INTRODUCTION Breast cancer, the second-leading cause of cancer

deaths in women, is the disease women fear most.

Breast cancer can also occur in men, but it's far less common.

Yet there's more reason for optimism than ever before.

In the last 30 years, doctors have made great strides in early diagnosis and treatment of the disease and in reducing breast cancer deaths.

80% of breast cancers occur in women older than age 50. In 30s, have a one in 233 chance of developing breast cancer. By age 85, chance is one in eight.

In 1975, a diagnosis of breast cancer usually meant radical mastectomy – removal of the entire breast along with underarm lymph nodes and muscles underneath the breast.

Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations.

SIGNS AND SYMPTOMS When the disease is discovered early, have more

treatment options and a better chance for a cure. Most breast lumps aren't cancerous. Yet the most

common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless.

Spontaneous clear or bloody discharge from the nipple, often associated with a breast lump

Retraction or indentation of the nipple Change in the size or contours of the breast Any flattening or indentation of the skin over the

breast

Redness or pitting of the skin over breast, like the skin of an orange

A number of conditions other than breast cancer can cause the breasts to change in size or feel.

Breast tissue changes naturally during pregnancy and the menstrual cycle.

Other possible causes of noncancerous (benign) breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.

If patient haven't yet gone through menopause, may want to wait through one menstrual cycle before seeing the doctor.

If the change hasn't gone away after a month, have it evaluated promptly.

CAUSES In breast cancer, some of the cells in the breast

begin growing abnormally. These cells divide more rapidly than healthy cells

do and may spread (metastasize) through the breast, to lymph nodes or to other parts of the body.

The most common type of breast cancer begins in the milk-producing ducts, but cancer may also begin in the lobules or in other breast tissue.

In most cases, it isn't clear what causes normal breast cells to become cancerous.

Only 5-10% of breast cancers are inherited. Families that do have genetic defects in one of

two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), have a much greater risk of developing both breast and ovarian cancer.

Other inherited mutations – including the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene – also make it more likely that will develop breast cancer.

If one of these genes is present in the family, will have a 50 percent chance of having the gene.

Yet most genetic mutations related to breast cancer aren't inherited.

These acquired mutations may result from radiation exposure – women treated with chest radiation therapy for lymphoma in childhood or during adolescence when breasts are developing have a significantly higher incidence of breast cancer than do women not exposed to radiation.

Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.

Each of breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy.

The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-feeding.

Small ducts conduct the milk to a reservoir that lies just beneath the nipple.

Supporting this network is a deeper layer of connective tissue called stroma.

RISK FACTORS Some risk factors, such as age, sex and family

history, can't be changed Whereas others, including weight, smoking and a

poor diet, are under control. Age Personal history of breast cancer. Family history. Genetic predisposition. Radiation exposure. Excess weight.

Early onset of menstrual cycles. Late menopause. First pregnancy at older age. Race. Hormone therapy. Birth control pills. Smoking. Excessive use of alcohol. Precancerous breast changes (atypical

hyperplasia, lobular carcinoma in situ). Mammographic breast density.

WHEN TO SEEK MEDICAL ADVICE Although most breast changes aren't cancerous,

it's important to have them evaluated promptly. Discover a lump or any of the other warning

signs of breast cancer, especially if the changes persist after one menstrual cycle or they change the appearance of the breast.

If treated for breast cancer, report any new signs or symptoms immediately.

Possible warning signs include a new lump in the breast or a bone ache or pain that doesn't go away after three weeks.

Screening and diagnosis

Screening – looking for evidence of disease before signs or symptoms appear – is the key to finding breast cancer in its early, treatable stages. Depending on age and risk factors, screening may include breast self-examination, examination by nurse or doctor, mammograms (mammography) or other tests.

Self breast examination is an option beginning at age 20.

Screening

Breast self-exam

Clinical breast exam

Mammogram - to check breast tissue

Other tests

Computer-aided detection (CAD) Digital mammography Magnetic resonance imaging (MRI) Breast ultrasound (ultrasonography)

Experimental procedures

Ductal lavage Molecular breast imaging (MBI)

Mammogram

CAD Mammogram

Digital mammography

Breast Ultrasound

Diagnostic procedures

Ultrasound Biopsy – Fine-needle aspiration biopsy, core

needle biopsy, sterotactic biopsy, wire localization biopsy, surgical biopsy

Estrogen and progesterone receptor tests Staging tests – Stage 0 to IV Genetic stage

Breast biopsy

Tamoxifen inhibits estrogen receptor

activity

AE = antiestrogenic

E = estrogenic

TREATMENT In addition to coping with a potentially life-

threatening illness – must make complex decisions about treatment.

Treatments exist for every type and stage of breast cancer.

Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy.

