Breast Cancer:

What every medical student should know.

Women agonize... over cancer; we take as a personal threat the lump
in every friend's breast.

Martha Weinman Lear, Heartsounds

 With 1 million new cases in the world each year, breast
cancer is the most common malignancy in women and
comprises 18% of all women’s cancers.

 Breast cancer incidence in women in the United States is 1 in

8 (about 13%). Women have a 3% chance of breast cancer
causing their death.

 For women in the U.S., breast cancer death rates are higher
than those for any other cancer besides lung cancer.

 The American Cancer Society estimates that each year, about

2000 new cases of invasive breast cancer are diagnosed in
men.

 It is estimated that about $8.1 billion is spent each year on

breast cancer treatment in the U.S.
 Epidemiology:
• Over 75% of women who are diagnosed with breast cancer are age 50 or older.

• The five-year relative survival rate is now 98 percent for women with breast cancer
caught before it spreads beyond the breast (compared to 72 percent in 1982).

• Breast cancer incidence is greater in women of higher socio-economi background.

The relationship of breast cancer risk with socio-economic factors is most likely
related to life style differences like number of pregnancies and age at first
childbirth.

• Death rates have been decreasing since 1990. These decreases are thought to be
the result of treatment advances, earlier detection through screening, and
increased awareness.
 Incidence and Mortality of Female Breast Cancer
Based on Race and Ethnicity in the U.S.

Rate
Per
100,000
 About 90% of breast cancers are due to genetic abnormalities
that happen as a result of the aging process and life in
general, not to inherited mutations.

Probabilities of Developing Invasive Breast Cancer Based on Age

Current Age Probability of breast cancer
in next 10 years
20 0.05% or 1 in 1,837
30 0.43% or 1 in 234
40 1.43% or 1 in 70
50 2.51% or 1 in 40
60 3.51% or 1 in 28
70 3.88% or 1 in 26

Lifetime risk: 12.28%; 1 in 8 women

 Hereditary Breast Cancer:

• While about 20-30% of women diagnosed with breast cancer have a family history of breast
cancer, only about 5-10% of breast cancer cases are caused by inherited gene mutations. BRCA1
and BRCA2 mutations are the most common.

Lifetime breast Median age of breast

cancer risk cancer (years)
General population 12% 61

BRCA1 65% 43

BRCA2 45% 41
 Breast Cancer Kills Men,Too.

Risk factors for male • Less than 1% of all new breast cancer
cases occur in men.
breast cancer
Testicular abnormalities: cryptorchidia, congential
inguinal hernia, orchiectomy, orchitis, testicular • Men with a BRCA1 mutation have a 1%
trauma
risk of developing breast cancer by age
Hormonal alterations: 70; BRCA2 mutations confer a 6% risk.
Infertility, Klinefelter’s syndrome, obesity, cirrhosis
(and heavy alcohol intake)

Family history of breast cancer, mutations in • Breast cancer prognosis, even in stage I
BRCA1/2, CHEK2, PTEN cases, is worse in men than in women.
Benign breast lesions:
Nipple discharge, breast cysts, breast trauma

Exposure to radiation or high temperatures

• Treatment for male breast cancer has
usually been a mastectomy, which may be
Old age followed by radiation, hormone therapy
(such as with tamoxifen), or
Jewish descent chemotherapy.
 Ductal carcinoma in situ
Types of Breast Cancer (DCIS) is the most common
type of non-invasive breast
DCIS: Ductal Carcinoma In Situ cancer.
LCIS: Lobular Carcinoma In Situ
IDC: Invasive Ductal Carcinoma
ILC: Invasive Lobular Carcinoma
Inflammatory Breast Cancer
Male Breast Cancer
Recurrent and Metastatic Cancer

Invasive ductal carcinoma (IDC) is the most

common type of breast cancer, comprising
about 80% of all breast cancers.
Signs to watch out for:

• a lump felt in the breast

• an inverted nipple
• nipple discharge (clear or bloody)
• nipple pain
• sores on the nipple and areola
• enlarged lymph nodes under the arm
 Signs and Symptoms
Rapid change in the appearance of one
breast (days or weeks), with visible
enlargement of one breast,
discoloration with red, purple, pink or
bruised appearance and warmth of the
affected breast suggests Inflammatory
Breast Cancer.

In inflammatory breast cancer, cancer cells invade local lymphatic ducts, impairing drainage
and causing edematous swelling of the breast.

Peau d’orange: The skin of the breast is tethered by the suspensory ligament of Cooper,
which, with the accumulation of fluid, can cause the breast to take on a dimpled appearance
similar to an orange.
 Inflammatory Breast Cancer
 Inflammatory breast cancer (IBC) accounts for between 1 percent and 6
percent of all breast cancer cases in the United States.

 The 5-year survival rate for patients with IBC is between 25-50 percent,
significantly lower than the survival rate for patients with non-IBC breast
cancer.

 IBC has a high risk of recurrence and is the most aggressive kind of breast
cancer. IBC is more likely to have metastasized at the time of diagnosis than
other breast cancer types.

