BREAST CANCER is the leading cause of cancer death among Hispanic women. The cumulative lifetime risk of developing breast cancer is around 12%, studies claim that 1 in 8 women will develop it throughout their lives.
Male breast cancer accounts for about 1% of all cases. In the United States in 2021 there were 2650 new cases of invasive breast cancer and 530 deaths due to this reason. In men, the manifestations, diagnosis and treatment are the same, although they tend to present the disease at a later stage.
The risk of suffering from breast cancer increases with age, presenting two peaks of maximum incidence: the first would take place between 45 and 50 years of age (premenopausal), and the second, coinciding with the age group of older risk, between 60 and 79 years of age.
Its incidence is increasing but its early diagnosis has reduced mortality.
RISK FACTORS
Age, family history, Breast cancer gene mutation (BRACA 1 or BRACA 2), Personal history, gynecological history of: early menarche, late menopause, late first pregnancy, use of oral contraceptives, hormone therapy, radiotherapy , high-fat diet, smoking and alcohol.
SYMPTOMS
At first it is usually asymptomatic, later it can manifest with breast enlargement, breast asymmetry, pain, nipple discharge, orange peel skin. Many breast cancers are discovered by the patient as a lump during her self-exam or routine physical exam, as well as by screening her with a MAMMOGRAPHY.
ANATOMOPATHOLOGICAL CLASSIFICATION
According to whether or not the basement membrane is affected, they are classified as non-invasive (in situ) or invasive.
NON-INVASIVE TUMORS
Intraductal carcinoma in situ: The most frequent form of presentation is a palpable tumor. Mammography shows a central necrotic lesion with microcalcifications grouped in a mold.
Lobular carcinoma in situ: They are usually an incidental biopsy finding. They are usually bilateral and multicentric. They are treated by means of a wide biopsy plus lymphadenectomy and subsequent follow-up.
INVASIVE CARCINOMA
It is the one that invades beyond the basement membrane and enters the mammary stroma, from where it can invade blood vessels, regional and distant lymph nodes.
Among the main histological types of breast carcinoma are:
- Ductal (79%)
- Lobular (10%)
- Tubular (6%)
- Mucinous (2%)
- Core (2%)
- Papillary (1%)
- Metaplastic (1%)
Another way to classify breast carcinoma is through the use of immunohistochemistry, which allows detecting proteins in cells, which has led to categorizing breast carcinomas according to the expression of estrogen receptors, progesterone receptors and receptors. HER2 (epidermal growth factor).
Between 75% and 80% of cancers are positive for hormone receptors for estrogens or progesterone, and between 15% and 20% are positive for HER2. The remaining percentage between 10% and 15% represents triple negative breast carcinomas (TNBC) defined by the absence of expression of hormone receptors and HER2.
From the point of view of gene expression, they are divided into 5 groups
- Normal
- Luminal A
- Luminal B
- Basal
- HER2
DIAGNOSIS
Self-examination: has not been shown to be effective in reducing mortality from the disease.
Mammography:is the main diagnostic imaging method in breast pathology. It is used in asymptomatic patients as a screening method and in symptomatic patients, basically two projections are made (craniocaudal and external oblique at 60 degrees).
They are signs of malignancy:
- Dense, spiculated nodule with irregular contours
- Fine and irregular grouped microcalcifications in number greater than six and not disseminated
- Breast tissue breakdown with loss of its architecture
Screening should be done after 40 years of age.
The BI-RADS system is standardized, establishing categories that set guidelines for action, see Table 1.
Ultrasound: It is more useful in young women due to the density of the breast tissue. It has a greater ability to differentiate cystic lesions from solid ones.
Malignant nodules appear irregular, heterogeneous, lobulated and with an acoustic shadow.
Breast ultrasound is also used to assess the axilla in case of suspected lymph node involvement.
Magnetic Resonance: Its main indication is the detection of multifocality and the control of scars in the case of conservative treatments in patients with breast prostheses.
In women of childbearing age, it should be carried out between days 7 and 15 of the menstrual cycle to reduce the rate of false positives due to hormonal stimulation.
The prognosis and its treatment not only depend on the histological grade mentioned but also on its TNM classification.
TREATMENT
The approach will depend on the staging of the neoplasm according to the established criteria. Basically it can be divided into:
Early disease: all efforts are focused on the goal of cure, most tumors are approached surgically. Subsequently, based on the pathological results (TNM, histological grade, invasion of lymphatic and vascular vessels, overexpression of HER-2, Ki67 proliferation index), an adjuvant treatment with chemotherapy is planned.
