Content

Introduction

Breast cancer is the most common form of cancer in the female population. It is estimated that around 55,000 new cases were diagnosed in Italy in 2020. One in nine Italian women, therefore, has the theoretical probability, in the course of their life, of being affected by it.

Men, albeit rarely, can get sick as they have small amounts of breast tissue from which cancer can develop. Generally, in males this happens in one in 500-1000 cases and in people over the age of 70.

Thanks to the assessment of the disease in the initial phase (early diagnosis), through checks aimed at large sections of the population (screening), and the improvement of treatments (therapies), the possibility of recovery and survival five years from the assessment of disease are in moderate but steady increase (read the Bufala).

A woman's breasts are made up of a collection of glands, fatty tissue, connective tissue and skin. The glandular structures, called lobules, are joined together to form a larger structure, the lobe. There are 15 to 20 lobes in one breast. When a woman breastfeeds a baby, milk arrives at the nipple from the lobules through small tubes called milk ducts (or milk ducts).

There are different types of breast cancers, they develop in different areas of the breast and are classified as non-invasive and invasive cancers based on their ability to spread over a distance.

The most common non-invasive form (called breast cancer in situ) generally originates from the milk ducts and does not have the ability to spread to other parts of the body outside the breast. Breast cancer in situ does not typically appear as a lump that is palpable with the fingers (to the touch), but is discovered during a mammogram.

Invasive forms of breast cancer include the infiltrating lobular carcinoma, rarer, and the infiltrating ductal carcinoma, more common as it accounts for over three-quarters of all breast cancer cases. These two types of cancer are able to spread to other organs in the body, usually through the lymph nodes (small glands that normally defend against bacteria and viruses).

If the tumor is discovered while it is still small, there is a very good chance of recovery, so it is especially important to seek immediate medical attention if you notice any changes in the shape of your breasts, discharge of nipple discharge or lumps. Just as it is equally important to undergo periodic checks (screening) (Video).

Symptoms

The first sign of breast cancer that most women notice is a lump or thickened area.

In most cases, about 90%, it is not a tumor but it is always advisable to consult a specialist doctor to ascertain its nature.

Possible disorders (symptoms) associated with breast cancer are:

  • lumps or thickened areas, inside one or both breasts
  • changes in the nipple
  • nipple retractions
  • fluid leakage from one of the nipples
  • lumps or swelling in one of the armpits
  • indentations, depressions on the skin of the breast
  • redness around the nipple
  • irritations, skin alterations with orange peel skin

The appearance of breast pain, although not a disorder (symptom) directly related to the presence of a tumor, should not be underestimated and should be reported to the doctor if it persists.

Being aware of the natural changes that occur in your breasts in response to hormonal changes or with menopause makes it easier to identify any abnormalities to be investigated with the help of a doctor.

Causes

The causes of breast cancer are not yet known, however the risk factors (read the Hoax) that can contribute to its development have been identified.

Some can be prevented, some not (Video).

Age

The risk of breast cancer increases with advancing age. The largest number of cases occur in menopausal women who are over 50.

Relatives Affected by the Disease (Family History)

Having one or more close family members (mother, sister, daughter) affected by breast or ovarian cancer before age 50 could increase the chances of getting sick. Although breast cancer is not inherited in most cases , some genetic alterations, in particular of the BRCA1 and BRCA2 genes, which can be transmitted from parents to children, increase the risk of developing breast or ovarian cancer. their doctor, who can direct them to centers specialized in genetic counseling and screening.

Previous breast cancer

If you have already had breast cancer, or another benign breast disease, you are more likely to get sick again, either in the same breast or in the other.

Breast density

Women who have dense breasts, containing more glandular tissue and less adipose (fatty) tissue, are at a higher risk of developing breast cancer as they have more cells that can turn into cancerous cells.Furthermore, dense breasts make it difficult to identify a possible tumor through mammography. As we age, the glandular tissue is progressively replaced by adipose tissue and, therefore, the density of the breast decreases.

Exposure to estrogen

Estrogens, hormones produced by the female body starting from puberty, can stimulate the growth of cancer cells in the breast. Prolonged exposure to estrogen, as in the case of women who have had their first menstruation (menarche) very early (precocious) or a late menopause, can increase the chances of getting sick.

Overweight or obesity

The risk of breast cancer is higher in overweight or obese women who go through menopause. This is probably due to the increased estrogen production linked to excess weight.

Above average height

Women of above average height are at greater risk of breast cancer than others. The reason may lie in the interaction between genes, nutrition and hormones.

Alcohol

The risk of breast cancer increases proportionally to the amount of alcohol consumed.

Radiation

Some medical procedures that use radiation, such as x-rays and computed tomography (CT) scans, can increase the chances of developing breast cancer. These types of tests should be performed when deemed necessary by the doctor.

Hormone replacement therapy

Hormone replacement therapy, used to relieve the symptoms (symptoms) caused by menopause, carries a modest increase in the risk of breast cancer.

Oral contraception

Women who use birth control pills (oral contraception) have a slightly higher risk of developing breast cancer. However, it decreases when you stop taking the pill, until it disappears altogether ten years after the interruption.

