Chapter 2

Breast Cancer & Early Detection

 Important Points  

Objectives of the Chapter  

After reading this chapter, you will be able to:

· Recognize signs and symptoms of breast cancer

· Identify the most common risk factors of breast cancer

· Discuss major methods of treatment and therapy for breast cancer

· Explain the importance of early breast cancer detection

· Explain the procedure for Breast Self Examination (BSE), Clinical Breast Exam (CBE), and mammography 

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 Important Points of the Chapter

  ·  All women are at risk for breast cancer

 ·  Breast cancer screening is critically important to detect breast cancer at an early and treatable stage

 ·  BSE, CBE and mammography are three methods of early breast cancer detection

 ·  A lot of information is available to help patients with breast cancer, as well as their families and friends, better understand this disease

    2.1 Breast Cancer

1. Alarming Numbers

    An estimated 203,500 new invasive cases of breast cancer are expected to occur among women in the United States during 2002. An estimated 39,600 women will die from breast cancer.  Though the risk is significantly lower, breast cancer also occurs in men.  It was estimated that 1,500 men will be diagnosed and 400 men will die from breast cancer during 2002.9  Breast cancer is the major cancer site among American women and is second only to lung cancer in cancer deaths.  It is the leading cause of cancer deaths among women ages 40-59.

2. Factors that contribute to Breast Cancer

    The exact causes of breast cancer are unknown though risk increases with age.  Most women who are diagnosed with breast cancer are older than 45, but younger woman may also be affected.  Research and studies have revealed the following factors contribute to breast cancer development. 10

a. Estrogen 
     Breast Cancer is often triggered by normal female hormones.  Evidence suggests that the longer a woman is exposed to estrogen (estrogen made by the body, taken as a drug for the purpose of treatment or prevention of disease, or delivered by a patch for the purpose of family planning), the more likely she is to develop breast cancer.
    Women who began menstruation at an early age (before 12) or experience menopause late (after age 55) have an increased risk of breast cancer because of the increased length of time their body is exposed to estrogen.  H
ormone replacement therapy may also increase the risk of breast cancer while protecting against many other diseases.

b. Late childbearing
    Women who complete their first full term pregnancy after age 30 have an increased risk of beast cancer.  Never having been pregnant is also an increased risk factor.  However, women who breast-feed have lower rates of breast cancer.

c. Personal history of breast cancer
Women who have had breast cancer or at greater risk of the cancer recurring or appearing in the other breast. Furthermore,  women who have had a breast biopsy are statistically at greater risk of getting breast cancer. Although the biopsy itself does not cause cancer, women who have had a breast biopsy are at higher risk because of whatever breast changes prompted the biopsy.

d. Family history 
    Between 5 and 10% of all breast cancer cases are associated with genetic factors.  A woman's risk for developing breast cancer increases if her mother, sister, or daughter had breast cancer, especially at a young age.

    Other factors may increase a woman’s risk of developing breast cancer, including:
        1. age
        2. breast changes 
        3. radiation therapy (women whose breasts were exposed to radiation during radiation therapy before age 30, especially those who were treated with it for Hodgkin's disease, are at an increased risk for developing breast cancer.)
        4. weight gain (critical weight gain after age 18)
        5. physical inactivity
        6. heavy alcohol consumption (over 2-5 drinks a day).

    Most women who develop breast cancer have none of the risk factors listed above, other than the risk that comes with growing older.  Scientists are conducting research into the causes of breast cancer to learn more about risk factors and ways of preventing this disease.


3. Signs and Symptoms of Breast Cancer  

The early stages of breast cancer usually do not cause pain.  In fact, when breast cancer first develops, there may be no symptoms at all.  But as the cancer grows, women might find or feel following changes in their breast (s):

a. A lump or thickening in or near the breast or in the underarm area that may or may not be painful
b. A change in the size or shape of the breast
c. Nipple discharge, tenderness, or pulling back (inverted) into the breast
d. Ridging or pitting of the breast (the skin turns the color of an orange)
e. A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen,   red,  or scaly)

    An abnormal growth of cells that stays within the area in which it started and does not spread is called carcinoma in situ (CIS). The term in situ means “in place.” DCIS is a precancerous condition that appears in the ducts that carry the milk from the lobules to the nipple of the breast. DCIS is highly treatable.12  In advanced stages, breast cancer can spread to other organs or the bones.  Signs and symptoms of abnormalities of these organs may also be present.