Experimental treatments are also available at cancer treatment centers.

SURGERY Lumpectomy Partial or segmental mastectomy Simple mastectomy Modified radical mastectomy

Sentinel lymph node biopsy Axillary lymph node dissection Radiation therapy Chemotherapy

Reconstructive surgery

Reconstruction with implants Reconstruction with a tissue flap Deep inferior epigastric perforator (DIEP)

reconstruction Reconstruction of the nipple and areola

Hormonal therapy

Selective estrogen receptor modulators (SERMs) Aromatase inhibitors

Biological therapy

Trastuzumab (Herceptin) Bevacizumab (Avastin) Lapatinib (Tykerb)

PREVENTIONChemoprevention Tamoxifen (Nolvadex) Raloxifene (Evista)

Preventive surgery Prophylactic mastectomy Prophylactic oophorectomy

LIFE-STYLE FACTORS Taking aspirin No / limit alcohol Maintain a healthy weight Avoid long-term hormone therapy Stay physically active Eat foods high in fiber Emphasize olive oil Avoid exposure to pesticides

New directions in research Retinoids - Natural or synthetic forms of vit-A

have the ability to destroy the growth of cancer cells. Effective in premenopausal women and in those whose tumors aren't estrogen positive.

Flaxseed – High in lignan, a naturally occurring compound that lowers circulating estrogens in the body. Decreases estrogen production – acts like tamoxifen – inhibit the growth of breast cancer tumors. Lignans are also antioxidants with weak estrogen-like characteristics. These characteristics may be the mechanism by which flaxseed works to decrease hot flushes.

COPING SKILLS Telling others Maintaining a strong support system Dealing with intimacy Self-care taking

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Breast tenderness is pain or discomfort in the breasts. It is the most common breast symptom women have. It is usually not a sign of breast cancer.

Most common cause of breast tenderness is called fibrocystic breast changes.

These changes are caused by the swelling of very tiny fluid-filled cysts in fibrous tissue in the breast.

The changes usually happen 7-10 days before the menstrual period and go away when period ends.

CAUSES Puberty (boys / girls) Pregnancy Infection of the breast Hormone imbalance – too much estrogen Birth control pills Breast-feeding – when breasts engorged (milk) Injury of the breast Noncancerous tumor in the breast (fibroma) Breast cyst Condition called hyperprolactinemia Breast cancer, but often cancer does not cause any pain.

DIAGNOSIS Mammogram (a special x-ray of the breasts) Ultrasound scan of the breasts (a scan with sound

waves) Thermography of the breasts (a heat test that

outlines the breast in a color pattern) Biopsy (removal of a small piece of tissue or

fluid from the breast). Examination of discharge from a nipple Blood test.

TREATMENT Drink fewer or no beverages with caffeine. Add vitamins E and A to the diet. Reduce salt intake – 1-2 weeks before

menstruation. Put heat on the breast with a heating pad or warm

water bottle. Diuretics. Surgery is rarely needed.

SELF-CARE Follow the physician’s recommendations for

preventing and treating breast tenderness. Learn how to examine the breasts after the

menstrual period every month.

Nipple discharge is any kind of fluid that comes out of the nipple.

Nipples contain tiny openings through which fluid can pass.

Although most nipple discharge is not serious, any discharge should be evaluated.

The color and consistency of the discharge will help in diagnosis.

A clear, straw-colored discharge sometimes develops in early pregnancy.

A whitish or greenish discharge occurring in nonpregnant women is galactorrhea – cause – birth control pills, hormone imbalance, pituitary tumor, or cyst under the areola.

Pus discharge indicates a breast infection.

DIAGNOSIS No menstrual periods Headaches Visual problems. Lab tests of the discharge Blood tests Mammogram (x-ray of the breasts) Ultrasound scan of the breasts CT scan of the brain.

TREATMENT Surgery Radiation therapy Chemotherapy.

Galactorrhea is a milklike discharge of fluid from the breast nipples.

Usually the discharge is from both breasts rather than just one.

A discharge like this is called galactorrhea unless pregnant or breast-feeding.

Galactorrhea usually occurs when the body produces too much prolactin. Prolactin is a hormone produced by the pituitary gland. Normally, prolactin helps a woman make milk when she has a baby.

ETIOLOGY Birth control pills and other medicines Underactive thyroid gland Problems with the pituitary gland Some brain diseases, such as meningitis Cyst under the darkened area around the nipple

(galactocele) Shingles caused by the chickenpox virus in the

chest wall Surgery on the chest Other medical problems – kidney failure, liver

disease, sarcoidosis, or Cushing's disease.

DIAGNOSIS Medical history – stopped having menstrual

periods, having trouble getting pregnant, or having headaches or vision problems. OTC medicines if any. Sample of the discharge may be tested in the lab.

