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Breast cancer is the most common malignant neoplasm diagnosed in women. The incidence of breast cancer is steadily increasing - in Poland, about 18,000 new cases are diagnosed every year. Despite the growing trend of the disease, the effectiveness of this cancer therapy is constantly improving. Thanks to preventive examinations, it is more and more often detected at an early stage - when the chances of a full recovery are much greater. What are the risk factors for developing breast cancer? Which symptoms should be worrying? What is the process of diagnosis and treatment?

Breast canceris a common name - doctors use the namesbreast cancerorbreast cancer(Latincarcinoma mammae ). Breast cancer is a malignant tumor that originates in the cells of the epithelium that line the inside of the lobules and milk ducts. It is also possible to cause cancer of other tissues that make up the breasts - the resulting tumors are called sarcomas. However, it is a much rarer phenomenon - cancers constitute as much as 99% of malignant neoplasms of this organ. Knowing the anatomy of the breast glands, it is also easy to understand where the most common forms of breast cancer originate from:

  • ductal carcinoma of the breast(from the tubes leading to secretions)
  • lobular carcinoma of the breast(from the cells that produce it)

Breast cancer - symptoms

Changes in the external appearance of the breastora palpable lumpwithin them is often the first reason to see a doctor.

Each change in the structure of the breast gland, thickening or wrinkling of the skin, as well as suddenly noticedbreast asymmetryshould be consulted with a specialist. Also disturbing arechanges in the nipple- anydischarge , discoloration, itching or its dragging inside.

Often the cause of great anxiety among patients isbreast pain . It is not very characteristic symptom and does not have to be related to the neoplastic cause - it may result from hormonal fluctuations accompanying various phases of the menstrual cycle, the presence of benign changes (e.g. cysts) or it may be inflammatory.

A typical symptom of breast cancer is the so-calledorange peel(skin around the breastits color and structure resembles the skin of this fruit), caused by the tumor infiltrating and pulling the connective tissue fibers.

The orange peel symptom may accompany the so-calledinflammatory breast cancer . This is a special form of tumor manifestation through the symptoms of inflammation:

  • fever
  • swelling
  • warming
  • pain
  • redness

They are caused by blockage of the lymphatic vessels by the neoplastic infiltration with the subsequent stoppage of the outflow of lymph from the mammary gland. Inflammatory cancer is relatively aggressive and does not always present as a nodule, which in turn contributes to delayed diagnosis.

Symptoms of breast cancer in more advanced stagesmay relate to locations associated with the formation of metastases.

Usually,axillary lymph nodesare affected first, manifested as enlargement and swelling. It happens that a massive infiltration of this group of nodes hinders the outflow of lymph from the adjacent upper limb and results in its swelling.Subsequent metastasesmay occupy nodes located in the supraclavicular fossa.

Symptoms of advanced, disseminated form of cancerare not very characteristic:

  • chronic fatigue
  • weight loss
  • wasting

They can also apply to organs in which metastases occur most frequently:

  • liver (jaundice)
  • lungs (coughing)
  • brain (neurological disorders)
  • bones (bone pain)

Breast cancer - where does it come from? Breast structure

To understand wherethe different types of breast cancer come from , it's helpful to learn about the structure of this organ. The breast is made up of glandular tissue that is responsible for producing milk.The tissue of the mammary glandsis divided into several lobes (so-called lobules), in which thetubes leading to secretionbegin. These tubes run towards the nipple, transporting milk from the gland cells to the top of the nipple.

The parenchyma of the mammary glandis surrounded by additional tissues: connective tissue capsule, muscle bands, and adipose tissue. Its amount in relation to the amount of glandular tissue changes with age, body weight and hormonal changes taking place in the woman's body.

In young women, glandular tissue is usually dominant, while the amount of adipose tissue surrounding her increases with age.

Breast cancer - epidemiological data

Statistics showa steadily growing trendbreast cancer incidence . Over the last 30 years, the number of cases in Poland has doubled. On the other hand, thanks to preventive examinations enabling early diagnosis and constantly developing methods of therapy,survival statistics are systematically improving .

The five-year survival rateof patients struggling with breast canceris currently over 80%(this means that as many as 80% of patients with who are diagnosed with this cancer survives for at least the next 5 years). The frequency of diagnosing very advanced and / or disseminated disease is also significantly decreasing.