A woman should see her doctor about any of these symptoms.  Most of the time they are not cancerous, but it's important to check with the doctor so that any problems can be diagnosed and treated as early as possible.

4. Diagnosising Breast Cancer

    After a doctor performs a clinical breast exam (CBE), suspicious breast lumps are usually subjected to an x-ray examination, suspicious breast lumps are usually subjected to an x-ray exam called mammogram and a needle biopsy.  Women 40 years old and older, should have mammograms done every year even if there are no symptoms.

    Mammography is an x-ray exam that helps to see the size of the lump.  It is sometimes combined with an ultrasound of the breast to determine if the lump is mainly solid or cystic (filled with liquid).  Mammography is slightly uncomfortable as the breast is flattened against a surface to obtain a good x-ray image, which is called a mammogram.

     A biopsy involves using a needle to remove tissue from the lump.  The tissue is processed and sent to a pathologist who will look at the tissue under a microscope.  The pathologist will be able to tell if the tissue is cancerous.  If cancer is diagnosed, other tests such as chest x-rays, ultrasounds, and bone scans may be required to determine if the cancer has spread to other parts of the body.

 5. Treatment and Therapy
    According to the National Cancer Institute, breast cancer may be treated by local or systemic therapy.
13  Some patients have both kinds of treatments.  Treatment aims to preserve the breast if possible, removing the cancer and the safest minimal required amount of surrounding tissue.  This is call wide excision.

      Local Therapy
                 To remove or destroy
                     cancer in a specific area

              Systemic Therapy
                                To destroy or control cancer
                    throughout the body




    For those patients whose breast cancer has spread to the lungs, liver, bones and even brain, either at the time of diagnosis or years after the original breast cancer has been removed, a combination of hormone treatment, chemotherapy, surgery, and radiotherapy may be used.  These types of treatments along with mammography developments have been arose from years of clinical trials.

6. Prognosis of Breast Cancer
       Prognosis means the probable outcome of an illness based upon all the relevant facts of the case.  All findings from clinical examinations, x- ray investigations, and pathology reports are important and must be considered together when deciding what the prognosis of an individual case of breast cancer. The following features will influence breast cancer prognosis:

  1. Size:  The larger the cancer, the more likely the cancer will recur.  The size of the cancer also determines if it can be safely removed by surgery.
  2. Number:  The more lymph glands involved, the more likely the cancer will recur.  Women with more than 10 lymph glands affected have a very high chance of recurrence.
  3. High Risk Features: Blood vessels or lymph channels in the mastectomy specimen increases the risk of recurrence and spreading of the disease. 
  4. Maturity:  Mature cancer cells increase risk of recurrence.

2.2 Early Breast Cancer Detection

    Studies conducted among different populations show that early breast cancer detection is the best defense against the disease.  When breast cancer is detected early and treated promptly, suffering and ultimately loss of life, can be significantly reduced. if detected early (when confined to the breast), breast cancer has a five-year survival rate of over 95%.14

  Breast Self Exam (BSE), Clinical Breast Exam (CBE), and Mammogram are the three methods of early detection.  The Susan G. Komen Breast Cancer Foundation recommends the following breast health practices as important steps to early detection 15 (for detailed steps and methods, please look at the highlight of this chapter or visit our website at:

 Table 2.2a   
The Susan G. Komen Breast Cancer Foundation’s 
Early Detection Recommendation

Type of Exam

Starting Age


Brest Self Exam (BSE) 20 years old Monthly

Clinical Breast Exam (CBE)

20 years old

1. Every three years before  40
2. Annually from age 40


40 years old

* Women under age 40 with either a family history of breast cancer or other concerns about their personal risk should consult a trained medical professional about when to begin mammography

    All breast lumps should be checked in 3 ways: by self-exam, clinical breast exam by a trained health care provider, and by mammogram.  

