Emma White, RGN, BSc, is a breast care nurse specialist formerly at Walsall Manor Hospital Breast Clinic, now working as a research and development nurse at St Luke’s Hospital, Bradford
Art, cinema and the media portray breasts as symbols of femininity. Breasts are part of sexuality which is not just about sex and relationships, but about women’s conception of themselves as women, including their behaviour and feelings.
Each woman brings to a breast clinic personal views, fears, experiences, support, career and home circumstances. Initial presentation involves strong feelings of apprehension and fear of breast cancer, although most women attending breast clinics have benign conditions.
Patients with breast problems, both screen-detected and symptomatic, should be diagnosed and managed by a multidisciplinary team of specialists working together in a dedicated breast unit.
An overview of the physiology and anatomy of the breast
Each breast has 15-20 sections called lobes, which contain smaller lobules which can produce milk. These are linked by tubes called ducts which lead to the nipple. Fat fills the spaces around the lobules and ducts. The pectoralis major muscles lie under each breast and cover the ribs. Each breast contains blood vessels and lymph vessels which lead to the lymph nodes found in the axilla, above the clavicle and in the chest.
Benign breast conditions
These can be placed into several broad categories:
Lumpiness - often referred to as fibrocystic disease which is benign lesions of epithelial origin;
Cyclic breast changes - swelling, tenderness and pain before periods, and increased lumpiness;
Atypical hyperplasia - increased layers of cells where cell structure is disorganised.
- Cysts - which are fluid filled sacs (usually found in women aged 35-50). These show up on ultrasound and either left or aspirated;
- Fibroadenomas - solid and round benign tumours made up of structural (fibro) and glandular (adenoma) tissues (usually occur in teenagers and those in their twenties). These are usually removed;
- Fat necrosis - lumps forms by damaged and disintegrating fatty tissues. Can occur after trauma and can be removed;
- Sclerosing adenosis - a benign condition of excess growth of tissues in the breast lobules. Biopsy provides diagnosis and treatment.
Nipple discharge - can occur in women taking the oral contraceptive pill (OCP)or other medications. Occurs in a variety of colours which can define cause:
- Milky discharge - can be due to OCP, thyroid malfunction;
- Brown/green - infection;
- Bloody - can be due to intraductal papilloma, a growth which projects into breast ducts near nipple and can be removed surgically.
Infection/inflammation - can be due to:
- Mastitis - when the duct becomes blocked causing inflammation and possibly infection. This is usually in women breast-feeding. The breast appears red, swollen, tender and feels warm. Mastitis is often treated with antibiotics;
- Abscesses - these will require drainage/compresses or surgical removal;
- Mammary duct ectasia - the ducts beneath the nipple become inflamed and blocked. Can produce a grey/green discharge. Treated with antibiotics, compresses or surgical removal of the duct.
Triple assessment is the gold standard and includes:
Clinical examination-palpation of the breast and axilla;
Imaging - mammography which is the X-ray examination of the breast. This can show microcalcifications which can indicate cancer as they occur in areas of rapidly dividing cells. Between 10 and 15% of cancers do not show up on mammograms. Ultrasounds use high frequency soundwaves to analyse breast tissue. The pattern of echoes from the soundwaves is converted into an image. The ultrasound can distinguish between solid and fluid-filled lumps;
Pathology-fine needle aspiration cytology (FNAC) and core biopsy (CB):
- FNAC involves aspirating the suspicious area or lump. If the syringe fills with fluid and the lump collapses this effect is typical of a cyst. A solid lump may be a benign tumour like a fibroadenoma or a breast cancer. A cell sample from the aspiration is placed on a slide and the pathologist categorises the cells accordingly: C1=inadequate cells for diagnosis, C2=benign, C3=equivocal, abnormal but more likely to be benign, C4=suspicious of cancer, C5=malignant. If the suspicious area is seen on mammogram or ultrasound but is not palpable then the radiologist will do the FNA using ultrasound/mammographic guidance;
- Core biopsy - this takes out a small piece of breast tissue for analysis and provides histological information. The results are reported as:
B1=normal breast, B2=benign breast tissue (ie, fibroadenoma), B3=equivocal, a lesion with possible malignant potential, B4=suspicious of malignancy, B5=malignant;
- Excisional biopsy- this can be performed under local anaesthetic, and the lump is removed;
- Needle localisation biopsy -inpalpable areas seen on imaging are identified using a guidewire which is inserted into the suspicious area under ultrasound, and then the woman goes to theatre for excisional biopsy. The biopsy is then X-rayed to ensure complete removal of the area and then the tissue is sent to the pathologist.
