Breast Cancer

By Cynthia M. Jones, M.D.

Breast Cancer a leading cause of death of women in the U.S., second only to lung cancer. It is newly diagnosed in approximately 182,000 women per year and about 46,000 die from this disease.

As with many types of cancer, African-Americans tend to have a worse prognosis and a decreased survival when compared with our white counterparts. Although the overall incidence of breast cancer is higher in Caucasians, the incidence in young, pre-menopausal African-American women is higher. Overall we have a higher mortality rate. There are a number of risk factors associated with the development of breast cancer.

1. Age: It is relatively rare under the age of 30 but increases steadily with age until menopause at which time it increases much more slowly.
2. Genetics: There are specific genetic mutations which when present lead to an marked increase in the development of certain cancers. These genetic mutations may be inherited or may develop spontaneously. Their presence greatly increases the risk of development of cancer. These may be inherited from the father as well as the mother.
3. Family history: Two or more first degree relatives, (i.e. mother, sister, daughter), with bilateral or premenopausal breast cancer. Other family members with breast cancer, unilateral and/or postmenopausal, only confers a slightly increased risk.
4. Menstrual history: Onset of menstruation before age 12 and menopause after age 55.
5. Pregnancy history: First child born after age 30, or no pregnancies
6. Other cancers: Colon or Endometrial (Uterine) cancer
7. Diet: High-fat or high-calorie

*Numbers 4-7 refer to moderately increased risk*

The diagnosis of breast cancer is made through a combination of physical examination, mammography and biopsy, (obtaining a sample of breast tissue).

Every woman should perform monthly breast self-examinations. The reason for this is twofold. One - many women have 'lumpy' breasts. Once a woman becomes familiar with the architecture of her own breasts she is better able to detect a new lump or one that appears different from the rest of her breast tissue and bring it to the attention of her physician. This may lead to an earlier diagnosis and ultimately a better outcome. Two some lumps found on physical examination are not seen on screening mammography. The breasts can change in response to hormonal influence, and because of this, the best time to perform the exam is one week before or one week after menstruation. Not all breast cancers can be felt, some are detected only by their appearance on mammography.

Mammography is used as a screening tool for breast cancer. The current recommendations of the American Cancer Society are that annual screening mammograms be performed beginning at age 40. Mammography should also be performed prior to biopsy in all women over the age of 30. There are some limitations to mammography. It is not as sensitive in detecting lesions (masses or lumps) in young women because they tend to have denser breast tissue and it is more difficult for X-rays to penetrate dense tissue. Mammography can miss up to 15% of the masses found on physical exam. The most effective screening employs a combination of physical examination and mammography.

Research has shown that at the time of diagnosis many African-American women are at an advanced stage of breast cancer. The best chance we have at affecting survival is to find it at an earlier stage. Part of the delay in diagnosis is secondary to a lack of routine screening mammography, and perhaps a lack of emphasis by treating physicians, on self-examinations.

There are other imaging modalities used to evaluate the breast. Ultrasonagraphy is sometimes used to differentiate whether a lump is solid or contains fluid (cystic). It is not a good screening tool in terms of determining whether a mass or lump is benign or malignant. Magnetic Resonance Imaging (MRI) is a test in which magnets are used to create an image, much the same way that X-rays are used in mammography. New improvements in this technique may increase its use in the future but is not likely to replace mammography as a screening tool because of its high cost.

Obviously, not all lumps are cancerous. The only way to determine whether a lump or a 'suspicious area' on mammogram is a cancer, is to perform a biopsy. If the mass can be felt, and is < 3cm, it can be removed in its entirety, through a small incision with the use of local anesthesia in the operating room. This is an ambulatory procedure and typically the patient is in the hospital for only a few hours. This is called an excisional biopsy. Patients with masses larger than this can have a small biopsy performed in the office using a special needle, or an incisional biopsy, (i.e. only a portion of the mass is removed to make the diagnosis), can be performed in the operating room. If a lump cannot be felt, it can be localized with the use of mammography on the day of the operation. A wire is placed in the area and that area is removed in the operating room, again with the use of local anesthesia. There are also methods in certain centers of performing biopsies in the mammography suite, called a stereotactic or core biopsy. (This typically involves taking only a sample of the tissue, not the entire mass).

Once the diagnosis of breast cancer is made, the therapy depends upon the stage of the tumor, and the characteristics of the tumor. Breast cancer is categorized as Stages 0 - IV. Stage 0 being cancer that has not invaded into the surrounding breast tissue, and Stage IV which means that the cancer has spread out of the breast to other parts of the body.

Therapy consists of surgery, and may include chemotherapy, hormonal therapy and/or radiation therapy as well.

Surgery - Lumpectomy, Wide local excision' Quadrantectomy -- these all refer to taking out the mass and leaving the rest of the breast intact. This may be combined with Axillary Lymph Node Dissection (taking the lymph nodes or glands which drain the breast in the axilla or underarm area). Modified Radical Mastectomy refers to removing the entire breast as well as the lymph nodes that drain the breast.

Chemotherapy is given prior to surgery in patients with Stage III disease and may be given to patients with Stage II disease after surgery who are found to have involvement of cancer in the lymph nodes.

Hormonal therapy is given to patients whose tumors demonstrate responsiveness, this is determined by special tests performed on the biopsy specimen.

Radiation therapy is given to patients who have only a portion of their breast removed to treat the remaining breast tissue. It may also be used in patients who have locally advanced disease.

Survival of breast cancer is spoken of in terms of 5 years. The lower the stage the higher survival. Stage I - 90%, II - 75%, III - 50%, IV- 15%. There have been a number of studies looking at the disparity in survival rates between African-American women, and Caucasian women. Overall, 5yr-survival in African-American women is 62% compared with 79% for Caucasian women.

As was stated previously, African-American women tend to present at a more advanced stage of disease. In studies that control for stage and that compare equivalent stages among both races, there was still found to be a slight survival disadvantage for African- women. This may mean that the tumors are more biologically aggressive or there may be some other variables, perhaps genetic, that need further investigation. Socioeconomic factors appear to affect the stage at diagnosis. Improved access to mammographic screening, better education concerning self-examination and physician follow-up will help to improve early diagnosis and hopefully survival.

Dr. Cynthia M. Jones did her undergraduate and medical school training at the University of Michigan. Her residency training in general surgery was at the Albert Einstein College of Medicine and Montefiore Medical Center, we she now serves as the Director of the Breast Care Center at the Bronx Municipal Hospital Center.

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