Health
Content
Breast Cancer
Screening and Early Detection
Dr. Mohammed Tarawneh
Consultant Family Physician
What is Cancer?
• A group of 100 different diseases
• The uncontrolled, abnormal growth of cells
• Cancer may spread to other parts of the
body
What is Breast Cancer?
• The most common type of cancer in women in the Jordan and
the second most frequent cause of death from cancer in women
• A disease in which normal cells in the breast begin to change,
grow without control, and no longer die
• Cancer that has not spread is called in situ, meaning “in place”
• Cancer that has spread is called invasive or infiltrating
Scope of Breast Cancer
Dr. Mohammed Tarawneh , Jordan-Amman, 2607/23/15
28 / 4 / 2010
5
Median Age at diagnosis of Female Breast cancer cases in some Arab
Countries
1996
50
1997
50
1998
50
1999
51
2000
51
2001
51
2002
50
2003
49
2004
49
2005
50
2006
51
2007
50
2008
51
53
49.6
51
47.6
51
45
Median Age in Developed Countries
6
49
48
46.4
65 years
Dr.Mohammed Tarawneh-NCDMOH-2010
07/23/15
Ten most common cancers among Jordanian Females,
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
7
Ten most common cancers among Jordanians
( both genders ) 2008
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
8
3606
6235
2332
07/23/15
Dr.Mohammed Tarawneh-NCD4466
MOH-2010
9
Number of registered Female breast cancer cases in Jordan, 1996-2008
X2
Year
1996
1997 1998
1999
2000
2001
2002
2003 2004
2005
2006 2007 2008
Projection !!! Breast Cancer in Jordan will increase by 1.5 every 10 years
Trend of Female breast cancer incidence (ASR) - Jordan
X
X 1.7
Projected
Projected
ASR / 100.000
X
Year
1996
2000
2005
2006
2007
2008
2020
11
Number of Cases
New Cases of Breast Cancer – JNCR- Jordan
Projected
90%
Years
% of female
breast cancer
of all
female cancers
28.5%
32.7%
36.2%
34.8%
35.8%
36.7%
46%
12
Age-Standardized Rate of Female breast
cancer –Jordan -2008- compared with some
countries
3 / 12
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
13
Incidence Rate /100.000 of Female Breast cancer
by Governorates , 2008
Central
North
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
South
14
Percentages of Female Breast Cancer
cases by Governorates -2008
Central
North
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
South
15
% Female Breast Cancer –Jordan as compared with some countries
3
16
Dr.Mohammed Tarawneh-NCDMOH-2010
07/23/15
Age- group
% of Female Breast Cancer cases By Age-group during 1996-2008
17
07/23/15
Dr. Mohammed Tarawneh-NCD-MOH-2010
Percentages of Breast Cancer cases by laterality – 1996-2008
1.4%
4.8%
45.4%
48.4%
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
18
Percentages of Breast cancer cases by Histopathological type- Jordan/2008
All
oth
er
Ad
en
oc
arc
in o
Infilt
ratin
g Lo
bula
r
Medu
lary
1.
4
4.
8
ma
Ty
pe
s
5.
9
Infiltrating Duct Carcinoma IDC
84.
7
IDC%
Lebanon 82.6% 07/23/15
Palestine 78.1%
KuwaitTarawneh-NCD79.4%
KSA 78.9% Oman 60%
Dr.Mohammed
MOH-2010
US SEER (1999-2001 ) 70.2%
Egypt 74%
19
Stages of Breast Cancer in Jordan based on JCR data
Stage 0
2.9%
Stage IV,
13.5%
Stage 0,
0.5%
Stage I
23.2%
Stage 1
6.7%
2007
Stage IV,
12.9%
Stage II
30.5%
Stage II
23.7%
2005
Stage
III
20.4%
9.5%
unknown
Stage 0
3.2%
Stage III
56.2%
Stage I
69%
Stages
111-IV
23.3%
2008
Stage II
28.8%
37.2%
Stage IV,
14.1%
Stage
III
23.1%
7.5%
unknown
20
What is the Structure of the Breast?
