductive organs, the brain, liver, bones, or lungs (metastatic cancer).
It isn’t known precisely why normal breast cells become cancerous, although families that have genetic defects or mutations in certain breast-cancer-related genes have an increased likelihood of developing breast cancer. Age, family history of cancer, radiation exposure, and increased exposure to estrogen (including use of birth control pills and hormone replacement therapy) are among factors that may also influence breast cancer development. Screening mammograms, a series of x-ray images of breast tissue, are considered to be the best diagnostic imaging procedure for detecting cancer early.
When a breast lesion or lump is discovered, a biopsy of breast tissue will be performed to examine the cells and surrounding tissue and determine if the cells are malignant (cancerous) or benign (noncancerous). Additional testing may indicate if the cells have migrated within the breast, outside the breast, or to other areas of the body. Based on biopsy results, the cancer is graded. Stage 0 is cancer that has remained within the ducts or lobes where it originated (ductal carcinoma in situ, or DCIS, and lobular carcinoma in situ, or LCIS). Stage I cancer has invaded nearby breast tissue but has not migrated beyond the breast. Stage II cancer has grown progressively larger, and cancerous cells may have reached the lymph nodes under the arm, indicating possible involvement of other organs. Stage III cancer has grown to at least 2 inches in diameter, and a significant number of cancerous cells have spread to the lymph nodes. In Stage IV cancer, metastasis has already occurred, and cancerous cells have spread to distant organs.
The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS), accounting for 20% of new breast cancer diagnoses ("Detailed Guide"). Mammography can detect DCIS early, and nearly all individuals with this type of breast cancer can be treated effectively. Lobular carcinoma in situ (LCIS) can also be detected early and does not usually become invasive (metastatic) itself but can be predictive of other, more invasive breast cancers, necessitating more frequent clinical examination and mammography.
The most common type of invasive breast cancer is infiltrating ductal carcinoma (IDC), accounting for up to 80% of all invasive breast cancers; infiltrating lobular cancer (ILC) accounts for 10% of invasive breast cancers (“Detailed Guide”). Like IDC, it can also metastasize to other organs, but ILC is quite difficult to detect by mammography.
Medullary carcinoma is a rare (3% to 5% of breast cancers) type of invasive breast cancer characterized by distinct boundaries between the breast tumor and normal tissue (“Detailed Guide”). Mucinous (colloid) carcinoma is another rare type of invasive cancer that is formed by mucus-producing cancer cells. Both medullary and mucinous carcinomas have a better prognosis than other invasive types of breast cancer. Other rare breast cancers include phyllodes tumors (usually benign), tubular carcinoma (2% of breast cancers), inflammatory breast cancer (1% to 3% of breast cancers), and Paget’s disease (1% of breast cancers) (“Detailed Guide”).
Inflammatory breast cancer is distinguished by breasts that appear inflamed and red and are warm to the touch, due to cancer cells blocking the lymphatic vessels. The skin may have pits or ridges. This type of cancer spreads especially quickly.
Paget's disease originates in the breast ducts and spreads to the nipple and areola. It may be associated with other in situ or invasive breast cancers.
Other changes may be found in the breast that are benign—please see Fibrocystic Breast Disease for more detail.Risk: The risk of breast cancer increases with age. The disease is less commonly diagnosed in women under 40, with 77% of all breast cancers diagnosed in women older than 50 years of age ("Detailed Guide"). The lifetime risk is about 1 in 8; the age-specific risk is 1 in 250 by age 40 and 1 in 35 at age 60 and older (Abeloff). Other risk factors include previous breast cancer, one first-line relative (mother, daughter, or sister) or at least 2 second-line relatives (cousin or aunt) with breast cancer, and breast tissue with previous precancerous changes. Relatives with ovarian cancer also increase the risk for breast cancer. A woman's genetic predisposition to breast cancer can sometimes be determined by testing for defects or mutations in genes known to be associated with breast cancer (BRCA1, BRCA2, and CHEK2) (“Breast Cancer”). The lifetime risk for women with mutations in these genes is 10 times greater than that of women with no defects in these genes (“Cancer Advances”). Of women with breast cancer, 20% to 30% have a family member with the disease ("Detailed Guide").
