Introduction
Data by the US Institute of Medicine indicates that the number of patients diagnosed with breast cancer yearly stands at an alarming figure of two hundred and fifty thousand. It further shows that breast cancer claims forty thousand lives each year 1. The aforementioned statistics coupled with the fact that current research estimates on the probability of a woman developing breast cancer during the course of her lifetime stand at one out of eight women are the factors that prompted my interest in writing on this particular topic. This paper will therefore focus on the symptoms and treatment of breast cancer.
Body
The presenting symptoms and signs of breast cancer depend on the stage of the disease. During the early stages, the disease is asympatomatic and the small lump or lesions are normally palpated either accidentally or during self or clinical breast examinations like mammograms. Although the disease can affect any part of the breast, the lumps tend to favor the upper outer quadrant because it’s the location where most of the breast tissue is found. These breast cancer lesions have the following characteristics; they are fixed as opposed to being mobile, nontender rather than painful and hard with irregular borders. Late signs of the disease include nipple retraction and/or erosion, dimpling of the skin of the breast, orange-peel or peau d’orange appearance of the skin of the breast which occurs due to swelling secondary to the blockage of lymphatic circulation within the dermal layer. Patients in the late stage may also complain of severe pain in the breast. Breast cancer may also manifest with fungating and ulcerative lesions of the breast in the late stages. Palpation of the breast during late stages normally reveals large lumps which are fixed to the chest wall. Other signs of the disease include abnormal nipple discharge or drainage and changes in the size or symmetry of the breast. Changes on the nipple whereby a patient complains of an itchy or burning sensation in the nipples are also indicative of breast cancer 2,3.
The management of breast cancer depends on the stage of the disease. Breast cancer is classified according to the TNM (tumor, node and metastasis) system into five stages. Stage 0 is used in reference to a patient who has a lesion involving the breast ducts otherwise termed ductal carcinoma in situ. In stage I, the tumors or lumps have a diameter of less than 2cm and are confined to the breast. Characteristics of the disease in stage II include tumors which have a diameter of less than 5cm but which additionally involves the axillary lymph nodes with the affected nodes being mobile on palpation. In stage IIIa, the lesions are more than 5cm in diameter or alternatively the tumors have extensive axillary lymph node involvement with the nodes being enlarged and fixed either to one another or to the tissues adjacent to them. Stage IIIb on the other hand manifests with more advanced lesions which have satellite nodules, these lesions are in addition either fixed to the chest wall or the skin. Further, the stage is marked by ulceration and edema of the skin of the breast and intraclavicular or supraclavicular lymph node involvement. Tumor metastasis to distant tissues on the other hand is the hallmark of stage IV of the disease 3.
Breast cancer staging is done on the basis of findings of physical examination and an array of histological diagnostic tests which include fine needle aspirate (FNA), incision or excision needle biopsies, needle biopsies, stereotypic biopsies amongst others. Other tests whose results are used in the staging of breast cancer include chest x-rays, liver function tests (LFTs) and bone scans amongst others 2,3.
As previously mentioned, decisions on how to manage breast cancer are influenced by the stage of the disease. However, surgery, radiation and chemotherapy are the mainstay in the treatment of breast cancer. Surgery is normally aimed at removing the cancerous cells from the breast. There are various variants of surgery used. Breast conserving surgery (BCT) is used in reference to those procedures that involve the removal of different amounts of breast tissue that is the malignant tissues together with some of the surrounding tissue with or without the removal of axillae lymph nodes. These procedures include lumpectomy, wide excisions, and partial mastectomy amongst others. Total mastectomy on the other hand refers to the surgical operation whereby only the breast tissue is removed. Modified radical mastectomy (MRM) is used in reference to surgical procedures whereby breast tissue together with some or all axillary lymph nodes is removed. The nodes are removed to determine the extent of the disease, a procedure that is otherwise referred to as axillary lymph node dissection. Radical mastectomy is similar to MRM except that in RM, the pectoralis major and minor muscles are also removed.