•
The breast is composed mainly of fatty
tissue, which contains a network of
lobes made up of tiny, tube-like
structures called lobules that contain
milk glands
•
Tiny ducts connect the glands, lobules,
and lobes, and carry the milk from the
lobes to the nipple
•
Blood and lymph vessels run
throughout the breast
•
About 90% of all breast cancers
originate in the ducts or lobes of the
breast
Overview
1) Biology of the development of breast cancer
2) Risk factors for breast cancer (in light of biology)
3) Potential for modification of breast cancer risk
Breast Cancer Arises
From The Interaction of
Two Processes
1) The Cancer Formation Process
2) The Process of Development
of the Breast
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Development of the Breast Ductal Tree
Differentiation Occurs With Pregnancy
Birth
2 years
Proliferation
After
Puberty
Proliferation
After
Pregnancy
Proliferation
Differentiation
Cells at Risk Are Analogous
to a Target’s Bull’s-eye
Cells
at
Risk
Cells
at
Risk
Cells
at
Risk
Carcinogens
• A larger number of cells at risk produces a larger
(and easier to hit) bull’s-eye.
Interaction of a Cell at Risk
with a Carcinogen Can Produce
an Initiated Cell
• An initiated cell is the first step
in formation of a tumor
Cells
at
Risk
• For an initiated cell to become a
tumor both the Promotion and
Progression stages have to
occur
• The larger the number of
initiated cells the higher the
breast cancer risk
What Are the Risk Factors
for Breast Cancer?
•
•
•
•
•
•
•
•
•
•
Age
Race
Individual or family history of breast cancer
A history of ovarian cancer
A genetic predisposition (mutations to the BRCA1 or
BRCA2 genes cause 2% to 3% of all breast cancers)
Estrogen exposure
Atypical hyperplasia of the breast
Lobular carcinoma in situ (LCIS)
Lifestyle factors (obesity, lack of exercise, alcohol use)
Radiation
Hereditary Breast Cancer
• About 15% of breast cancers are inherited
• Approximately 80% of hereditary breast cancer is caused by
mutations in the BRCA1 or BRCA2 genes
• Women who inherit a BRCA mutation have a 50% to 85%
chance of developing breast cancer in their lifetime
• Women with especially strong family history may consider
preventive surgery to remove breast tissue and/or
chemoprevention
Risk factors
Age
Adiposity
Gender
Diet
Family
history
Benign breast
disease
Reproductive factors
Endogenous
hormones
Exogenous hormones
Physical
activity
Alcohol
Radiation
Established Risk Factors
for Breast Cancer
Risk Factor
Relative Risk
Age Related
- Age (>50 vs <50 yr)
Reproduction Related
- Age of menarche (<12 vs >14 yr)
- Age of menopause (>55 vs <55 yr)
- Age at first birth (>30 vs < 20 yr)
6.5
1.2-1.5
1.5-2.0
1.3-2.2
Established Risk Factors
for Breast Cancer
Risk Factor
Environment Related
- Exposure to ionizing radiation
Breast Disease
- Breast Biopsy (any finding)
- Atypical hyperplasia
Relative Risk
1.0 - 8.7
1.5 - 1.8
4.0 - 4.4
Age at menarche
Later
age - lower risk
Age 15 vs age 11 gives 30% lower risk
to age 70
Lack of physical activity associated with
earlier menarche
Diet may play a role as might fewer
childhood infections
Menopause
Early
menopause reduces risk
High circulating hormones levels after
menopause increase risk, as does use
of postmenopausal hormones
Anti-estrogens may have a role
– who is target population
– how are they identified, counseled, etc.
– balance risks vs. benefits
Hormonal exposure after
menopause
Obesity
is related to poor survival
Tamoxifen reduces mortality among
women with breast cancer
Tamoxifen and Raloxifene reduce risk of
breast cancer in randomized controlled
trials of breast cancer prevention
Weight and weight gain
Adult
weight gain increases risk of breast
cancer
Relation seen most clearly among
postmenopausal women who never have
used hormones
20 kg gain from age 18 associated with
doubling in risk of breast cancer vs. stable
weight
Physical activity
Evidence
from more than 30 studies
Typical reduction in risk with 4 hours per
week = 20% decrease in risk
Evidence present for pre and postmenopausal women
– Barriers to physical activity include
neighborhood safety, time and family
responsibilities, social pressures
Breast Cancer and Early Detection
• Early diagnosis means a better chance of
successful treatment
• Mammography is the best tool doctors have to
screen for breast cancer
• Many organizations recommend that women obtain
a mammogram each year, starting at the age of 40
• Regular clinical breast examinations and breast
self-examinations are also recommended
• Women are encouraged to discuss the frequency
of screening with their doctors
What Are the Symptoms of Breast Cancer?
