Breast Cancer
Introduction

​​​​​What is Breast Cancer?

Breast cancer is a heterogeneous disease, commonly known to start as a local lesion in the breast, and then spread gradually, developing into an invasive cancer that attacks the lymph nodes in the armpits, and other organs. Several factors serve as alarms, and determine the type, treatment and result.

Key Facts:
  • Breast cancer is the most common of all cancers internationally, regionally and nationally.
  • Breast cancer is the most common cancer among women in the Kingdom.
  • Breast cancer in KSA is more common among women aged 40 years old or more.
  • Over 50% of breast cancer cases in the Kingdom are detected at a late stage, compared to 20% in advanced countries. This causes higher breast-cancer mortality, less potential for cure, as well as higher treatment cost.
  • Early detection of breast cancer, through radiography and mammography, significantly increases the chances of cure and survival.
  
Breast Cancer Statistics in KSA – 2016:
​​Saudis​ ​
​​Non-Saudis​ ​​Total
​Males
​Females
​Total
​Males
​Females
​Total
​16,859
​5,803
​7,358
​13,161
​1,872
​1,826
​3,698

Why Early Detection of Breast Cancer by Mammography Is Important?
  • Early detection is among the most important breast-cancer prevention strategies.
  • Mammography is aimed to detect breast cancer at an early stage, which makes it easier to treat the disease at hospitals.
  • Early detection of breast cancer is essential for treating the disease, raising the potential for cure by over 95%, and reducing mortality by up to 30%.

Symptoms:
In most cases, breast cancer does not develop any symptoms at early stages. Symptoms start to appear as the disease develops, and the tumor grows.

Breast cancer causes changes in the shape or feeling of the breast. Those changes may include:
  • A breast or armpit lump that feels different from before, or from the surrounding tissue;
  • Change in the breast shape or size;
  • New, continuing pain in the nipple;
  • Peeling, redness, scaling, crusting or flaking of the breast or nipple skin;
  • Newly inverted nipple;
  • Nipple secretions.
On the onset of any of these symptoms, as a doctor. They may also be caused by triggers other than breast cancer.

Risk Factors:
Etiology: 
The etiology of breast cancer is not fully understood. A variety of interrelated factors, such as genetics, hormones, the environment, sociobiology and physiology can influence its development. Other risk factors such as proliferative breast disorders are also associated with breast cancer development, especially if the biopsy shows a typical hyperplasia. However, in 70% of breast cancer patients no risk factors can be identified.

Genetic Predisposition:
A positive family history increases the risk of breast cancer in first-line relatives (mother, sister, or daughter). The risk is dependent upon whether the cancer was bilateral and whether it occurred in the pre- or postmenopausal period. It has been established that if the original cancer occurred during the premenopausal period, the risk of breast cancer in immediate relatives is approximately three times higher than in those who have no family history of breast cancer. 

In those with a family history of breast cancer, 5%–10% of cases are attributed to inheritance of autosomal genes. The probability of genetic inheritance increases if there are multiple affected relatives and the cancer occurs at a younger age. 

Two genes, BRCA 1 and BRCA 2 group, and p53, account for the majority of hereditary breast cancers.

Hormonal Factors:
Hormone regulation is important in the development of breast cancer. Early pregnancy and early oophorectomy lower the incidence of breast neoplasm. In contrast, late menopause is associated with an increase in the incidence of breast cancer. 

Many of the hormonal risk factors such as long duration of reproductive life, multiparity and late age at the time of the birth of the first child imply increased exposure to estrogen peaks during menstrual cycles. Functioning ovarian tumors that elaborate estrogen are also associated with an increase in breast cancer in postmenopausal women. 

Among the factors that can also influence hormonal balance, resulting in the development of breast cancer, are the use of oral contraceptives and hormone therapy during menopause. A small increase in the risk of breast cancer has been noted in users of oral contraceptives. This risk, however, drops following the cessation of contraceptive use so that at ten years post-use, there is no significant increase in the risk of developing breast cancer. 

Use of oral contraceptives at an older age has also been linked to an increase in the number of breast cancer cases diagnosed. 

Current and recent users of hormone replacement therapy are at a higher risk of developing breast cancer than women who have never used hormone therapy. The risk increases with duration of hormone use, while it decreases significantly following cessation of the therapy. Thus, the lapse of five years post-hormone therapy eliminates the risk of developing breast cancer. A recent preliminary study of approximately 160,000 women conducted in the United States over a five-year period, assessed the major health benefits and risks of the most commonly-used combined hormonal preparations. The study showed that the risk of breast cancer increases by 26% in those women who have used estrogen progesterone therapy compared with those who have not.
 