1. Breast Self Exam (BSE):

    All women should begin practicing BSE at age 20, especially if there is a family history of breast cancer.  It is recommended that women conduct BSE once a month, on the same day of each month.  For women who menstruate regularly, the best time to perform BSE is 2 to 3 days after her period ends when the breasts are less tender or lumpy.  For women who are post-menopausal or who menstruate irregularly, it is best to choose a particular day, such as the first day of each month, to perform the examination.  For those women taking hormones, it is important to consult with their doctors about the best time to do BSE.

To perform BSE, woman should first look for changes: 
a.  Stand in front of a mirror in good lighting. Undress to the waist and visually inspect the breasts to see what they normally look like. (Picture 1)
b.  Look for any change in the size and shape of the breasts and any dimpling or puckering of the skin as well as exam for changes in or around the nipple .
    c.  Raise both arms above her head and again look carefully for any changes. (Picture 2)
    d.  Put both hands on the hips and tighten the chest muscles to check for any of the symptoms mentioned above. (Picture 3)


             Picture 1                                Picture 2                                    Picture 3  

       Next feel for changes:
         e.  Start BSE below the collarbone (picture 4).
         f.  Use the left hand for the right breast.
g.  Moisten the pads of the three middle fingertips with body lotion.
         h.  Apply firm pressure and make small circles as you go back or forth (up and down, circular or spoke       style) in a pattern covering all the breast area including the nipple (picture 5).
         i.  Extend the examination to the breast tissue in the underarm.
         j.  Change hands and repeat BSE on the opposite breast .
         k.  Lie down and raise one arm above your head. Examine both breasts as before, omitting the underarm (picture 6).   


                       Picture 4                               Picture 5                                   Picture 6 

    Look for any changes out of the ordinary and take note of them.  If any of the following occurs, women should immediately check with her doctor: 
· a
lump or thickening in the breast or underarm, 
· red or hot skin,
· orange peel colored skin,
· dimpling or puckering, 
· unusual pain, 
· change in direction of the nipple axis, 
· bloody or spontaneous discharge from nipple, 
· a sore on the breast that does not heal.

    Although most changes are benign, and most breast lumps are not cancer, breast cancer may be successfully treated if woman find it early.

 2. Clinical Breast Exam (CBE):

    A clinical breast exam is performed by a trained medical professional who both visually and physically examines the entire breast/chest area including the lymph node areas above and below the collarbone and under each arm.  CBE is conducted manually using a circular motion.  In order to examine the breasts and underarms more thoroughly, women are asked to lie down and raise each arm above her head .  If any abnormal lumps are found, the patient will be given further testing to determine if there is a problem.

3. Mammography:

    The mammogram is the record of a safe, low-dose x-ray of the breast.  It is used to detect tumors too small to be detected through physical examination.  A high-quality mammogram, together with a clinical breast exam, are the most effective tools for the early detection of breast cancer.  Early detection of breast cancer may allow more treatment options and could even mean saving women’s breast or life.  The National Institute of Cancer (NIC) indicated that mammogram can greatly reduce the risk of dying by breast cancer by about 16% in women in their 40s and 30% after age 50.15  The risk of breast cancer increases as women get older, therefore, mammogram examinations should be done not only once but for a lifetime. 16 The following table shows the odds of getting breast cancer by age.17

Table 2.2b The fisk of getting breast cancer by age




Mammogram Procedure:

a.  Patient undresses from the waist up and will be given a gown to wear.
b.  Patient stands in front of an x-ray machine
(picture 7).
c.  O
ne breast at a time is rested on a flat surface that contains the x-ray plate and compressed firmly to help flatten out the breast tissue which improves the quality of the picture (picture 8).
d.  Each breast is pressed between two pieces of plastic just enough so all the breast tissue is seen on the   mammogram.  The x-ray pictures are taken from several angles (picture 9). Women are sometimes asked to hold her breath while the picture is taken to reduce movement and improve picture quality.


                            Picture 7                                            Picture 8                                                    Picture 9

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