Increased exposure to estrogen is another risk factor for breast cancer. Women who had early onset of menstruation (before age 12) or late menopause (after age 55), whose first pregnancy was after age 30, or who have used hormone replacement therapy or birth control pills over a long period of time, have been exposed to increased levels of estrogen. Women whose breast tissue includes a higher proportion of lobular or ductal tissue in which breast cancer typically arises, and women whose breasts have been exposed to radiation, such as in the treatment of Hodgkin's disease, are also at increased risk. Other risk factors include alcohol use, cigarette smoking, sedentary lifestyle, and obesity. White women are at greater risk for developing breast cancer than black, Hispanic, or Asian women, but black women have been found to be more likely to die of breast cancer because the cancer is more advanced when diagnosed (“Breast Cancer”).
Although research studies have identified these risk factors, many women with breast cancer have none of them. Likewise, most women with these risk factors never develop breast cancer. Incidence and Prevalence: Over 2 million women in the US have breast cancer, and about 178,000 new cases are diagnosed annually, based on 2007 statistics (“Breast Cancer”). There are about 2,000 cases diagnosed each year in men. The number of new cases per year has decreased since 2001, when 276,000 new cases were diagnosed, of which 217,000 were invasive cancer and 59,000 were in situ (Abeloff). After lung cancer, breast cancer is the second leading cause of cancer death in American women. However, worldwide, breast cancer is the leading cause of death among women, followed by lung cancer. Mortality rates have decreased in recent years (Abeloff), due in part to early detection, advances in treatment, and increasing awareness of the influence of estrogen exposure on development of breast cancer. Incidence rates are steadily rising, but at a slower rate since the 1990s. Thirty-five years ago, about 75% of women with breast cancer survived their disease at least 5 years; now, about 90% of women with breast cancer survive the disease at least 5 years (“Cancer Advances”). |
Source: Medical Disability Advisor
| History: A complete medical history, including reproductive/gynecologic history, other medical conditions, medications, family history, and occupation, should be obtained. Changes to the breast may be detected during breast self-examination. The individual may report a lump or thickening of the breast or tissue under the arm. The breast may have changed shape or size, or the skin may have an unusual texture. There may be a discharge from the nipple, or the nipple may be turned inward (inverted). The skin on the breast or the nipple may be red, warm, or scaly. It is important to ask about the duration of the mass, changes with menses, rapid growth of the mass, pain, and fever.
Signs of breast cancer are not always evident or identifiable during self-examination. Physical exam: Physical examination begins with inspection of the breasts in both the upright and supine positions. The breasts are assessed for symmetry, nipple inversion, skin dimpling, and edema. During a breast examination, the physician uses his or her fingers to feel (palpate) and press on the breast and surrounding tissue. As in breast self-examination, signs of breast cancer may include a lump or thickening, change in breast shape or size, discharge from or change in a nipple, and/or a change in skin texture, including inflammation. The supraclavicular, infraclavicular, and axillary lymph nodes are also assessed. Tests: Screening mammography is a series of x-rays that screen for breast cancer, sometimes revealing tumors that are too small to be felt. Mammography is able to provide additional information about lumps, thickening, or other changes that may have been discovered during clinical breast examination. Sometimes mammography can also indicate an area of concern when no actual problem exists (false-positive result). Breast ultrasound is able to determine whether lumps are fluid-filled sacs (cysts) that are typically benign or solid masses that are more typically malignant. Neither mammography nor ultrasound tests can confirm or rule out a diagnosis of cancer. To confirm a diagnosis, a sample of suspicious tissue must be removed (biopsy), stained, and then examined under a microscope to determine whether malignant cells are present. The size and location of the tumor determine whether the biopsy will be a fine-needle aspiration biopsy, core needle biopsy, stereotactic biopsy (core needle biopsy during mammography), or surgical biopsy. If malignant cells are found, a biopsy will also be performed on tissue obtained from lymph nodes under the arms. Specific hormone tests (estrogen receptor assay and progesterone receptor assay) may be performed to determine whether cancer growth is dependent on estrogen or progesterone and if it will respond to hormone-suppression treatment.
A Herceptin test may also be performed on a breast tissue sample to determine if the cancer cells manufacture too much of a protein called HER2, which may guide future treatment.
Newer imaging technologies available to detect breast cancer in high-risk individuals, include full-field digital mammography, in which the computer image of the mammogram may be manipulated to improve visualization; computer-aided detection and diagnosis (CAD), in which a computer assists the radiologist in examining mammography images; and scintimammography, in which a radioactive tracer that attaches to breast cancer cells is injected intravenously to allow differentiation between normal cells and malignant cells.
MRI, CT scans, PET, and bone scans may also help in diagnosing secondary cancers that may have metastasized from breast tissue to reproductive organs, bones, liver, or lungs.
