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WOMEN: A
NARRATIVE
LITERATURE
REVIEW]
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Disease Presentation
Breast cancer in women is a complex and factor disease that occurs to a large extent
between and within the heterogeneity of the tumor. For this reason it is necessary to
apply an adapted approach according to the needs of the patients and to choose the
right way of treatment in order to achieve the best response. Two types of tumor
heterogeneity have described. Heterogeneity between tumors and that within the
tumor. Thanks to high-resolution resolution, a molecular classification of breast
cancers is available that distinguishes four subtypes. Luminal a luminal b HER 2+ and
basal like (Roulot et al., 2016).

The etiology of breast cancer in women is unknown. However, a number of

endogenous or exogenous factors have been shown to be associated with the disease.
These factors include the following:

Age. There is an increase in the incidence of breast cancer with age, in fact more than
85% of cases are diagnosed in women over 45 years (Sun et al, 2017).

Genetic factors are also blamed. Female first-degree relatives of breast cancer patients
such as sister mothers and daughters are three times more likely to develop than the
general population. If the disease occurred at the age of less than 40 years, the risk of
occurring in relatives is higher. 2nd suppressor genes have been linked to the
development of breast cancer. Mutations in these genes lead to tumor growth and the
risk appears to increase if relatives have had breast cancer in both breasts or were
diagnosed before the age of 40 (Sun et al, 2017).

The duration of menstruation there is also a very important parameter for the
occurrence of breast cancer in women. Statistics have shown that the relative risk of
developing it is higher in women with early menopause, late menopause, infertile
women and women with their first pregnancy after the age of 30, or in women with a
family history of ovarian cancer (Sun et al, 2017).

Exposure to ionizing radiation also has an effect on the development of breast cancer.
Especially in the second decade of life it has been shown to increase the risk of
developing breast cancer after about 20 years (Center for Environmental Health
Studies,1943; Fenga, 2016).

Finally, diet has a direct effect on breast cancer. More specifically, the high fat
content in food and moderate consumption is associated with a high rate of cancer in
women in Western societies and the affluent classes, especially after menopause (Sun
et al, 2017).

The clinical picture of the disease in more than 80% includes the location of a hard
painless tumor in the breast that is revealed during the physical examination by the
doctor or during the self-examination by the patient. The tumor is a solitary unilateral
solid solid irregular and immobile.

In 50% of cases the mass is located in the upper outer quadrant of the breast. Bloody
secretions appear from the nipple of the affected breast in 30 to 40% of cases when
the tumor invades the lymphatic vessels and the flow of lymph is obstructed, causing
swelling and the appearance of the skin as an orange peel.

Breast cancer belongs to the slow-growing malignant neoplasms,with the

development of the disease to have a great diversity. Metastases can occur and 10
years after tumor removal the cancer cells follow the lymphatic and bloodstream
pathways to the site of metastasis. The first target is the axillary lymph nodes. The
number of affected lymph nodes is important for the prognosis of the disease. The
higher the number the worse the prognosis. The most common areas of metastatic
disease from breast cancer are the bones, the lungs, the brain and the liver (Fenga,
2016).

Diagnosis
An important role in the diagnosis of breast cancer is to obtain a complete and
detailed family and personal history. Necessary data to be recorded when taking the
history are the risk factors for the disease that are identified, including the age of
menstruation, the use of hormone replacement therapy after menopause, the use of
oral contraceptives, a family history of ovarian cancer or breast cancer in first-degree
relatives. Symptoms such as chest pain, weight loss, bone pain and nipple pain should
also be noted.

The physical examination includes an overview of the breast as well as the areas
around the neck and the clavicle and armpits. Deformities such as bumps or other
manifestations of cancer are reviewed and the lymph nodes that usually enlarge in
patients with breast cancer are examined. Self-examination also seems to be important
(Akram et al., 2017).

In women with dense breasts, additional ultrasound is applied as this reveals a

percentage of false positive cases. More specifically, the complete breast ultrasound
allows the projection of tumors that can not be measured by mammography in dense
breasts where the sensitivity of the method seems to be lower. Ultrasound shows the
size and location of the tumor as well as whether it is filled with fluid or solid. Biopsy
is necessary to rule out cancer (Akram et al., 2017; Shamsi and Islamian, 2017).

Nuclear medicine also helps in the diagnosis of breast cancer, ie the type of molecular
imaging where a radioactive substance is introduced into the patient and the radiation
from the radiopharmaceutical is perceived by emission detectors located outside the
patient's body. Through this process, the boundaries of the tumor and its proximity
can be identified. The spectrophotography is a precision scan of the target organ that
is being investigated but can also be used throughout the body as it is safe in terms of
the amount of radiation it receives and helps identify primary and metastatic cancers
(Akram et al., 2017; Shamsi and Islamian, 2017).