The greatest risk of developing the diseaseconcerns the group of women aged 50-69. Increasingly, however, breast cancer is also diagnosed in younger patients, aged 20-49.

The number of deathsfrom this cancer has remainedrelatively constant . This means that more and more people are living with a diagnosis of breast cancer.

The confrontation with the diagnosis constantly causes fear among patients, but the way of perceiving it gradually changes. Breast cancer is more and more often treated asa chronic disease- similar to asthma, diabetes or hypertension - with which you can lead a normal life.

Breast cancer risk factors

  • Sex and breast cancer

99% of breast cancer cases are in women. However, it is worth knowing that male breast glands, although they are less developed, in rare cases can also become the starting point for cancer.

  • Age and breast cancer

The risk of developing breast cancer increases with age. The most common cases of the disease are women aged 50-69. Due to the constantly increasing life expectancy, one should expect growing trends in the incidence of neoplastic diseases, including breast cancer.

  • Hormonal factors and breast cancer

The breast tissue is strongly influenced bysex hormones- estrogens and progesterone. There are many different factors that, by affecting the endocrine system, may increase the risk of breast cancer.

One of them is the so-calledprolonged estrogen stimulation , i.e. a long period of estrogen's influence on the mammary gland. It is associated with both the early onset of menstruation and the late onset of menopause.

Other risk factors arethe late birth of the firstchildlessness or childlessness .

The effect of breastfeedingon the development of breast cancer remains unclear - according to some studies, it causes structural and biochemical changes in the mammary glands, reducing the risk of developing cancer.

The use of oral contraceptives and hormone replacement therapy have a significant impact on the intracorporeal metabolism of sex hormones - these groups of drugs also increase the likelihood of breast cancer.

  • Genetic factors and breast cancer

About5% of breast cancercasesare genetically predisposed . The familial occurrence of this neoplasm is related to the mutation of the BRCA1 and BRCA2 genes. It also increases the risk of developing ovarian cancer.

The mere presence of the mutation does not mean, however, that the patient will develop breast cancer in 100%. The risk is estimated at 50-80%, depending on the sources.

Cancer caused by mutation of BRCA1 and 2genes is statistically more common in younger women and is more aggressive in nature. Neoplastic outbreaks can appear in both breast glands at the same time.

Detection of the BRCA1 or 2 mutation is an indication for taking appropriate preventive measures.

  • Dietary and environmental factors and breast cancer

Obesity, low physical activity, a diethigh in animal fats and the consumption of alcohol increase the risk of developing breast cancer.

The excess of adipose tissue affects the hormonal balance of the body, including the estrogen metabolism, which is so important for the mammary glands.

  • Changes in the mammary glands and breast cancer

Occasionally, breast cancer may develop as a background of pre-existing benign changes.Atypical proliferative changes , in which cells that may have a tendency to malignant are detected, require careful observation and sometimes removal.

  • History of breast cancer and breast cancer

Patients who have had breast cancer in the past have a significantly increased risk of developing cancer in the other breast.

  • Exposure to ionizing radiation and breast cancer

Exposing radiation (e.g. radiotherapy) to the chest at a young age may contribute to the cancer process.

Breast cancer diagnosis: history, tests

Breast cancer diagnosishas several stages - from collecting a medical history and examiningphysical, through imaging tests, to detailed histopathological and molecular diagnostics.

  • Medical interview

During the first conversation with a doctor in the case of suspected breast cancer, you should expect questions about both current ailments and possible chronic diseases. The history of menstruation, past pregnancies and the use of hormonal drugs should be particularly precise. Your doctor will likely also ask about your family history of malignant tumors (including breast cancer).

  • Physical examination

A physical examination should include all organs of the body, with a particularly careful assessment of the mammary glands.Palpationcan reveal the potential malignancy of a tumor, and also allows you to determine its location and approximate dimensions. The glandular tissue assessment should also take into account the so-calledSpence's tail , which is a physiological fragment of the mammary gland in some women, running towards the armpit. The attending physician will also check the condition of the axillary lymph nodes for signs of possible metastasis.