Diagnosis

Changes in the appearance of the breast, or the presence of a lump, are events to be investigated with the support of the attending physician and, possibly, of specialized breast care centers (Video).

The early stage (early diagnosis) assessment of breast cancer is carried out through self-examination and the regular execution of the investigations provided for according to age.

The tests indicated for the assessment (diagnosis) of breast cancer are mammography and ultrasound.

Mammography (read the Bufala) is an X-ray examination of the breast that allows to highlight the presence of a lump even before it can be palpated. It has a very high sensitivity, especially for tumors in their early stage. It is also used as a general control test (screening) to be performed every two years in women aged 50-69 with the aim of detecting any diseases that may be present very early.

Ultrasound is a non-invasive technique that uses high-frequency ultrasound. In younger women, because the glandular tissue in the breast is denser, ultrasound results offer more information than mammography results.

The choice of one exam or the other depends on various factors such as age and breast density but, in most cases, both are used because they are complementary.

In some special cases, such as in the case of very dense breasts or alterations (lesions) that are difficult to classify, it is possible to use nuclear magnetic resonance (MRI), a technique that uses magnetic fields to process detailed images of the skeleton, joints and internal organs.

At times, it may be necessary to study the cells present inside suspicious nodules or formations by taking them through an examination called a biopsy. It consists in introducing a needle inside the nodule and taking very small quantities of tissue.In some situations it may require local anesthesia and special tools. If the alterations to be investigated are so small as to not be detectable to the touch, the sampling of cells or tissues is performed under the guidance of ultrasound or magnetic resonance imaging which allow to see the path of the needle right into the nodule. Subsequently, on the cells and on the collected tissues, a microscopic examination will be performed to establish the nature and biological characteristics.

A particular type of biopsy is the mammotome, also called biopsy under stereotaxic guidance because to guide the needle in depth, for a more effective aspiration of the tissue to be examined in the laboratory, is a completely computerized system with precise measurements (stereotaxis).

Therapy

The advances made in the last thirty "years in the treatment of breast cancer allow women to rely on different treatment strategies (read the Hoax).

If the cancer is found early, it can be treated before it spreads to surrounding parts of the body with therapy that combines surgery, chemotherapy, and / or radiation therapy. Generally, surgery is the first level treatment, followed by chemotherapy and / or radiotherapy and, in some cases, by hormone or biological therapy (Video).

The type of surgery, and the choice of subsequent treatment (therapy), are closely linked to the characteristics of the tumor and to those of the sick person (for example, age and possible presence of other diseases) because they can affect the evolution of the disease and response to treatment.

It will be the doctor's task to identify and share the therapeutic program that you deem most appropriate for each individual case (Video).

Choice and planning of treatment

When deciding which treatment is most suitable, a team of specialists including, for example, the oncologist surgeon specializing in breast cancer, the oncologist, the radiotherapist, the radiologist, the pathologist, the cancer nurse, the nutritionist , the psychologist, prepares a treatment plan considering:

  • stage and grade of the tumor (how big and how widespread is it)
  • general state of health
  • presence or absence of menopause

Therapeutic strategies

Surgery

Before proceeding with surgery, the diagnosis is confirmed by studying a small sample of tissue or cells taken by needle biopsy or fine needle aspiration. In addition, radiological (thorax), ultrasound (abdomen and pelvis) and scintigraphic (bone) investigations are carried out. to rule out the presence of malignant cells in other organs (metastases).
There are two types of surgery:

  • conservative (quadrantectomy)
  • demolition (mastectomy)

Conservative surgery consists in the "removal of the tumor and surrounding tissue. The extent of the removal depends on the type and size of the tumor, its location, the amount of tissue to be removed and the size of the breast.

Demolition surgery involves the removal of the entire breast, including the nipple.

If there are no obvious signs that the cancer has also extended to the lymph nodes, a partial intervention is performed (quadrantectomy) and biopsies of the tumor are performed, to precisely identify all the characteristics, and of the sentinel lymph node (the first lymph node to be reached from any metastases). If the biopsy is positive, a more extensive removal will be required which also includes the axillary lymph nodes. Mastectomy can be followed by so-called reconstructive surgery to reshape the breast using tissue from another part of the body or by implanting a prosthesis.

To prevent the disease from returning, so-called therapies are performed after the surgery adjuvants because they help increase the likelihood of healing. These include chemotherapy, radiation therapy, hormone therapy and biological therapy.

Chemotherapy

Chemotherapy consists of the administration of drugs that, through the bloodstream, can reach and kill cancer cells in every part of the body. In some cases it is given before surgery to reduce the size of the tumor. In this case we speak of therapy neoadjuvant. Chemotherapy drugs are generally administered through courses of treatment with varying intervals, intravenously and, in some cases, in tablets. The sessions are performed on an outpatient basis; hospitalization may sometimes be required.

Radiotherapy

Radiation therapy uses controlled doses of high-energy radiation to destroy cancer cells while not causing damage to healthy tissues. It is used after surgery and after chemotherapy to destroy any remaining cancer cells and is indicated if the patient is under 65 or if she has had conservative surgery.

