Breast cancer: a physician's view.

A 28-year-old woman discovered a breast lump while showering. It was about the size of a marble, didn't hurt, and caused her little concern. A month later she had a routine checkup with her gynecologist. The gynecologist referred her to a surgeon. Biopsy revealed cancer. Within a week she had undergone a modified radical mastectomy and immediate reconstruction. The pathologist's report revealed cancer cells in a lymph node taken from the underarm. Chemotherapy was recommended.

This young woman was dumb-founded to learn the innocent-appearing lump in her breast was breast cancer. Her impression had been that breast cancer occurs only in older women. No one in her family had ever had breast cancer. She just couldn't believe it.

Who is at risk? The answer to this question is "everyone." Clearly, men are at lesser risk, since less than I percent of breast cancers occur in men. Nonetheless, men - specially men over 50 years of age - should be aware of this possibility. Young women and children are at risk also, although there is no doubt that risk increases with age. Still, in Pennsylvania alone, for example, between 1987 and 1991, approximately 1,000 new cases of breast cancer were diagnosed in women under the age of 35 (representing about 2 percent of all new cases diagnosed in the same period).

Shockingly, six adolescents between the ages of 15 and 19 were diagnosed with breast cancer! Although most women under the age of 25 should be reassured that breast cancer is uncommon in their age group, all breast lumps should be checked by a physician knowledgeable about breast diseases.

Risk factors. Several factors are associated with an increased risk of developing breast cancer. The highest risk is in women who have already had a breast cancer diagnosed in one breast. There are also some benign breast diseases, characterized by highly abnormal cells, that commonly are a harbinger of a future diagnosis of breast cancer. (If you have had a previous breast biopsy revealing benign disease, you might want to ask your doctor if an increased risk of breast cancer is associated with that type of disease.)

Family history is an important factor. Women with close relatives, sisters or mother, who have had breast cancer are at increased risk. This is particularly true if more than one relative has been affected, or if the relatives have developed cancer at an early age. Extremely high is predicted if more than one relative has developed, breast cancer in both breasts at a young age. Risk does increase dramatically with age. A 75-year-old woman has five times the risk of developing breast cancer as compared to a 40-year-old woman. It remains important to note that more than two third of women who develop breast cancer are not identified as members of a high-risk group.

Can you protect yourself! Unfortunately, in most instances, it is not possible or not practical to alter risk. If you're a woman, that's a risk factor you must live with. You have relatives you didn't choose, and if you're like most women, you won't choose to have your ovaries removed in order to decrease the risk of breast cancer.

It is clearly in every woman's interest to control her weight and fat intake; however, even sustained attempts at approximating an Asian diet have not proved to decrease the risk of breast cancer in Western cultures.

The best protection remains a three-pronged approach aimed at detection of breast cancer as early as possible. According to the American Cancer Society, self-breast exam should be learned under the skilled guidance of a knowledgeable instructor and practiced monthly beginning before the age of 25. Physician exams should be performed annually after the age of 40 and at least once every three years in women between 20 and 40 years of age. Mammographies should be performed annually in women over the age of 50, and every one to two years between the ages of 40 and 50.

Recently controversy has risen about screening mammograms for women under the age of 50. The National Cancer Institute recently dropped its recommendation for routine screening mammography for women in the 40- to 50-year-old age range. I disagree with that decision and agree with the positions of both the American College of Radiologists and the American Cancer Society that screening mammography is warranted for women after the age of 40.

Women who have higher risk than the general population should be particularly persistent in receiving age of 40. Adequate breast cancer surveillance. For women in high-risk groups, annual physician exams and mammography should be recommended by your doctor on an individual basis, starting possibly as early as age 25.

Treatment options. Two basic surgical options for treatment of breast cancer localized the breast and lymph nodes remain. Modified radical mastectomy involves removing the entire breast mound, including the nipple, and the lymph nodes under the arm. The other is lumpectomy, which can be done in most cases. Sparing the breast is possible by employing radiation treatments after removing only the lump and a rim of surrounding normal tissue. In this type of treatment lymph nodes are removed also, and the amount removed is essentially the same as if a mastectomy were done.

Compared to 10 years ago, chemotherapy or hormonal therapy (most commonly with the antiestrogen medicine tamoxifen) is used much more commonly. Now even women whose lymph nodes are found to be free of cancer sometimes receive these treatments in an attempt to protect against future tumor growth in other parts of the body.

Nearly all women who have lymph nodes containing cancer cells receive chemotherapy or antiestrogen medication. If more than a few positive nodes are discovered, aggressive therapy is usually recommended. In some research centers, bone marrow transplantation is being used in conjunction with high-dose chemotherapy.

What does the future hold? The greatest hope for the near future comes from the world of molecular biology, that is, understanding how genes control development of cancer. Certain types of genetic alterations are being discovered in many breast cancers. We hope that increased understanding of these changes will lead to development of a practical test to identify those women who are destined to develop breast cancer. Ultimately researchers must find ways to utilize this knowledge to prevent breast cancer.

Breast

Cancer Risk

Factors

* Prior history of breast cancer in the opposite breast.

* Certain benign breast diseases, especially "lobular neoplasia."

* Family history of breast cancer, especially if those affected were young, and particularly if their breast cancer affected both breasts.

* Living in a Western culture (Japanese women have a lower risk).

* High fat intake and obesity

* Onset of menses at an early age and menopause at an advanced age. (Having your ovaries removed at an early age decreases the risk.)

* Delaying your first pregnancy until after the age of 30

* Long-term use of replacement estrogens.(*)

(*) It is important to note that the increased risk with use of estrogens appears to be small. Further, the protective effects of estrogens with respect to heart disease and osteoporosis outweigh the slight increase in risk of breast cancer for most women.