Environmental Factors:
The primary environmental factor that has been shown to have a direct link with breast cancer is nuclear radiation. Epidemiological studies have shown that women exposed to radiation due to nuclear war and medical diagnostic or therapeutic procedures are at an increased risk of developing breast cancer. Multiple chest fluoroscopes, breast irradiation for metastasis and radiation treatment, particularly for Hodgkin’s lymphoma and thyroid cancer, have all been linked to an increase in breast cancer. Radiation exposure after the age of 40 results in a minimal increase in risk, while radiation in adolescence is associated with the greatest risk of breast cancer development. Irradiation during infancy for thymus enlargement has a linear dose-response risk for subsequent breast cancer development at a later stage in life. Also, geographic variation in incidence of breast cancer may be partially explained by environmental factors influencing the development of the disease.

Sociobiological Factors:
Age and gender have been found to be risk factors for developing breast cancer. Worldwide, 75% of new cases and 84% of breast cancer deaths occur in women aged 50 and older, with the number of breast cancers diagnosed in women in their fourth decade of life rating at 1 in 232 compared to those in their seventh decade of life, which are rated at 1 in 29. This increase may be directly related to hormonal changes in women in this age group. 

Nutritional intake and imbalances can also influence the risk of developing breast cancer. Consumption of fruits and vegetables may reduce the risk of developing breast cancer, while dietary intake of fat seems to increase the risk. In postmenopausal women, obesity increases the risk of breast cancer. This association is not observed in premenopausal women

Physiological Factors:
Physical activity levels can have an impact on the risk of breast cancer. Although data in this area is not entirely consistent, moderate physical activity is associated with a lower risk of breast cancer. Studies have shown a 30% reduction in risk level associated with a few hours per week of vigorous activity compared to no exercise at all.

Diagnosing Breast Cancer:
Tests and procedures used to diagnose breast cancer include:
  1. Breast Examination: Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.
  2. Mammogram: A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality.
  3. Breast Ultrasound: Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst.
  4. Removing a Sample of Breast Cells for Testing (Biopsy): A biopsy is the only definitive way to make a diagnosis of breast cancer. During a biopsy, your doctor uses a specialized needle device guided by X-ray or another imaging test to extract a core of tissue from the suspicious area. Often, a small metal marker is left at the site within your breast so the area can be easily identified on future imaging tests. Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options.
  5. Breast Magnetic Resonance Imaging (MRI): An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. Unlike other types of imaging tests, an MRI doesn't use radiation to create the images.

Staging Breast Cancer:
When a woman is diagnosed with breast cancer, her doctor should define its stage, to determine how the disease is likely to develop, and how it should be treated.

The breast cancer staging procedures include:
  • Blood tests, such as a complete blood count
  • Mammogram of the other breast to look for signs of cancer
  • Breast MRI
  • Bone scan
  • Computerized tomography (CT) scan
  • Positron emission tomography (PET) scan
Not all women will need all of these tests and procedures. The doctor selects the appropriate tests based on your specific circumstances.

Breast cancer stages range from 0 to IV.
  • Stage 0: A non-invasive or local breast cancer. Cancer at this stage is unable to invade unaffected tissue in the breast, or spread to other body organs, yet it should be removed, since it can potentially develop into an invasive cancer in the future.
  • Stages I – IV: Invasive tumors, capable of invading previously unaffected tissue in the breast, and spreading to other body parts. Stage I cancer is a small, local tumor contained in the breast, with high potential of cure. The higher the stage, the lower the potential of cure.
  • Stage IV: A tumor that spread outside the breast tissue to other body organs, such as the lungs, liver and bones. Although it cannot be treated, it can still show a good response to a variety of treatments, that can control the tumor for a relatively long time.

Treatment:
The doctor determines the breast cancer treatment options based on your type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones. 

Breast Cancer Surgery:
Most women undergo surgery for breast cancer and many also receive additional treatment after surgery, such as chemotherapy, hormone therapy or radiation. Chemotherapy might also be used before surgery in certain situations.  
  • Removing the breast cancer (lumpectomy): During a lumpectomy, which may be referred to as breast-conserving surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue.
  • Removing the entire breast (mastectomy): A mastectomy is an operation to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (total or simple mastectomy). And there is the option of skin-sparing and nipple-sparing mastectomy.
  • Removing a limited number of lymph nodes (sentinel node biopsy): To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that are the first to receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.
  • Removing several lymph nodes (axillary lymph node dissection), in cases where cancer is found in the sentinel lymph nodes.

Radiation Therapy:
Radiation therapy (also known as radiotherapy) uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).
External beam radiation of the whole breast is commonly used after a lumpectomy. Breast brachytherapy may be an option after a lumpectomy if you have a low risk of cancer recurrence.

Chemotherapy:
Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells. If your cancer has a high risk of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur.
Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery.

Hormone Therapy:
Hormone therapy is used to treat breast cancers that are sensitive to hormones. Doctors refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.
Hormone therapy can be used before or after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.
Treatments that can be used in hormone therapy include surgery or medications to stop hormone production in the ovaries.

Targeted Therapy Drugs:
Targeted drug treatments attack specific abnormalities within cancer cells.

Immunotherapy:
Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that blind the immune system cells. 

Stem-cell Therapy:
Stem-cell therapy is a treatment option for triple-negative breast cancer. It is a mixture of immunotherapy and chemotherapy usually used for treating advanced breast cancer spread into other body parts.