  • Imaging tests

The role of imaging tests is to visualize the internal structure of the breast and to enable a preliminary assessment of the nature of the changes found. The most common are:

-mammography , i.e. imaging of the mammary gland using X-rays. This is thebasic screening test for breast cancer in women over 40 years of age. Mammography is most useful in imaging breasts made largely of adipose tissue (with a predominance over glandular tissue). For this reason, it is rarely used in young patients. Mammography allows for the visualization of disturbing nodules - with microcalcifications in their structure and with a tendency to infiltrate the surrounding tissues.

-USG, i.e. ultrasound examination- its feature is good imaging of glandular tissue. They are most often used in young patients. It is also safe for pregnant women. Breast ultrasound allows for a preliminary assessment of the density of lesions (distinguishing tumors from, for example, fluid-filled cysts), their demarcation from the surrounding tissues and precise dimensions.

-Magnetic resonance imaging (MRI)is the best image quality test when you have doubts about the interpretation of the above tests. Magnetic resonance imaging is also availableused as a prophylactic examination in women from high-risk groups (e.g. with BRCA1 and 2 gene mutations).

  • Pathomorphological examination

Viewing tissue specimens or tumor cells under a microscope is of crucial importance in the diagnosis of breast cancer. The material for the examination is most often obtained by thick- or fine-needle aspiration biopsy, i.e. collecting a fragment of suspicious tissue with a special needle (usually under the control of mammography or ultrasound).

Pathomorphological assessmentallows to determine the malignancy of the lesion, the nature of its cell structure and the degree of advancement.Microscopic examinationof materials obtained during surgical procedures allows to determine the extent of the tumor, lymph node involvement and the maintenance of surgical margins (whether the tumor has been completely removed).

Advances in pathomorphological diagnostics now allow the use of additional tests (so-called immunohistochemistry) to help identify the individual characteristics of cancer cells and find their "weak points" - for example, the presence of hormone-binding molecules.

Yesa thorough analysis of the structure of breast cancer cellsallows for the initial prediction of its sensitivity to various types of therapy. Thanks to such efficacy forecasts, it is possible to implement individually tailored treatment regimens.

  • Additional research

If advanced breast cancer is suspected,may need additional teststo look for possible metastases. The most common locations of distant metastatic lesions are the liver, lungs, bones and brain.

In case of suspiciondisseminated neoplastic processare ordered:

  • chest X-ray
  • ultrasound of the abdominal cavity
  • sometimes also computed tomography of the brain and bone scintigraphy

An additional test to locate metastases is positron emission tomography (PET).

As with other neoplasms, breast cancer may manifest itself as an increased concentration of the so-called tumor markers. The most common types of markers are Ca 15-3 and CEA.

Their importance in the diagnosis of breast cancer is limited: they may suggest suspicion of this neoplasm, but are not specific for it. Their concentrations may also be increased in other diseases.

Increased concentration of Ca 15-3is also found in neoplasms of the reproductive organ or liver diseases. On the other hand,increase in CEAmost oftenaccompanies colorectal cancer, but may also coexist with other diseases (not only cancer).

Tumor markers are more often used to monitor the progress of treatment: if their concentration decreases with the course of therapy, it may be one of the signals of the effectiveness of the treatment.

Determination of marker concentrations may also be usefulin detecting tumor recurrence .

Types of breast cancer

Breast cancer can be classified according to various criteria : depending on the severity, microscopic structure and potential malignancy. Usually, a detailed description of the diagnosis for each patient involves the assignment of several classification systems. The most important of them are:

  • histological evaluation

The microscopic examination allows you to answer the following questions:

-Which cells does breast cancer originate from?

The most common starting point for carcinogenesis is theepithelial cellsthat line the secretion ducts. These cells are the source of the so-calledductal cancer . Less commonly, breast cancer develops in the glandular lobule cells that produce milk. This type is calledlobular carcinoma . Other, rarer subtypes are (depending on the type of cells that make up the tumor) incl.mucus cancer ,tubular cancerimedullary cancer .

- Do cancer cells infiltrate surrounding tissues?

Histopathological examination enables the initial assessment of the stage of advancement. As a result of the study, we can see 2 basic types of diagnoses:

  • carcinoma in situ( non-invasive- neoplastic cells are malignant, however, they are strictly separated from the environment and do not invade nearby tissues). Removal of cancer in situ offers a very good chance for a full recovery.
  • invasive cancer- cancer cells have the ability to spread to surrounding tissues.

- What are the malignancy characteristics of cancer cells?

