Malignant Conditions of the Breast
cancer is a major health problem in the United States. Its overall incidence
rose by 54% between 1950 and 1990. In the 1990s, the incidence leveled off and
stabilized (American Can-cer Society [ACS], 2002). At present, there is no cure
for breast cancer. Between 1990 and 1994, the mortality for breast cancer
decreased by 5.6%, the largest short-term decline in more than 40 years,
suggesting that the combination of early detection and better systemic treatment
options is having an effect on overall survival.
statistics indicate that a woman’s lifetime risk for de-veloping breast cancer
is 1 in 8, but this risk is not the same for all age groups. For example, the
risk for developing breast cancer by age 35 years is 1 in 622; the risk for
developing breast cancer by age 60 years is 1 in 23. Approximately 80% of
breast cancers are diagnosed after the age of 50. According to the American
Cancer Society, more than 193,000 cases of breast cancer are diagnosed each
year, with an estimated 40,000 deaths. About 1% of these cancers occur in men.
Women who are diagnosed with early-stage localized breast cancer have a 5-year
survival rate of 98% (ACS, 2002).
situ carcinoma of the breast is being detected more frequently with the
widespread use of screening mammography. Since the in-troduction of widespread
mammographic screening over the past two decades, ductal carcinoma in situ (DCIS) has accounted for approximately 20%
of diagnosed breast cancers (Winchester, Jeske & Goldschmidt, 2000). This
disease is characterized by the proliferation of malignant cells within the
ducts and lobules, with-out invasion into the surrounding tissue; therefore, it
is a non-invasive form of cancer and is considered stage 0 breast cancer. There
are two types of in situ carcinoma: ductal and lobular.
the more common of the two types, is divided histologi-cally into two major
subtypes (comedo and noncomedo), but there are many different forms of
noncomedo DCIS. Because DCIS has the capacity to progress to invasive cancer,
the most traditional treatment is total or simple mastectomy (removal of the
breast only), with a cure rate of 98% to 99% (Winchester et al., 2000). The use
of breast-conserving surgery for invasive cancer led to the use of breast-conservation therapy (limited
surgery followed by radiation) for patients with DCIS, and this option is
appropriate for localized lesions. More than half of cases of DCIS are now
being treated with breast-conservation therapy; however, the rate of local
recurrence is 15% to 20% (Solin, Fourquet, Vicini et al., 2001). In some cases,
lumpectomy alone is an option, but this is decided on a case-by-case basis. In
1999, a large study demonstrated that tamoxifen (Nolvadex) significantly
reduced local recurrence rates (Fisher, Dignam, Wolmark et al., 1999).
Following this, the FDA approved the use of tamoxifen for women with DCIS after
treatment with surgery and radiation. It is usually prescribed for 5 years.
is characterized by proliferation of cells within the breast lobules. LCIS is
usually an incidental finding discovered on pathologic evaluation of a breast
biopsy for a breast change noted during physical examination or on screening
mammography. It is commonly associated with multicentric disease and is rarely
associated with invasive cancer. Historically, treatment was bi-lateral total mastectomy, but current thinking
that LCIS is a marker of increased risk for the development of an invasive
cancer (rather than an actual malignancy) has changed this ap-proach. Long-term
surveillance is one appropriate option. An-other option is a bilateral
prophylactic mastectomy to decrease risk; current research (Hartmann et al.,
1999) suggests that a 90% reduction in risk is possible with this option. The
other treatment option for LCIS is chemoprevention. In fall 1998, the FDA
approved the use of tamoxifen (Nolvadex) as a chemopreventive agent prescribed
for 5 years for women at high risk; however, as with any drug, tamoxifen has
both benefits and risks, along with possible side effects.
ductal carcinomas are the most common histologic type of breast cancer and
account for 75% of all breast cancers. These tumors are notable because of
their hardness on palpation. They usually metastasize to the axillary nodes.
Prognosis is poorer than for other cancer types.
lobular carcinoma accounts for 5% to 10% of breast cancers. These tumors
typically occur as an area of ill-defined thickening in the breast, as compared
with the infiltrating ductal types. They are most often multicentric; that is,
several areas of thickening may occur in one or both breasts. Infiltrating
ductal and infiltrating lobular carcinomas usually spread to bone, lung, liver,
or brain, whereas lobular carcinomas may metastasize to meningeal surfaces or
other unusual sites.
Medullary carcinoma constitutes about 6% of breast cancersand
grows in a capsule inside a duct. This type of tumor can be-come large, but the
prognosis is often favorable.
cancer accounts for about 3% of breast cancers. A mucin producer, it is also
slow-growing and thus has a more favorable prognosis than many other types.
ductal cancer accounts for only 2% of cancers. Because axillary metastases are
uncommon with this histology, prognosis is usually excellent.
carcinoma is a rare type of breast cancer (1% to 2%) with symptoms different
from those of other breast cancers. The localized tumor is tender and painful,
and the skin over it is red and dusky. The breast is abnormally firm and
enlarged. Often, edema and nipple retraction occur. These symptoms rapidly grow
more severe and usually prompt the woman to seek health care sooner than the
woman with a small breast mass. The disease can spread to other parts of the body
rapidly; chemotherapeutic agents play a major role in attempting to control the
progression of this disease. Radiation and surgery are also used to control
Paget’s disease of the breast accounts for 1% of diagnosed
breastcancer cases. A scaly lesion and burning and itching around the
nipple–areola complex are frequent symptoms. The neoplasm is ductal and may be
in situ alone or may also have invasive cancer cells. Often, a tumor mass
cannot be palpated underneath the nipple where this disease arises. Mammography
may be the only diagnostic test that detects the tumor, but results of the
mam-mogram are often negative, making biopsy of the lesion the only definitive