Genetic testing may be done to identify gene defects and risk in individuals with a family history of breast cancer or other types of cancer. Routine genetic testing is not recommended. |
Source: Medical Disability Advisor
| The size and location of the cancer, its stage, and the results of laboratory tests such as hormone receptor and Herceptin tests determine the course of treatment. The physician may also consider the woman's age, health status, and breast size, as well as her menopausal status. Most breast cancer is treated both locally at the site of the cancer and systemically, involving the whole body.
In general, the smaller and more contained the cancer, the more localized the treatment (e.g., lumpectomy and focused radiation). Conversely, the larger the cancer and the more it has invaded nearby tissue or spread throughout the body, the more aggressive and systemic the treatment (e.g., mastectomy and chemotherapy).
Surgery is the most common breast cancer treatment and can take several different forms. A lumpectomy is the removal of only the cancerous lump and its surrounding tissue, sparing most of the breast tissue. Surgeries known as segmental or partial mastectomies spare as much healthy breast tissue as possible but remove the tumor and surrounding tissue. More extensive surgeries involve removal of the entire breast (modified radical mastectomy). A radical mastectomy, which is rarely performed today, removes the entire breast, all or most of the nearby lymph nodes, usually some of the lining over the breast, and some chest muscles. A woman can choose to have surgery to rebuild her breast (breast reconstruction with implants or tissue flaps) at the time of the initial surgery or at a later date.
Studies indicate that survival rates improve with the use of chemotherapy and/or radiation following surgery. Chemotherapy is the use of a drug or a combination of drugs to destroy cancer cells. The drugs are taken either orally or intravenously according to a predetermined schedule. The patient receives chemotherapy for a limited amount of time, followed by a break for a limited amount of time. Treatment cycles repeat as often as prescribed, and the individual's response to treatment is monitored. Radiation therapy irradiates cancer cells to destroy them. The radiation may come from a machine (external radiation) or from radioactive material surgically implanted inside the individual (brachytherapy).
Hormone-suppression or hormone-blocking therapy robs estrogen-dependent or progesterone-dependent cancer cells of the estrogen or progesterone they need in order to grow. Hormone suppression chemically alters the hormones to make them unusable by the malignant cells, thereby suppressing their continued growth. Another type of drug therapy employs selective estrogen receptor modulators (SERMs) that prevent breast tissue cells from using estrogen, which in turn slows or stops the growth of cancer cells. Preventative use of SERMs also reduces the frequency of breast cancer in women at high risk. Used following surgery, SERMs reduce the chances of the cancer returning or a new cancer forming in the other breast. Aromatase inhibitors are another class of drugs that block the conversion of a hormone-related substance into estrogen to stop estrogen production in any cells except ovarian cells; these drugs have only been shown to be effective in postmenopausal women. Eliminating the natural source of hormones, such as surgery to remove the ovaries (oophorectomy), is another option for treating or preventing estrogen-dependent cancer.
Chemotherapy, radiation, and hormone-suppression therapy can also be recommended as adjuvant therapies before and/or after surgery. For example, radiation therapy may be used before surgery to shrink a tumor in order to facilitate its removal. Radiation can also be used after surgery to help kill any cancer cells that surgery missed. Radiation therapy can be combined with chemotherapy or hormone-suppression therapy.
Some cancers may only respond to heavy doses of chemotherapy that may destroy an individual's bone marrow, the primary source of blood cells. The most aggressive treatments for breast cancer are autologous bone marrow transplants and peripheral stem cell transplants. These transplants attempt to replace an individual's bone marrow with cells that will regrow healthy bone marrow once chemotherapy has ended.
Monoclonal antibody therapy is a newer biological therapy that can be helpful in treating the one-third of breast cancers that overproduce growth-promoting protein. Use of monoclonal antibodies to attack the HER2 protein may inhibit the growth of breast cancer cells and stimulate the immune system to produce anticancer antibodies. This technique may be also be used in conjunction with chemotherapy and/or hormone-suppression therapy, especially in women with advanced metastatic breast cancer. Another biological therapy, bevacizumab, targets new blood vessels required by cancer cells for survival; the drug stops the growth of blood vessels and destroys the cancer cells. Many new drugs that target cancerous breast tissue are in clinical trials. |
Source: Medical Disability Advisor
| The outcome depends primarily on the type of cancer and its stage (0 through IV) at discovery. A woman's age, menopausal status, and overall health also contribute to the outcome.
The best outcome occurs with small tumors that have not yet invaded nearby tissue or spread to any lymph nodes. Women with stage I breast cancer have a 5-year survival rate of 84%; the 5-year survival rate for those with stage IV is 18% ("Prognosis").