When viewed under a microscope, breast cancer cells may look like the surrounding he althy cells. We then call them highly diverse.Highly differentiated cellsare associated with a better prognosis than those that are significantly different in structure from normal. The features of high malignancy of neoplastic cells are disturbed, chaotic structure, uncontrolled multiplication, loss of proper microscopic structure.

The scale of histological malignancy of cellsis called Gradingand has three levels of advancement:

  1. GI(highly mature cells - least malignant)
  2. GII
  3. GIII(least mature cells - most malignant)

  • assessment of receptors for hormones and molecular subtype

A very useful tool in the assessment of prognosis and selection of therapy is to check whether the tumor cells respond to hormonal signals thanks to special receptors located in the cell membrane.

The most frequently searched for isestrogen receptors , progesterone and the so-calledHER2 receptors . The presence of these receptors is a good starting point for targeted therapies.

If cancer cells have, for example, an estrogen receptor, there is a high probability of a good response to therapy with the so-called anti-estrogens.

The combination of knowledge about the presence of hormone receptors with additional, specialized microscopic examinations allowed for the emergence ofmolecular classification of breast cancer . This division includes subtypes with different prognosis and expected response to therapy. These include:

  • Luminal subtype A : Estrogen receptor usually present, low-grade cells
  • Luminous subtype B : estrogen receptor frequently present, cells with higher malignancy
  • Basal subtype : usually missing all three receptor types (estrogen, progesterone, HER2) - for this reason this subtype is also called "triple negative". Its features determine the limited applicability of some therapies and cause a worse prognosis.
  • HER2-positive subtype : increased activity of the HER2 receptor is associated with greater tumor aggressiveness, but on the other hand, it allows the use of targeted treatment against this receptor (Trastuzumab drug).

TNM classification

The international TNM classificationtakes into account the 3 basic features of cancer :

  • T (tumor)- tumor size
  • N (nodes)- local lymph node involvement
  • M (metastases)- creating distant metastases

The degree of clinical advancementdetermines the prognosis and the possibility of using various types of therapy (more below).

Breast cancer treatment

Choosing a method of treating breast cancerrequires consultation with a team of specialists - surgeons, oncologists, radiotherapists, taking into account the patient's perspective, as well as an in-depth analysis of alltest results.

It is worth realizing thatbreast cancer is not one disease- there are many subtypes that differ in aggressiveness and response to different types of therapy. The key factor in selecting a treatment regimen is always the stage of the disease.

Surgical treatment of breast cancer

Surgery is the basic method of breast cancer treatment. The earlier a tumor is detected, the greater the chance of complete and successful surgical treatment. The operation may involve different tissue ranges:

  • lumpectomy , i.e. removal of the tumor itself - this type of surgery is used for small tumors
  • quadrantectomy , i.e. removal of the tumor together with one of the four quadrants of the breast

Both of the above treatments belong to the so-calledsaving operations . In the case of more advanced breast cancer,radical surgery - mastectomyis used. It is a procedure to remove the entire breast.

In addition to surgery on the mammary gland, it may also be necessary toremove the affected lymph nodes . To see if cancer cells have spread to them, the so-calledsentry node . This is the closest lymph node through which the tumor from the tumor area flows first.

If cancer cells are found in the sentinel node, it means that they may also have invaded the axillary lymph nodes further away. In this case, it is necessary to remove them (the so-calledlymphadenectomyprocedure).

Whensentinel node is "clean" , devoid of neoplastic cells, it is not necessary to remove the remaining lymph nodes.

Radiotherapy in the treatment of breast cancer

Irradiationmay be a treatment complementary to a surgical procedure - they allow the complete destruction of tumor remnants. Thanks to the additional use of radiotherapy, it is possible to perform conserving surgeries.

Sometimes irradiation is also used before surgery - in order to initially reduce the size of the tumor. The combination of different types of therapy is calledcombination treatment .

Localcomplications of radiotherapymay include:

  • skin redness
  • itchy rash
  • local swelling and soreness

Chemotherapy in the treatment of breast cancer

The goal of chemotherapyis to stop cells from dividing uncontrollably. Like radiation therapy, it can be used both pre- and postoperatively.

Chemotherapy is sometimesthe mainstay of treatmentin cases of advanced breast cancer where surgical treatment is not possible.

