A Closer Look at Breast Cancer

Author: Amber Hurt, M.D., FACS, General Surgeon

Education on breast cancer is a priority that will improve our efforts to bring awareness to the disease and ultimately save lives. Improving quality of life for many men and women diagnosed with earlier stages can also be achieved by increasing awareness as cancers may be found earlier.

Based on data from 2007-2009, one in eight (12.38%) of women born today will be diagnosed with breast cancer at some time during their lifetime. It is the most common cancer in women worldwide. It is estimated that more than 1.6 million new cases of breast cancer occurred among women worldwide in 2010 (most recent data available).

In 2013, among U.S. women there will be 232,340 new cases of invasive breast cancer. This includes new cases of primary breast cancer among survivors, but not recurrence of the original breast cancer among survivors. In addition to invasive cancers, there will be 64,640 new cases of in situ breast cancer. In situ carcinomas include ductal and lobular types. Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer and lobular carcinoma in situ is a condition that increases the risk of invasive breast cancer. Of the new cases of in situ breast cancer, 85% are DCIS. Unfortunately an estimated 39,620 breast cancer deaths will occur in 2013.

Among men, breast cancer is rare, but it does happen. In 2013, it is estimated that among men in the U.S. there will be 2,240 new cases of invasive breast cancer and 410 breast cancer deaths. It is these deaths that we are trying to reduce by earlier detection.

Screening Recommendations

The American Society of Breast Surgeons supports annual screening mammography for women age 40 and older. Many studies show screening mammography leads to improved survival due to earlier detection. Mammography can be less sensitive for younger women and women with dense breast tissue, but digital mammography has improved detection. Digital mammography simply allows for better detail and interpretation.

Despite the limitations, screening mammography is the most cost-effective, practical, and accurate screening tool available for early detection of breast cancer. Early detection can allow for breast conservation, decrease need for chemotherapy, and improved survival compared to cancers found in later stages.

Screening varies for different age groups. The American Cancer Society recommends a clinical breast exam every 3 years for women age 20-39 with average risk. Annual screening mammography is recommended beginning at age 40 and continuing as long as the patient is of good health.

Risk Factors for Breast Cancer

Appropriate screening is important, but, awareness also includes an understanding of known risk factors. Several risk factors for developing breast cancer have been studied and altering lifestyle to decrease these risks can have a positive impact in reducing chances of developing breast cancer.

According to the National Cancer Institute, these risk factors include: estrogen exposure, hormone replacement therapy, radiation exposure, obesity (especially in postmenopausal women), alcohol consumption, and inherited risks.

Ways to Alter Risk Factors

Exercising four or more hours a week can decrease hormone levels and help lower breast cancer risk. Decreasing estrogen exposure can also decrease your risk of developing breast cancer, but some of these exposures are out of your control. Estrogen levels are lower during pregnancy and having a full term pregnancy before the age of 20 has shown to lower the risk associated with breast cancer. Estrogen levels are also lower while a woman is breastfeeding (another good reason to breastfeed your child). Menstrual periods starting at age 14 or older are associated with less time that the breast tissue is exposed to estrogen. Similarly, beginning menopause earlier is associated with less years that breast tissue has estrogen exposure. If you have a strong family history of breast cancer or known genetic mutation such as BRCA1 or BRCA2, other options to decrease breast cancer risk may include medications or prophylactic surgeries to decrease your risk. In these special instances, speak with your physician regarding options available.

BRCA Mutations

With Angelina Jolie's recent decision to have prophylactic mastectomies due to her known BRCA mutation, more people are aware of what these mutations are and how they increase a person's chances of developing breast cancer. However, many still do not know about these genetic alterations.

A person's lifetime risk of developing breast and/or ovarian cancer is greatly increased if he or she inherits a harmful mutation in BRCA1 or BRCA2. Fifty-five to sixty-five percent of women who inherit a harmful BRCA1 mutation and forty-five percent of women who inherit a harmful BRCA2 mutation will develop breast cancer by age 70 years.

About 1.4 percent of women in the general population will develop ovarian cancer sometime during their lives. By contrast, 39 percent of women who inherit a harmful BRCA1 mutation and 11 to 17 percent of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by age 70 years - a significant increase.

Who should be tested? Because harmful BRCA1 and BRCA2 gene mutations are relatively rare in the general population, most experts agree that mutation testing of individuals who do not have cancer should be performed only when the person's family history suggests the possible presence of a harmful mutation in BRCA1 or BRCA2. The likelihood of a harmful mutation in BRCA1 or BRCA2 is increased with certain familial patterns of cancer.

These patterns include the following:
• Multiple breast and/or ovarian cancers within a family (often diagnosed at an early age)
• Two or more primary cancers in a single family member (more than one breast cancer, or breast and ovarian cancer)
• Cases of male breast cancer

In a family with one of these cancer history patterns, it may be most informative to first test a family member who has breast or ovarian cancer if that person is still alive and willing to be tested. If that person is found to have a harmful BRCA1 or BRCA2 mutation, then other family members may want to consider genetic counseling to learn more about their potential risks and whether genetic testing for mutations in BRCA1 and BRCA2 might be appropriate for them.

Even if it is not possible to confirm the presence of a harmful BRCA1 or BRCA2 mutation in a family member who has cancer, women with a family medical history that suggests the presence of such a mutation may also want to consider genetic counseling and possible testing.

Some women may not know their family history (ie. adopted, estranged from family). If a woman with an unknown family history has an early-onset breast cancer or ovarian cancer, it may be reasonable for her to consider genetic testing for a BRCA1 or BRCA2 mutation.

Children should not be tested for BRCA, even those with a family history suggestive of mutation. This is because no risk-reduction strategies for children exist, and their risk of developing a cancer type associated with a BRCA1 or BRCA2 mutation is extremely low. After they become adults, however, they may want to obtain genetic counseling about whether or not to undergoing genetic testing.