•
New lumps or a thickening in the breast or under the arm
•
Nipple tenderness, discharge, or physical changes
•
Skin irritation or changes, such as puckers, dimples, or new creases
•
Warm, red, swollen breasts with a rash resembling the skin of an
orange
•
Pain in the breast (usually not a symptom of breast cancer, but should
be reported to a doctor)
•
No visible or obvious symptoms (asymptomatic)
How is Breast Cancer
Evaluated?
• Screening and/or diagnostic mammography
• Ultrasound
• Magnetic Resonance imaging (MRI) scan
• Biopsy is necessary to confirm a diagnosis
• Blood tests are often used to determine if the cancer has spread
outside the breast
• Additional tests may be used to determine stage
Breast Cancer Staging
• Staging is a way of describing a cancer, such as the
depth of the tumor and where it has spread
• Staging is the most important tool doctors have to
determine a patient’s prognosis
• Staging is described by the TNM system: the size of the
Tumor, whether cancer has spread to nearby lymph
Nodes, and whether the cancer has Metastasized
(spread to organs such as the liver or lungs)
• The type of treatment a person receives depends on the
stage of the cancer
Stage 0 Breast Cancer
• Known as “cancer in situ,” meaning the cancer
has not spread past the ducts or lobules of the
breast (the natural boundaries)
• Also called noninvasive cancer
• Ductal carcinoma in situ (DCIS) is the most
common in situ breast cancer
Stage I Breast Cancer
• The tumor is small and has not spread to the
lymph nodes
Stage IIa Breast Cancer
• Stage IIa breast cancer
describes a smaller tumor
that has spread to the
axillary lymph nodes (lymph
nodes under the arm), or a
medium-sized tumor that
has not spread to the axillary
lymph nodes
• Stage IIa may also describe
cancer in the axillary lymph
nodes with no evidence of a
tumor in the breast
Stage IIb Breast Cancer
• Stage IIb breast
cancer describes a
medium-sized tumor
that has spread to the
axillary lymph nodes
• Stage IIb may also
describe a larger
tumor that has not
spread to the axillary
lymph nodes
Stage IIIa Breast Cancer
• Stage IIIa breast cancer describes any size tumor that
has spread to the lymph nodes
Stage IIIb Breast Cancer
• Stage IIIb breast cancer has spread to the chest wall,
or caused swelling or ulceration of the breast, or is
diagnosed as inflammatory breast cancer
Stage IIIc Breast Cancer
• Stage IIIc breast cancer has spread to distant lymph
nodes but has not spread to distant parts of the body
Stage IV Breast Cancer
• Stage IV breast cancer can be any size and has
spread to distant sites in the body, usually the bones,
lungs or liver, or chest wall
Diet, Lifestyle and
Breast Cancer Risk
Vegetables and Fruits
• Eating large amounts of vegetables, in general,
may be linked to a small decrease in breast
cancer risk
• Evidence is stronger for a decrease in risk
with dark green and yellow vegetables
• Vegetables may have a greater effect for
women with a family history of breast cancer
• Eating fruit, in general, is unrelated to breast
cancer risk
• Supplements do not appear to offer the
same protection as food
Anti-cancer Agents in Vegetables & Fruits
Inhibition of Initiation Stage of Cancer Formation
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Anti-cancer Agents in Vegetables & Fruits
Inhibition of Initiation Stage of Cancer Formation
A) Block carcinogen activation
• Flavonoids and isoflavonoids
• Coumarins
• Isothiocyanates in cruciferous vegetables
• Organosulfur compounds in garlic & onions
B) Enhance carcinogen detoxification
• Antioxidants in plants
• Isothiocyanates in cruciferous vegetables
• Organosulfur compounds in garlic & onions
C) Increase DNA repair
• Polyphenols in green tea
• Selenium
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Anti-cancer Agents in Fruits & Vegetables
Inhibition of Promotion Stage of Cancer
Formation
A) Scavenge reactive oxygen species
• Antioxidants in plants
B) Alter proliferation & differentiation
• Phytoestrogens (+/-)
• Retinoids
Phytoestrogens
- Estrogen-like chemicals in plants
- Soy products