Systemic adjuvant therapy significantly increases the odds of a successful outcome. |
Source: Medical Disability Advisor
| Physical therapy may be needed after mastectomy to reduce postoperative swelling, stretch and strengthen arm and shoulder muscles, and promote normal posture.
An important facet of physical therapy for individuals after a mastectomy is lymphedema education. Lymphedema is a swelling in the arm on the side of the mastectomy that is caused by an interruption in the flow of lymph. Individuals learn to recognize the early symptoms of lymphedema, such as increased heaviness in the arm, tightness of the skin, stiffness in the hand and fingers, and altered sensation in the arm.
Individuals with lymphedema as a result of a mastectomy or radiation therapy may require additional physical or occupational therapy to reduce swelling. Individuals also learn to avoid sources of overload on the lymphatic system, such as prolonged arm activities and heat (including heating pads).
Individuals may also benefit from psychological counseling or a support group for cancer survivors. Postmastectomy individuals may require help as they adjust their body image. Men who are afflicted by breast cancer may also have special support needs. |
Source: Medical Disability Advisor
| Metastatic cancer can cause a variety of symptoms, depending on where secondary cancer has developed; for example, if cancer has spread to the bone, it can be very painful.
The psychological impact of breast cancer cannot be ignored. Most women report feeling a loss of self-esteem, decrease or total loss of sexuality, fears about dying, general feelings of anxiety, sadness, anger, irritability, difficulty with concentration, and changes in sleep and eating patterns. Depression is common.
Hormone-suppression treatment, radiation, and chemotherapy are known to cause other complications. |
Source: Medical Disability Advisor
| Reassignment of job duties may be needed if work requires upper body motion and strength. Following a mastectomy, muscle strength in a woman's arms and shoulders may diminish, and range of motion may also be reduced. These losses may be temporary or permanent.
Lymphedema in an arm may interfere with job duties requiring use of that arm. Because an injured arm is more at risk for lymphedema, protection of the affected arm while on the job may be prudent. Use of a compression garment for the arm may be necessary.
Individuals undergoing radiation therapy, chemotherapy, or hormone-suppression therapy may feel fatigued and may require a private place to rest. While undergoing chemotherapy, accommodations may be needed for time off or for lenient breaks in order to handle side effects such as nausea and vomiting. Damage done to the skin by radiation may require that loose clothing be worn until the skin heals.
Bone marrow and peripheral stem cell transplants require a long preparation and recovery period, during which the individual cannot work. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Was diagnosis of breast cancer confirmed?
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Were conditions with similar symptoms ruled out?
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Does individual have an underlying condition such as pregnancy that may affect recovery?
Regarding treatment:
- Was treatment based on the size and location of the cancer, stage of the cancer, and results of certain laboratory tests such as hormone receptor tests?
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Did treatment also take into consideration the woman's age, menopausal status, health, and breast size?
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Since systemic adjuvant therapy significantly increases the odds of a successful outcome, was appropriate chemotherapy, radiation, and/or hormone therapy used as adjuvant therapy both before and after surgery?
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If aggressive treatment is warranted, is individual a candidate for a bone marrow transplant?
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Although unavoidable, are treatment side effects being effectively managed?
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Are appropriate efforts being made to prevent or manage lymphedema?
Regarding prognosis:
- If individual had a mastectomy, was breast reconstruction an option?
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Was reconstruction surgery performed? If not, what are the barriers to having that surgery?
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How is individual's nutritional status? Is individual getting enough rest?
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Because surgery and chemotherapy increase the risk of infection, is individual unnecessarily exposed to infection at home or on the job?
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Is the psychological impact of this disease being addressed? Was referral made for counseling?
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Source: Medical Disability Advisor
| Abeloff, Martin D., et al., eds. "Breast Cancer." In Clinical Oncology. 3rd ed. Philadelphia: Churchill Livingstone, Inc., 2004. "Breast Cancer." MayoClinic.com. 18 Feb. 2009. Mayo Foundation for Medical Education and Research. 6 Apr. 2009 <http://www.mayoclinic.com/health/breastcancer/DS00328>. "Cancer Advances in Focus: Breast Cancer." National Cancer Institute. New Media Systems, LLC. 29 Jul. 2009 <http://www.cancer.gov/cancertopics/cancer-advances-in-focus/breast.>>. "Detailed Guide: Breast Cancer." American Cancer Society. 18 Jan. 2005 <http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?rnav=cridg&dt=5>. "Prognosis." BreastCancerSource. 18 Jan. 2005 <http://hcp.breastcancersource.com/article/500287.aspx>. |
Source: Medical Disability Advisor
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