 IBC affects women at an average age of 59 — about three to seven years

younger than the average age at which other types of breast cancer are
diagnosed.

 Men can develop the disease, but at an older age. Black women are slightly
more likely than are white women to have IBC.
Risk Factors
• The most significant risk factors for
breast cancer include gender (being
female) and age (growing older).

• Factors with minimal or no risk

include fertility treatment
abortion, deodorant and folic acid.

• Short-term use of hormones for

treatment of menopausal symptoms
appears to confer little or no breast
cancer risk.
Factors that Increase the Relative Risk (RR)
for Breast Cancer in Women
• Female
• Age (65+)
• Inherited genetic mutations associated with breast cancer such as BRCA1/BRCA2
RR>4.0 • Two or more first-degree relatives with breast cancer diagnosed at an early age
• Personal history of breast cancer
• High density breast tissue
• Biopsy-confirmed atypical hyperplasia
• One first-degree relative with breast cancer
• High-dose radiation to chest
2.1<RR<4.0 • High bone density (post-menopausal)

Factors affecting circulating hormones:

• Late age at first full-term pregnancy (>30 yrs)
• Early menarche(<12 yrs)
• Late menopause
• No full-term pregnancies
• No breastfeeding
• Recent oral contraceptive use
• Recent and long-term hormone replacement therapy
1.1<RR<2.0 • Obesity

Other factors:
• Personal history of endometrium, ovary or colon cancer
• Alcohol consumption
• Height (tall)
• High socioeconomic status
• Jewish heritage
Breast Cancer Screening and Prevention
 Surveillance
Mammography
Sonogram
MRI
Clinical and self breast exam
 Risk Avoidance
Diet and Exercise
 Chemoprevention
Tamoxifen
Raloxifene
 Prophylactic Surgery
Bilateral Prophylactic Mastectomy
Oophorectomy
Mammograms:
for low-income women and the uninsured.
 Mammograms are usually covered by health insurance for women in the
recommended age bracket. While some insurance plans have no out-of-
pocket expenses required, others charge a $10-$35 co-pay.

 Uninsured patients pay the full-price cost of a mammogram, which ranges

from $80 to $120.

 Some state and local health programs and employers provide

mammograms free or at low cost. Health departments, hospitals,
women’s centers, or other community groups may also have information
on how to access low-cost or free mammograms.

 The Centers for Disease Control and Prevention (CDC) coordinates the
National Breast and Cervical Cancer Early Detection Program to provide
screening services, including clinical breast exams and mammograms, to
low-income, uninsured women throughout the United States. Visit the
CDC website to find contact information for local programs

 Information about low-cost or free mammography screening programs is

also available through NCI’s Cancer Information Service (CIS) at 1–800–4–
CANCER (1–800–422–6237).
Conventional Treatments
• Surgery
• Chemotherapy
• Hormonal therapy
• Radiation
• Just over the horizon: breast
cancer vaccine trials are under way
with vaccines like NeuVax, which
stimulates anti-Her2 immune
response, and Stimuvax, moving
into phase III trials.
Triple Negative Breast Cancer:
• Triple negative breast cancer (TNBC) is clinically characterized by the lack of
expression of estrogen, progesterone and HER2 hormone receptors.
• Comprises about 10-20% of breast cancers: more than one out of every 10.
• Does not respond to current hormonal therapy (such as tamoxifen or aromatase
inhibitors) or therapies that target HER2 receptors, such as Herceptin (trastuzumab).
Women diagonosed with TNBC generally face a poorer prognosis.
• Treatments that target other processes may be helpful in treating triple negative
breast cancer when combined with chemotherapy:
• Avastin: interferes with VEGF (vascular endothelial growth factor), inhibiting
the growth of new blood vessels at the tumor site.
• Erbitux: interferes with EGFR (epidermal growth factor receptor), which is often
overexpressed in triple negative cancer.
• PARP inhibitors: inhibit poly (ADP-ribose) polymerase, an enzyme used by
cancer cells to repair DNA damage. One PARP inhibitor, dubbed BSI-201, has
been shown to improve survival in triple negative breast cancer patients by 60%
when added to standard chemotherapy drugs.
 Changes in sexuality and
desire, premature
Physical changes to the breasts and menopause, infertility
side effects such as hair loss, fatigue
and lymphedema

Financial hardships,
The Breast Cancer occupational changes
Experience
Mental and emotional changes
such as “chemobrain,” depression
and fear of recurrence
Changes in relationships with
family and friends
Positive lifestyle changes such
as increased exercise, healthier
eating, stress reduction
Complementary medicine can improve quality of life for
breast cancer patients:
• Acupuncture • Spirituality & Prayer
• Meditation • Reiki
• Aromatherapy • Support Groups
• Guided Imagery • Tai Chi
• Hypnosis • Shiatsu
• Journaling • Yoga
• Chiropractic Therapy • Music Therapy
• Massage • Progressive Muscle
Relaxation
• In the year 2008, there were about 2.5 million
women in the U.S. who considered themselves
breast cancer survivors.
Advocacy