In the UK one in five female cancers is breast cancer and it is the commonest cancer in minority ethnic groups (Bhopal and Rankin, 1996). It is estimated that one in 12 women will develop breast cancer in their lifetime (CRC, 1996). In 1991, 34,500 were newly diagnosed with breast cancer in the UK (Office for National Statistics, 1996). Most cases (80%) occur in postmenopausal women.
Risk factors for breast cancer
There are large variations in the risk of breast cancer between countries. Risk factors have been identified as shown in Table 1 (CRC, 1996).
Breast cancer genes
Only 5-10% of breast cancer is thought to be genetic (Claus et al,1991). The discovery of two genes (BRCA1 and BRCA2) that predispose women to breast cancer led to the possibility of mutation searching and genetic testing to identify those at increased risk of developing cancer because they have inherited a faulty copy of the gene. Approximately 85% of BRCA1 gene carriers will develop breast cancer (Easton et al, 1994). The clinical, scientific and psychosocial issues surrounding genetic testing are complex.
Treatment of breast cancer
A woman diagnosed with breast cancer may be offered:
- Breast-conserving surgery (wide local excision/lumpectomy);
- Mastectomy, removal of all the breast tissue.
Choice may not be offered if the lesion is too large, multi-focal, lobular or, in the surgeon’s opinion, so close to the nipple that it is likely to cause distortion. In the case of a single focus of cancer, the choice of surgery is offered based on factors that vary between surgeons and between hospitals (Sainsbury, 1997). Axillary node sampling or clearance (dissection) will be done in order to stage the axilla in order to plan treatment.
If wide local excision is performed then the patient will receive radiotherapy as well to the breast. In some cases, chest-wall radiotherapy is indicated postmastectomy. Radiotherapy starts four to six weeks postsurgery and lasts three to six weeks.
Chemotherapy and/or hormonal therapy lasts for approximately six months and may occur before, during or after radiotherapy.
These characterise the breast cancer and include oestrogen receptor (ER) and progesterone receptor (PR) tests, which show whether breast cancer cells are sensitive to the oestrogen and progesterone hormones. If ER is positive, it indicates the use of antihormone therapy, for example tamoxifen. HER2 protein can stimulate cancer cells to divide aggressively. For metastatic breast cancer anti-HER2 therapy can be given, in other words Herceptin.
Types of breast cancer
Carcinoma in situ
This is when abnormal cells are present but have not grown beyond their site of origin into neighbouring tissue. They have not broken through the basement membrane. These can be lobular cancer in situ or ductal cancer in situ.
Infiltrating or invasive carcinoma is cancer that has started in a duct (infiltrating ductal carcinoma) or lobule (infiltrating lobular carcinoma), and has invaded nearby tissue. It is the most common form of breast cancer, making up between 70% and 85% of all breast cancers. Invasive lobular accounts for 5-10% of breast cancer.
Other types include medullary (2%), mutinous (2%) and tubular (2%).
Breast cancers are graded 1,2,3 dependent on cell arrangement and cell division:
- Grade 1 = well differentiated - low grade;
- Grade 2 = moderately differentiated - medium grade;
- Grade 3 = poorly differentiated-high grade.
Paget’s disease is a type of ductal cancer within the excretory ducts and skin of the nipple and areola. It is associated with invasive tumours.
Many factors influencing breast cancer are beyond our control, such as age, inheritance of a breast cancer susceptibility gene, age at menarche, age at menopause. Other factors may prevent or delay onset of disease.
A breast cancer prevention trial using tamoxifen is in progress in the UK as this drug has markedly reduced the risk of contraletral breast cancer.
Diets, including low-fat diets, are being looked at. Vitamins including C and E are being studied for their protective potential. Phytochemicals - naturally occurring chemicals in fruits and vegetables - are being looked at for cancer fighting substances that can be added to our diets.
What else can women do?
Be breast aware. Look for any changes/differences in the breasts, for example lumps/thickening, a change in the size or shape of the breast, nipple discharge or inversion, dryness, ridges or dimpling of the skin. Any change must be reported to the GP who should refer to a specialist clinic. All women aged 50 and over will be invited to attend breast screening for three-yearly mammograms, which aim to detect breast cancer early.
Detection and diagnostic tools for breast cancer are also being looked at, including Magnetic Resonance Imaging, Positive Emission Tomography and digital mammography. Clinical trials to advance the treatment of breast cancer are making progress.