Principles of breast cancer care.

Have a little read: ... * INTRODUCTION * ANATOMY AND PHYSIOLOGY OF THE BREAST. * AETIOLOGY AND RISK FACTORS. * PREVENTION. * BREAST CANCER SCREENING. * CLINICAL MANIFESTATIONS. * INVESTIGATIONS. * TREATMENT APPROACHES. * THE PSYCHOLOGICAL AND SOCIAL IMPACT OF BREAST CANCER. * PORTIFOLIO OF LEARNING EVIDENCE, CRITICAL INCIDENT ANALYSIS. * SUMMARY. INTRODUCTION Breast Cancer is the most is the most common malignancy and a leading cause of cancer deaths among women. It causes a threat to life, the treatment can involve such a degree of disfigurement that it is a potential threat to a woman's self image. Diseases of the breast do occur in men but much less frequently and these will not be discussed in detail. Before discussing breast cancer it is helpful to have some knowledge of the structure of the breast and it's development. THE FEMALE BREAST The breasts are a pair and are found on the anterior chest wall, extending from the second to the sixth ribs. They are made up of glandular, fatty and fibrous tissue covered by skin. In male's breasts do not develop but in females the breast develop during puberty in response to oestrogen. Natural changes also occur during menstruation, pregnancy and lactation. The full breast is dome shaped and contains a dark pigment called areola. Areola contains Montgomery tubules, which assist in moistening the nipples. The nipple has 15-20 openings called lactiferous sinuses where milk is stored during lactation. Lactiferous sinuses extend to lactiferous ducts and eventually ending into lobules called alveoli. The alveoli secrete milk during lactation. There are also blood vessels and lymph vessels in the breast. Lymph is a clear fluid waste product that gets drained out of the breast into lymph nodes. Lymph nodes are small pieces of tissue that filter and clean the lymph. Most lymph nodes are under the arm in what is called the axilla. Nerve supply is by the fourth fifth and sixth thoracic nerves. The nipple contains numerous nerve endings. The breast has several functions the main one being for the production of milk for the baby. It is also the organ of sexual stimulation and response and a symbol of beauty and motherhood. DIAGRAM 1.0 : The Structure of the Female Breast Reproduced from Baum, M and Schipper, H, Breast cancer, fast facts, 1999 Oxford, UK. BREAST CANCER Normally cells reproduce by diving in a regular orderly fashion so that growth and repair body tissues takes place. Disease can disrupt this normal fashion in various ways. Sometimes there is an uncontrolled growth of cells causing a tumour Baum and Schipper, 1999. However some rumours are not cancer because they cannot spread or threatens some ones life. These are called BENIGN TUMOURS. The tumours that can spread throughout the body or invade nearby tissues are considered cancer and are called MALIGNANT TUMOURS. Theoretically any of the type of tissue in the breast can form cancer but usually they come from either ducts or glands. It may take months to years for tumours to get larger enough to be felt in the breast . Dolinsky 2002. DIAGRAM 1.1 :Types of breast cancer Reproduced from Baum, M and Schipper, H, Breast cancer, fast facts, 1999 Oxford, UK. Invasive duct carcinomas account for over 90% of breast cancers. They present as hard, poorly defined lumps. Involvement of the ligaments and ducts leads to dimpling and pitting of the skin, and nipple inversion. Baum, M, 1999. Invasive lobular carcinoma is responsible for 8% of breast cancers, tumours occur at several sites, in the same breast or both. Pre-invasive carcinomas these are duct carcinomas or lobular carcinomas. Lumps are seldom detectable and are detected by mammographic screening. Baum, M, 1999, Denton S, 1996. It is important for a medical personnel to understand the anatomy and physiology of the breast so that they can explain to patient whether it is benign or malignant cancer. INCIDENCE Almost 35,000 women were diagnosed as having breast cancer in England and Wales in 1998. This is the most common form of female cancer accounting for nearly 30% of all cancers in women. Quinn M.J. , Brock A et al 2000. In the United Kingdom breast cancer causes about 15,000 deaths each year and about 50% of breast cancer occur in women aged between 50 to 64 years and a fur333ther 30% occur in women over the age of 70 years. There is also marked geographical variations in incidence, the highest being Western countries and the lowest the Asian and African countries. Willet WC 2001. FIGURE 1.0 Breast cancer mortality rates show marked geographical variations. The risk factors for breast cancer can be divided into those that cannot be changed and those that can be changed. Some factors that increase the risk of breast cancer that cannot be changed include: Being a woman (only one percent breast cancer occur in men beyond the age of 65) Alexander M 1994. Age, breast cancer is rare in women below the age of 35 the greatest numbers are diagnosed between the ages of 45 to 75 years Alexander M 1994,Dixon M 1998. A positive family history is a risk factor particularly if the involved relative developed breast cancer premenopausally. The risk is also greater if the affected relative is on the maternal side of the family, and if two or more relative developed breast cancer Baun M 1999. Starting menarche below 12 years and menopause after 55 years. Never having children or having them at the age of 30. Having radiation therapy to the chest region Dolinsky C 2002. Genetic mutations for breast cancer have become a hot topic of research lately. About 10% of breast cancers maybe related to changes in either the gene BRCA1 or the gene BRCA2. A genetic disposition can be inherited from either parent both of whom can transmit susceptibility without developing the disease themselves. If a woman is found to carry either mutation she has 50% of developing breast cancer before she is