Blood tests Mammogram (x-ray of the breasts) Ultrasound scan of the breasts CT scan of the brain to look at the pituitary

gland.

TREATMENT If a galactocele is causing the galactorrhea, the

cyst will be removed. If the discharge is caused by drugs, it will clear

up when stop taking the drugs. However, stopping drugs is not always necessary.

If the galactorrhea is caused by a pituitary gland tumor, needs surgery, radiation, or drug treatments. Can treat with bromocriptine (stops production of prolactin).

How long will the effects last? Once the cause of the discharge is diagnosed and

treated, she should no longer have the discharge. However, if pituitary tumor is present, may need long-term treatment with bromocriptine or radiation because the tumor could come back.

SELF-CARE Follow-up tests. Take drugs as prescribed. If the galactorrhea is mild and a cause cannot be

found, breast binders can help stop the discharge by preventing stimulation of the nipples.

Paget's disease is a slowly growing cancer of the nipple. It is a rare form of breast cancer. It mainly affects women and very rarely men.

When abnormal cells grow uncontrollably, they are called tumors. It is not known why they occur. In Paget's disease, the tumor starts in the milk ducts of the nipple.

SYMPTOMS Symptoms seem harmless. It is often thought to

be a skin inflammation or infection, which can delay its diagnosis and treatment.

Redness, oozing, and crusting of the nipple and the circular, dark area around the nipple (areola), which causes itching and burning.

Sore on the nipple that will not heal. Usually only 1 nipple is affected. Sometimes no

changes in the skin can be seen. May have a lump in the breast, which may or may not be able to feel.

DIAGNOSIS Sample of discharge from the nipple may be

examined under a microscope. Biopsy – to remove the sample of breast tissue to

test for cancer. Mammogram of both breasts to look for cancer

in other parts of the breasts. Ultrasound scan or MRI - both of these tests

create pictures of the breasts.

TREATMENT If the cancer is only in the nipple and not any other

part of the breast: Radiation treatments Surgery to remove just the nipple and

surrounding tissue.

If a mass is found deep in the breast: Surgery to remove all or part of the breast Chemotherapy.

How long will the effects last? Without treatment, the cancerous sore will

remain on the nipple and may spread deeper into the breast.

PREVENTION Check monthly for any lumps, sores, or oozing

from the breasts and report any breast changes to the physician right away.

Breast-feeding should be a comfortable and enjoyable experience.

Sore nipples are a common problem among breast-feeding mothers.

Often mothers quit nursing their babies early because of sore nipples, but this doesn't have to happen.

Sore nipples usually can be prevented or treated.

Nipple protectors

Mild nipple discomfort at the beginning of feedings during the first few days of breast-feeding usually needs no treatment.

Nipple pain that is severe or lasts throughout a single or for more than a week is not normal and should be evaluated by doctor or a lactation consultant.

• Protects sore nipples during breast-feeding

• Shaped to allow skin contact with baby

• Made with odorless, tasteless, ultra-fine silicone

CAUSES Position of the baby's mouth on the breast. Size and shape of the nipples and the baby's

mouth can affect how the baby latches on the breast.

Also, infant's sucking habits can cause nipple discomfort.

Other possible causes of nipple pain are an infection of the nipples (yeast or bacterial), breast infection or improper nipple skin care.

PROBLEMS CAUSED If baby is not latching on to the breast correctly,

he may not be getting enough milk. Also, nipple pain may cause to put off nursings

or not let the baby suck long enough when he nurses.

Sucking is important because this is what triggers the milk to begin to flow (let-down reflex).

Nipple pain can cause a drop in the milk supply. As a result, baby may not gain weight well. Sore nipples and low milk supply problems often

go hand-in-hand.

TREATMENT Make sure the baby is positioned correctly to nurse Begin a feeding on the less sore nipple to trigger

the let-down reflex and start milk flowing Frequent shorter feedings are better than less

frequent lengthy feedings Keep the nipples dry If any cracks or other breaks in the skin, keep the

nipples covered with a soothing ointment Use a pump to express the milk if the pain is so

severe that cannot nurse the baby Watch for signs of a breast infection

WHEN TO SEEK MEDICAL ADVICE Immediate – following symptoms additional to sore

nipples: chills, fever, headache, flu-like symptoms, or pain or redness in the breast.

OB/GYN – Nipples sting or burn and have shooting pains in the breast, especially after nursing. Nipple pain keeps from nursing long enough to trigger let-down reflex.

Pediatrician – baby unsatisfied after most nursings. Baby may not be satisfied because milk supply is low or baby is not emptying breasts. Nipples – yeast infection, see white patches in the baby's mouth, or baby has had a diaper rash for 3 or more days.

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