Breast Cancer:

What every medical student should know.

Breast Cancer
Awareness Month
October 2021
Women agonize... over cancer; we take as a
personal threat the lump in every friend's
breast.

Martha Weinman Lear,

Heartsounds
Impact:  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-economic 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 Probability of breast cancer
Age 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
cancer risk breast cancer
(years)
General 12% 61
population
BRCA1 65% 43
BRCA2 45% 41
 Breast Cancer Kills Men,Too.
Risk factors for  Less than 1% of all new breast

male cancer cases occur in men.

breast cancer
 Men with a BRCA1 mutation have
Testicular abnormalities: cryptorchidia,
congential inguinal hernia, orchiectomy, a 1% risk of developing breast
orchitis, testicular trauma cancer by age 70; BRCA2
Hormonal alterations: mutations confer a 6% risk.
Infertility, Klinefelter’s syndrome, obesity,
cirrhosis (and heavy alcohol intake)
Family history of breast cancer,  Breast cancer prognosis, even in
mutations in BRCA1/2, CHEK2, PTEN
stage I cases, is worse in men
Benign breast lesions:
Nipple discharge, breast cysts, breast
than in women.
trauma
Exposure to radiation or high  Treatment for male breast cancer
temperatures
has usually been a mastectomy,
Old age
which may be followed by
Jewish descent
radiation, hormone therapy (such
as with tamoxifen), or
chemotherapy.
 Types of Breast Ductal carcinoma in
situ (DCIS) is the

Cancer 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
 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
2.1<RR<4 • High-dose radiation to chest
• High bone density (post-menopausal)
.0
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
1.1<RR<2 • Recent and long-term hormone replacement therapy
• Obesity
.0
Other factors:
• Personal history of endometrium, ovary or colon cancer
• Alcohol consumption
• Height (tall)
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
 Changes in sexuality
and desire,
Physical changes to the premature
breasts and side effects menopause,
such as hair loss, fatigue infertility
and lymphedema

The Breast Financial hardships,

occupational changes
Cancer
Experience
Mental and emotional
changes such as
“chemobrain,”
Changes in
depression and fear of
relationships with
recurrence
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 Music Therapy
Therapy Progressive Muscle
Massage Relaxation
In the year 2008, there were about
2.5 million women in the U.S. who
considered themselves breast cancer
survivors.
Advocacy