Radiation therapy is normally done after BCT and it is aimed at eradicating any remaining cancer cells thus lowering the probability of recurrence. Patients in whom radiotherapy cannot be done like pregnant mothers and those with tumors under the nipple must therefore require mastectomy to ensure all cancerous cells are removed. Chemotherapy is aimed at limiting or totally eradicating the spread of the cancerous cells and involves the administration of a combination of several drugs like cyclophosphamide, doxorubicin and methotrexate. It’s normally started following breast surgery. Notably, there are no guidelines so far on how chemotherapy and radiation therapy should be sequenced after breast surgery 4. Hormone suppression therapy is indicated for patients whose tumors are estrogen receptor positive that is they have estrogen receptors and thus their spread can be limited by reducing the amount of the hormone estrogen in the body. Breast reconstruction surgery or prosthesis offer significant psychological benefit and hence they are normally recommended for patients who undergo mastectomy 3.
In regard to the treatment of breast cancer at the various stages; management for stage 0 of the disease involves either total mastectomy or lumpectomy and chemotherapy with radiation being indicated for lumpectomy. Stage I breast cancer is treated via breast conserving surgery or modified radical mastectomy with chemotherapy being indicated for all invasive tumors and radiation following breast conserving surgery. Breast conserving treatment (BCT) or modified radical mastectomy (MRM) are the surgical options utilized in the management of stage II breast cancer. Decisions on the chemotherapy regimens for this stage depend on both the size of the tumor and involvement of the nodes and similar to the previous stage, radiotherapy is indicated for patients who undergo BCT. MRM is the only surgical option employed in the management of stage III breast cancer. Chemotherapy for this stage is considered both in the preoperative and postoperative stages. Radiation to the chest wall and sometimes to the axillae is also done. Stage IV of breast cancer is marked by metastatic spread of the disease to other body organs and the prognosis is poor. In this case therefore, the management is mainly aimed at controlling the spread of the disease while offering palliation. Lumpectomy or MRM are the surgical options used in combination with both chemotherapy and radiotherapy 3.
Conclusion
In conclusion therefore, the symptoms of breast cancer depend on the stage of the disease and range from the presence of tumors in breast tissue to changes in the nipple, breast size and symmetry and the skin of the breast. Surgery, chemotherapy, radiotherapy and hormonal therapy are the major treatment modalities employed in the management of breast cancer. Decisions on the kind of surgical procedure as well as the drug regimens and indications for radiation are influenced by the stage of the disease and other factors like age of the patient and estrogen receptor status of the tumor.
References
1. US Institute of Medicine. Cancer care for the whole patient: Meeting psychosocial health needs [monograph on the internet]. Washington, DC: The National Academic Press; 2008 [Cited 2011 Sep 7]. Available from http://www.books.google.com
The contents of this book were obtained following a search on google books using the key words statistics and breast cancer. The information contained therein was important since it showed the magnitude of the problem of breast cancer specifically amongst women and hence provided me with the basis for justifying my question.
2. Scottish Intercollegiate Guidelines Network. Management of breast cancer in women: A national clinical guideline [homepage on the internet]. Edinburg: Scottish Intercollegiate Guidelines Network; 2005 [Updated 2005 May 10; Cited 2011 Sep 7]. Available from http:// www.sign.ac.uk/pdf/sign84.pdf.
This article was retrieved from a search on google scholar using the key words management and breast cancer. The article was useful because it contained vital information relating to the symptoms and diagnosis of breast cancer.
3. Brunner, LS, Smeltzer, SC, Bare, BG. Brunner and Suddarth’s textbook of medical surgical nursing [monograph on the internet]. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009 [Cited 2011 Sep 7]. Available from http://www. ebookee.org/Brunner-and-Suddarth-s-Te
This book was obtained from the net as a free ebook after a search using the key terms signs, symptoms and management of breast cancer on google scholar. It provided comprehensive coverage of contents relating to breast cancer ranging from symptoms, diagnosis and treatment amongst others and hence it was the mainstay of my research.
4. Hickey, BE, Francis, DP, Lehman, H. Sequencing of chemotherapy and radiation therapy for early breast cancer [homepage on the internet]. Philadelphia: Cochrane database of systemic reviews [Updated 2005 March 10; Cited 2011 Sep 7]. Available from http://www2.cochrane.org/reviews/en/ab005212.html.
The above article was obtained from the net after conducting a search on google scholar using the key words chemotherapy, radiotherapy and breast cancer. Its contents on chemotherapy and radiotherapy were essential for my research.