Supportive (Palliative) Care:
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care aims to improve the quality of life for both patients with cancer and their families.

Alternative Medicine:
No alternative medicine treatments have been found to cure breast cancer. But complementary and alternative medicine therapies may help the patient cope with side effects of treatment when combined with the doctor's care.
Many breast cancer survivors experience fatigue during and after treatment that can continue for years. When combined with your doctor's care, complementary and alternative medicine therapies may help relieve fatigue.
Talk with your doctor about:
  • Gentle Exercise: If you get the OK from your doctor, start with gentle exercise a few times a week and add more if you feel up to it. Consider walking, swimming, yoga or tai chi.
  • Managing Stress: The patient should control of the stress in her daily life. Try stress-reduction techniques such as muscle relaxation, visualization, and spending time with friends and family.
  • Expressing Your Feelings: Breast-cancer patients should find an activity that allows them to write about or discuss their emotions, such as writing in a journal, participating in a support group or talking to a counselor.

Breast Diseases:
Clinically, among 100 female patients aged 40–65 years presenting with breast complaints, the following is likely: 30% have no breast lesion, 40% have fibrocystic changes, 7% have a benign tumor diagnosis and 10% have carcinoma. 

Breast disease can therefore be divided into the following groups.
  • Inflammatory Lesions: These are rare breast lesions that can be acute or chronic and include acute mastitis, duct ectasia, post-traumatic lesions and granulomatous mastitis. 
  • Benign Fibrocystic Lesions: Fibrocystic changes represent the single most common disorder of the breast and account for more than 40% of all surgical operations on the female breast. It is diagnosed frequently between the ages of 20 and 40 years, and rarely develops after menopause. It is frequently influenced by hormonal imbalance. 
  • Benign Breast Diseases: These are rare tumors, which include fibro adenomas, phyllodes tumors and large duct papilloma. 
  • Proliferative Breast Disorder: Epidemiological studies have identified changes in the breast resulting in an increased risk of developing carcinoma. This risk is due to hyperplasia with or without atypia. These lesions are often accompanied by fibrocystic changes as well. They can be associated with mammographic abnormalities.
Combating Breast Cancer:
Breast cancer detection and prevention is a systemic and continuous management process that includes planning, developing and evaluating breast cancer detection programmes, including policy formulation and the identification of priorities. 

Comprehensive plans for screening and detection of breast cancer must be developed, including outreach and education with the general population, training for medical and technical staff, development of programmes and processes for accurate diagnosis of breast cancer, and facilities for timely and effective treatment. 

The responsibility for the development and implementation of a breast cancer detection programme rests with the Ministry of Health or other relevant organization. 

The overall aim should be to establish a mechanism for the political and technical support of the programme. A successful managerial approach to breast cancer detection rests on the combined impact of several activities including surveillance, protection, continuing education and prevention, early detection and care.

Surveillance:
Surveillance is key for identifying problems and developing appropriate and timely interventions. The aims of surveillance activities include, but are not limited to, the following: 
  • Estimating the burden of disease;
  • Identifying the risk factors that increase the incidence of breast cancer; and
  • Building the basis for appropriate clinical interventions. 

Protection:
Cancer protection can be defined as the activities and processes associated with protecting individuals from cancer or its recurrence, and affecting the burden of disease and disability. Protection includes a number of activities such as continuing education efforts, health promotion, prevention and early detection of disease (screening).

Continuing Education:
The first step to initiate an effective continuing education programme is advocacy on the urgency and importance of the programme to the government officials and policymakers who can place breast cancer detection on the KSA national agenda. 

Public education programmes should focus on prevention, better understanding of the illness and the benefits of early detection. In addition, education programmes for health care recipients and their families should be developed to ensure that the benefits of health care services are maximized. These programmes should be developed to increase understanding of the needs of patients and the ability to cope with these needs. Finally, health promotion is the key strategy for controlling the risk factors for breast cancer through a collective and multisectoral policy.

Prevention:
Although breast cancer cannot be prevented, the risks of developing breast cancer can be minimized through specific preventive activities. These include achieving changes in lifestyle, diet, overall physical characteristics and obesity, and interventions for women at high risk of developing breast cancer using tamoxifen and other anti-estrogen compounds. 

Early Detection:
The most important and beneficial area of protection activities is the early detection of breast cancer (screening). Diagnosis of breast cancer during the early stages of disease has been positively linked to a decrease in the mortality and morbidity of the illness. 

Care:
Cancer control programmes must ensure the diagnosis of the disease at the earliest possible stage when treatment is most effective, and cure is most likely. Beyond the initial early detection and diagnosis of breast cancer, improving the treatment and care provided to women with breast cancer is obviously an integral factor in decreasing overall mortality from breast cancer.
Treatment of breast cancer should be expanded beyond surgery to include interventions such as drug therapy and radiation procedures. Additionally, adjuvant therapies should be used to prevent the recurrence of breast cancer. Finally, increasing the psychosocial support and the palliative care available can increase the quality of life for women with breast cancer and their families.


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