Hormone therapy

It consists of the administration of drugs capable of blocking, or reducing, the activity of estrogen hormones, which are considered jointly responsible for the onset and development of some breast cancers. There are several drugs that perform this function: the choice is made on the basis of the characteristics of the person, the tumor and the stage of the disease.

Biological therapy

Monoclonal antibodies are drugs that can selectively recognize and specifically target proteins present on cancer cells. The growth of some types of breast cancer is stimulated by the HER2 protein (Human Epidermal Growth Factor Receptor 2).Under normal conditions, it regulates cell growth and proliferation but, if present in excessive quantities, causes uncontrolled cell growth. Trastuzumab is a monoclonal antibody that can bind to the HER2 protein and prevent cancer cells from growing and multiplying. Typically, it is given after chemotherapy.

Prevention

Although the causes of breast cancer are not fully known, correct lifestyles, possibly associated with preventive therapeutic treatments and behaviors, reduce the chances of getting sick, even for women with an increased risk of developing this type of cancer.

Diet and lifestyle

A healthy and balanced diet and an active lifestyle help prevent various diseases such as diabetes, heart disease and some forms of cancer.

Numerous studies have investigated the link between diet and breast cancer and, while not reaching definitive conclusions, have highlighted the beneficial effects of the following healthy habits:

  • healthy weight control
  • regular exercise
  • moderation in the consumption of alcohol and saturated fats (contained in meat and dairy products)

Women should avoid going through menopause with excess weight. Overweight and obesity, in fact, lead to a greater production of estrogen by the body, increasing the risk of breast cancer.
On the contrary, constant physical activity seems to decrease the chances of getting sick by a third.

Breastfeeding

According to multiple studies, breastfeeding women are less likely to develop breast cancer than others. Probably, this happens because during breastfeeding, ovulation is usually suspended and, therefore, the level of estrogen remains stable.

Treatments to reduce the risk

Currently, there are several treatments that reduce the chances of developing breast cancer in high-risk women.

The level of risk is determined by a complex of factors including age, family history and the results of genetic tests. Women at greater risk are usually referred to specialized genetic centers where the available forms of treatment are proposed. .

The most radical option is the surgical removal of the breasts, the so-called preventive mastectomy, which has found widespread use in the United States.

In our country, mastectomy performed for preventive purposes is considered an extreme solution, both for the complications that it can cause, like all surgeries, and for the strong impact that the loss of breasts has on the emotional sphere and on the sexual relations of the woman. The strategy suggested and encouraged in Italy is early diagnosis, through a plan of close, personalized checks for each woman in order to identify any tumor at an early stage and, therefore, curable.

An alternative solution is offered by long-term drug therapy, which, however, is not without side effects, like any drug-based treatment.

Preventive mastectomy

There preventive mastectomy it consists in the removal of the breasts in healthy women, carriers of genetic alterations that predispose to breast cancer. By eliminating as much breast tissue as possible, the technique reduces risk percentages by 90%.

During the mastectomy, or at a later stage, it is possible to proceed with the reconstruction of the breasts, by implanting prostheses or using tissue from another part of the body. Alternatively, removable artificial prostheses can be used, to be worn inside the bra (read the Bufala).

Pharmacological therapy

Pharmacological therapy is based on the use of tamoxifen, suitable for women of any age, or raloxifene, indicated for postmenopausal women.

The treatment involves the administration of one tablet a day for 5 years.

The use of these drugs is not recommended in women who are at risk of thrombosis (formation of blood clots) or uterus cancer, or who have suffered from these diseases in the past.

Side effects of raloxifene include flu-like symptoms (symptoms), hot flashes and leg cramps. The main undesirable effects (side effects) of tamoxifen are hot flashes and sweating, irregular menstruation, nausea and vomiting.

Women taking tamoxifen who wish to become pregnant must stop taking it at least two months before conception, due to the potential risks for the fetus.

Both drugs must be stopped at least six weeks before a scheduled surgery, as they can promote the formation of blood clots.

It is the doctor's task to establish whether the possible benefits deriving from the treatment outweigh the potential risks and to communicate the outcome of her evaluation to the woman.

Living with

Breast cancer interferes with the normal activities of daily living in different forms and degrees, depending on its stage and course of treatment.

It is not easy to deal with the assessment of the disease (diagnosis) and subsequent treatments, to which each person reacts in a completely subjective way. However, the assistance of the treating team and adequate emotional support can facilitate the process of adapting to the changes induced by the disease, both physically and psychologically.

Some women seek and find comfort within the family, others benefit from comparing and sharing their experiences with other people who are experiencing or have experienced the same situation.There are more and more support groups and patient associations that offer a meeting and listening space, even online, often providing information and psychological support.

There is no better or worse solution to living with the disease. Every woman must face the path of treatment by choosing the strategy that she deems best suited to her way of being.

Bibliography

Italian Association for Cancer Research (AIRC). Breast Cancer Screening

AIOM-AIRTUM working group. The numbers of cancer in Italy 2020

In-depth link

Italian Association of Cancer Patients, Relatives and Friends (AIMaC). Breast cancer

Italian Association for Cancer Research (AIRC). Breast cancer

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