The (PET CT) positron emission tomography method is also safe in terms of the
radiation absorbed by the patient's body and is an extremely useful method for
locating different areas of local lymph node extent or distant metastases that are not
perceived by conventional imaging. It is also used after the recurrence of the disease
in its re-examination, ie in the management and monitoring of treatment (Akram et
al., 2017; Shamsi and Islamian, 2017).

Cancer markers, according to some researchers, should be measured at all stages of

breast cancer even when predicting metastatic treatment, diagnosis and screening.
Cancer index CA 15-3 can be used to monitor breast cancer patients as it is observed
in less than 10% of patients at the beginning of breast cancer and in about 70% of
patients with advanced breast cancer in the blood. Another indicator is CA 27-29 used
to monitor breast cancer patients but does not appear to have better prognostic value
for early or advanced stage breast cancer (Akram et al., 2017).

The estrogen and progesterone receptors of cancer tissues, including the HER 2
antigen, are tested for breast cancer (Akram et al., 2017).

Immunohistochemistry is also a laboratory technique that combines histopathology

with immunology and chemistry in order to identify the disease and to make the
correct diagnosis. According to the findings, the malignancy is classified and the
doctors rely on the results of the immunohistochemistry in order to select the targeted
treatment for each patient individually (Akram et al., 2017).
Mammography has been considered the most appropriate screening method for breast
cancer for many years, but it can not help to distinguish between solid or cystic mass,
with the result that 10 to 15% of breast cancer cases go undiagnosed. MRI scans
provide more accurate results for women who develop breast cancer due to mutations
in the BRCA 1 and BRCA 2 genes and present with axillary lymph node adenopathy
(Akram et al., 2017).

The definitive diagnosis of breast cancer can only be made through breast biopsy.
Various techniques are used, such as fine needle aspiration or nucleus biopsy,
vacuum-assisted stereotactic nucleus biopsy, or surgical biopsy. Of course, in order to
enhance the diagnostic accuracy and to reduce the rates of false negative results, it is
proposed to perform a simultaneous imaging of the breast, a clinical examination and
a biopsy. As already pointed out, mammography is considered the golden option for
the early diagnosis of breast cancer, but it should be combined with other imaging
methods in women with dense breasts. Positron emission mammography can be used
as an alternative to magnetic resonance imaging in patients who do not want to have
an MRI scan for various reasons such as e.g. claustrophobia but the sensitivity of the
methods remains similar for the detection of cancerous lesions as well as invasive or
in situ carcinoma (Mocian et al., 2018 ; Liu and Huang, 2018).

The purpose of early diagnosis is to reduce mortality. Early detection is the key in this
direction as the five-year survival is lower in women with advanced cancer while the
5-year survival for women with localized breast cancer is 99% and decreases to 86%
when the disease has spread to the glands of the area. In metastatic cancer, five-year
survival is limited to 28% (American Cancer Society, 2021)

References (part 1 of 3 )
 Akram, M. et al. (2017) ‘Awareness and current knowledge of breast cancer’,
Biological research, 50(1), p. 33. doi: 10.1186/s40659-017-0140-9.
 American Cancer Society. Cancer Facts & Figures 2021. Atlanta, Ga:
American Cancer Society; 2021.
 Center for Environmental Health Studies. (1943) ‘Ovarian Cancer and
Exposure to Ionizing Radiation Findings of Human Health Research Studies
Other Research and Policy Findings’, 02210(617), pp. 80–83.
 Fenga, C. (2016) ‘Occupational exposure and risk of breast cancer (Review)’,
Biomed Rep, 4(3), pp. 282–292. doi: 10.3892/br.2016.575.
 Liu, J. and Huang, L. (2018) ‘Image-guided vacuum-assisted breast biopsy in
the diagnosis of breast  microcalcifications.’, The Journal of international
medical research, 46(7), pp. 2743–2753. doi: 10.1177/0300060518770577.
 Mocian, F. et al. (2018) ‘The Revisited Role of Ultrasound Guided Core
Needle Biopsy in the Breast Cancer  Diagnosis.’, Chirurgia (Bucharest,
Romania : 1990), 113(2), pp. 244–252. doi: 10.21614/chirurgia.113.2.244.
 Roulot, A. et al. (2016) ‘Tumoral heterogeneity of breast cancer.’, Annales de
biologie clinique, 74(6), pp. 653–660. doi: 10.1684/abc.2016.1192.
 Shamsi, M. and Islamian, J. P. (2017) ‘Breast cancer: Early diagnosis and
effective treatment by drug delivery tracing’, Nuclear Medicine Review, 20(1),
pp. 45–48. doi: 10.5603/NMR.2017.0002.
 Sun, Y.-S. et al. (2017) ‘Risk Factors and Preventions of Breast Cancer.’,
International journal of biological sciences, 13(11), pp. 1387–1397. doi:
10.7150/ijbs.21635.