The action of chemotherapeutic agentsis unfortunately not selective in addition to destroying neoplastic cells, they also have a great impact on he althy, properly dividing cells of the body. However, more and more drugs are available today to help reducethe persistent side effects of chemotherapy .

We are also constantly working on new chemotherapy regimens.

One of the achievements of recent years is the development of the so-calledmetronomic chemotherapy . Its main assumption is the administration of small doses of drugs at short intervals (as opposed to traditional chemotherapy in which large doses of chemotherapeutic agents were administered every few weeks).

Thanks to this, the therapy is safer, causes fewer side effects, while maintaining its effectiveness.

Hormone therapy in breast cancer

The presence of hormone receptors on the surface of cancer cells enables the implementation of hormone therapy. If the cancer has estrogen receptors, drugs that block these receptors (e.g. Tamoxifen) or inhibit estrogen synthesis (the so-called aromatase inhibitors, e.g. anastrozole) are used.

Another variant of hormone therapy is the inhibition of the production of sex hormones by the ovaries. The most common side effects of this type of treatment arean increase in blood clottingand a decrease in bone mineral density (osteoporosis).

Targeted therapy

Negligence in understanding the biology of cancer has resulted in the launch of new drugs targeting specific targets. One example is Trastuzumab, a drug that acts on HER-2 receptors. Many drugs in this group are currently in clinical trials. A significant disadvantage of this type of therapy is itsvery high costs .

Adjuvant and neoadjuvant therapy

Breast cancer patients may come across the termsadjuvant and neoadjuvant therapy . These arenames of therapies that complement operative treatments .

Adjuvant treatmentis used after surgical treatment - its goal is to eliminate those tumor cells that were not excised during surgery.

Neoadjuvant treatmentis used before the procedure - it allows you to initially reduce the tumor and slow down its growth.

In each casethe treatment regimen is selected individually- the role of adjuvant therapy andNeoadjuvant treatment can be performed by both chemo-, radio- and hormone therapy, as well as combinations of these methods.

Palliative treatment

Palliative treatmentis undertaken whenit is not possible to fully cure the disease . Its main goal is to extend and improve the quality of the patient's life. Treatment that works directly on the tumor (all the methods mentioned above) and relieving the symptoms of the disease are both used. The most important therapeutic directions include:

  • pain treatment
  • nutritional treatment
  • psychotherapy
  • reduction of symptoms associated with metastatic foci

Breast cancer prevention

In breast cancer, as in other diseases,there are two stages of prevention: primary and secondary . Primary prophylaxis is aimed at preventing the occurrence of the disease. The aim of secondary prophylaxis is to detect the cancer at an early stage and to start the treatment quickly.

Primary prevention of breast cancer

In the case of breast cancer, primary prevention is less important than secondary prevention - as there are no 100% guarantee of avoiding the disease. However, it is certainly worth getting acquainted with the risk factors for breast cancer and reducing those on which we have influence. These are mainly elements of a he althy lifestyle:

  • balanced diet
  • physical activity
  • reducing alcohol consumption
  • maintaining a he althy body weight

It is also good to be aware of risk increase caused by hormonal factors such as late motherhood or the use of estrogen-containing drugs.

Secondary prevention of breast cancer

Secondary prophylaxis is currently the most important method of activities aimed at improving the cure rate and prognosis of patients diagnosed with breast cancer.Detecting the disease at an early stageis the factor that gives the best chance for a fully effective cure.

Breast cancer can be latent for a long timeand may not cause any symptoms . For this reason, there are screening programs for this cancer, as well as information campaigns to raise awareness of their key role. The most common methods of secondary prevention include:

  • screening tests

There is a breast cancer prevention program in Poland, targeted at women aged 50-69. As part of the program, patients can havescreening mammography every 2 years . In some cases (for example, the presence of cancerfamily history) patients can be referred for examination every year.

In younger women, mammography screening is not recommended unless there are special indications. The condition for the improvement of the nationwide statistics on the effectiveness of breast cancer treatment is participation in screening tests of the highest percentage of invited patients.

In Poland, awareness of the prevention and reporting of women is constantly growing. However, they are still significantly lower than in Western Europe.