Locally advanced disease: neoadjuvant chemotherapeutic drug therapy is initially given, with the intention of reducing tumor volume, increasing the chances of resection, followed by surgical intervention.
Metastatic disease: In these cases, all efforts are focused on the goal of palliation (palliative medicine) with the intention of increasing the probability of survival, reducing the symptoms associated with the tumor and improving quality of life.
forecast
Long-term prognosis depends on tumor stage. Nodal status (including the number and location of nodes) correlates better with disease-free and overall survival rates than any other prognostic factor.
The 5-year survival rate (from the Surveillance, Epidemiology, and End Results (SEER) Program) depends on the stage of the cancer:
- Localized (limited to primary site): 99.0%
- Regional (confined to regional lymph nodes): 85.8%
- Distant (metastatic): 29.0% Unknown: 57.8%
- Poor prognosis: it is associated with the following additional factors:
Youth: The prognosis appears to be worse in patients with breast cancer diagnosed during the third and fourth decade of life compared to those in middle age.
Ethnicity: Breast cancer death rates between 2012 and 2016 were higher in the United States in non-Hispanic black women (28.9 per 100,000) than in non-Hispanic white women. Hispanic (20.6 per 100,000. Black women are diagnosed at a younger age compared to white women (median 59 versus 63 years) and are more likely to have triple-negative disease.
Large primary tumor: Larger tumors are more likely to be node-positive, but also confer a poorer prognosis regardless of node status.
High-grade tumor: patients with poorly differentiated tumors have a worse prognosis.
Lack of estrogen and progesterone receptors: Patients with ER+ tumors have a slightly better prognosis and are more likely to benefit from endocrine therapy. Those with progesterone receptors in a tumor may also have a worse prognosis. Patients with estrogen and progesterone receptors in a tumor may have a better prognosis than those with only one type of receptor, but this benefit is not clear.
Presence of HER2 protein: when the HER2 gene is amplified, HER2 is overexpressed and increases growth, reproduction and often produces more aggressive tumor cells. HER2 overexpression is an independent risk factor for poor prognosis; it can also be associated with high histologic grade, ER– tumors, increased proliferation, and a larger tumor, all of which are poor prognostic factors.
Presence of BRCA gene mutations For any given stage, patients with a mutation in the BRCA1 genes appear to have a worse prognosis than sporadic tumors, perhaps because they have a higher proportion of breast cancers. high grade, hormone receptor negative. Patients with a mutation in the BRCA2 genes probably have the same prognosis as those without a mutation in these genes if the tumors have the same characteristics. With any of these gene mutations, the risk of a second cancer in the remaining breast tissue is increased (perhaps as high as 40%).
BIBLIOGRAPHY.
- NATIONAL CANCER INSTITUTE: Cancer Data and Statistics.
- American Cancer Society: Cancer Facts and Figures 2021. Atlanta: American Cancer Society, Inc. 2021.
- American College of Obstetricians and Gynecologists (ACOG): Committee opinion no. 625: Management of women with dense breasts diagnosed by mammography. Obstet Gynecol 125 (3): 750–751, 2015. Reaffirmed 2020. doi: 10.1097/01.AOG.0000461763.77781.
- American Cancer Society (ACOG): Lobular Carcinoma in Situ (LCIS).
- Breast Cancer Association Consortium; Dorling L, Carvalho S, Allen J, et al: Breast cancer risk genes — Association analysis in more than 113,000 women. N Engl J Med 4;384 (5):428–439, 2021. doi: 10.1056/NEJMoa1913948 Epub 2021 Jan 20.
- U.S. Preventive Services Task Force: Screening for breast cancer: U.S. Department of Justice Preventive Services Task Force recommendation statement. Ann Intern Med 151 (10):716–726, W-236, 2009. doi: 10.7326/0003-4819-151-10-200911170-00008.
- American Cancer Society: Cancer Facts & Figures or African Americans 2019-2021.
- Jiménez G. (2010) Brochure Medical Treatment of Cancer Hospital Dr. Rafael Angel Calderón Guardia. Costa Rica, Editorial University of Costa Rica.
- https://www.msdmanuals.com/en/professional/gynecology%C3%ADa-and-obstetrics/breastdisorders/n%C3%B3mammary-lumps-of-breast.
Dra Diana Jimenez Calvo.
Gynecologist and Obstetrician.