  • breast self-examination

The effectiveness of breast self-examination in reducing mortality from breast cancer has not been scientifically proven. Nevertheless, most doctors encourage patients to regularly assess the appearance of the breasts and look for any changes in their area: lumps, skin wrinkles or nipple discharge.

The test should be performed in the first phase of the cycle. Self-examination helps to gain awareness of the normal appearance and consistency of the breast glands. Thanks to this, it is possible to notice any changes faster. Patients who regularly examine their breasts are also more aware of oncology and are more willing to undergo screening tests.

  • prophylaxis in high-risk groups

Special preventive recommendations apply to patients at high risk of developing breast cancer.The confirmation of the existence of mutations in the BRCA1 or BRCA2 genesor the presence of a family history of breast cancer is the basis for earlier implementation and more frequent screening.

Prophylactic mammographic examinations / ultrasound(depending on the structure of the breast) should be performed every year, from the age of 25. In carriers of the BRCA mutation, additional magnetic resonance imaging is recommended.

Some of the patients with this mutation decide toprophylactic mastectomy , i.e. breast removal. It is a method that significantly reduces the risk of cancer, but is also associated with a high psychological burden for patients.

Another type of prophylaxis reserved for women from high-risk groups ispreventive administration of estrogen blockers(e.g. tamoxifen). The decision to introduce such therapy is always made individually, because the use of these drugs is associated with the risk of serious side effects (for example, thromboembolic events).

Breast cancer and fertility, pregnancy, breastfeeding

AscendingBreast cancer incidence among young womenand late motherhood pose challenges for doctors and patients to plan and manage pregnancy in the face of neoplastic disease.

Patients planningpregnancy after breast cancer treatmentare advised to wait at least two years after the end of therapy. This is the period when the risk of relapse is greatest.

In addition, it is very important to consider the possible effect of anti-cancer treatment onthe patient's fertility . Chemotherapy has the most significant influence on reproductive function. Its significant side effect may be temporary or permanent infertility (especially in elderly patients). For this reason, some women, before starting therapy, decide to use assisted reproductive techniques (in vitro) - freezing eggs or embryos.

Detecting breast cancer in a pregnant womanmay be more difficult due to the physiological differences of this period. Some of the symptoms may be mistakenly associated with the course of pregnancy and therefore be overlooked.

The coexistence of pregnancy and cancerdoes not worsen the prognosis, although breast cancer at an early age is often more aggressive and more resistant to therapy.

Diagnosis and treatment of breast cancer in a pregnant patientis similar to other cases, but there are some significant differences.

First, diagnostic tests that use large amounts of radiation are avoided. The treatment does not involve radio- or hormone therapy.

The administration of chemotherapyis suspended in the first trimester of pregnancy - this is when the internal organs of the fetus are formed and the risk of their toxic damage is greatest. Most chemotherapy drugs can be administered during the second and third trimesters.

Surgical removal of the tumor can basically be performed at any stage of pregnancy. If there is a need for more aggressive treatment,you may need to advance your due date .

The possibility of breastfeedingduring and after cancer treatment depends on many factors. If you are receiving chemotherapy after having a baby, you must not breast-feed. There is a risk of drug penetration into the food and the related effects on the newborn.

Lactation capacity after surgery depends on its extent.

In turn, undergoing radiotherapy may be associated with disturbances in milk secretion and the risk of radiationinflammation of the breast gland.

Male breast cancer

About 1% of all breast cancer cases occur in men.

Many cases of this cancer in men are associated withgenetic predisposition- the presence of BRCA gene mutations (mainly BRCA2).

Other risk factors includehormonal disorders , in particular a decrease in the amount of male sex hormones (mainly testosterone) and an increase in the amount of female hormones (estrogens). The most common causes of such changes are liver disease, taking hormonal drugs, and obesity.

Another factor that increases the risk of developing the disease ischronic alcohol consumption .

The diagnosis of male breast cancermay be faster if you notice a lump (small volume of the mammary glands) earlier.

On the other hand, many men are unaware that their gender does not exclude the possibility of breast cancer.

The course of diagnosis and treatment is similar to the patterns used in women.

Male breast canceris characterized by estrogen and progesterone receptors relatively often, which makes it sensitive to hormone therapy.

The comparison of the effectiveness of different treatment regimens and the response to new targeted drugs have not yet been confirmed in multicentre research studies due to the relatively rare occurrence of this cancer in men.

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Oncology