High levels of phytoestrogens
Most studied phytoestrogens
- Studies of soy and breast cancer risk in
Asian population are conflicting
- Exposure before puberty may be necessary for
a protective effect
- Concern voiced because of estrogen-like effects
- Area of high interest
Whole Grains and Fiber
- A small decrease in breast cancer risk has
been associated with eating whole grains
- A small decrease in breast cancer risk
may be associated with dietary fiber
- 4 of 5 cohort no association
- 11 of 14 case-control small decrease
- Small decreases in tumors in animals
- Effects on circulating estrogens unclear
Meat and Fish
- Eating meat may be associated with increased
risk of breast cancer
- Women who eat red meat may have a higher
incidence of breast cancer
- Association of eating poultry and breast
cancer risk is unclear
- Most studies saw no association between
eating fish and breast cancer risk
- Studies examining methods of cooking and
doneness show a relationship to breast
cancer risk
Dairy Products
- Studies examining dairy product consumption
and breast cancer risk are conflicting
- Studies of childhood and adolescent
consumption of dairy products and
breast cancer risk are also conflicting
- Dairy products contain conjugated linoleic
acid (CLA) which decreases mammary tumor
formation in rats
Dietary Fat
Contradictory findings
- Positive association (increased risk)
Ecological studies, Animal studies
- Inconclusive association
Case-control studies of women
- No association
Cohort studies of women
Physical Activity
May be associated with decreased breast cancer
risk for women of all ages
Thought to possibly act by changing:
1)Menstrual activity
Exercise may increase age at menarche
2) Body characteristics
Exercise can decrease body fat
3) Hormone levels
Exercise may decrease estrogen levels
Smoking Tobacco
Effect of adult smoking (active & passive) is
unclear
Age beginning smoking may be important
• Heavy smokers below age 20 have a
30% to 80% increase in breast cancer
risk
Cigarette smoke contains numerous
chemical which can initiate and promote
cancer
Breast fluids of smokers contain
chemicals from cigarette smoke
Alcohol Use
• Adult use associated with risk (about 10%
increase for each drink per day)
• All studies have reported impact of early age
alcohol use on breast cancer risk
• About twice the risk of breast cancer for women
below 35 years
• Alcohol use increases estrogen levels
• Adequate folic acid (B vitamin) may decrease risk
in women who have more than 1 drink per day
Obesity
– Associated with decreased premenopausal
breast cancer risk (25% decrease)
• Interferes with regular menstrual cycling
• Less proliferation in breast
– Associated with increased postmenopausal
breast cancer risk (about 200% increase)
• Increases estrogen exposure
• Fat cells form estrogen from other hormones
Modifying the Stages of Cancer Formation
Decrease cells at risk
1) Childbirth
2) Diet?
Eliminate Initiated Cells
1) Childbirth?
2) Diet?
Initiated
Cell
Unspecialize
d
Cell
Initiation
•Mutation
•Cancer Gene
Decrease Initiation Process
1) Minimize Exposures
2) Childbirth
3) Diet
4) Avoid radiation exposure
Benign
Tumor
Promotion
•Proliferation
•Independence
Decrease Promotion Process
1) Decrease estrogenic exposures
2) Childbirth
3) Diet
4) Physical Activity
Prevention
Prevention
today refers mainly to lowering the
risk of disease.
Risk of most chronic diseases can't be totally
eliminated, it can still be significantly reduced.
If everyone in the US led a healthy lifestyle,
80% of the cases of heart disease and
diabetes could be avoided, as could 70% the
cases of stroke and over 50% of cancer.
How is Breast Cancer Treated?
•
Treatment depends on stage of cancer
•
More than one treatment may be used
•
Surgery
•
Radiation therapy
•
Chemotherapy
•
Hormone therapy
•
Targeted therapy
End
Screening and Early Detection
Dr. Mohammed Tarawneh
Consultant Family Physician
What is Cancer?
• A group of 100 different diseases
• The uncontrolled, abnormal growth of cells
• Cancer may spread to other parts of the
body
What is Breast Cancer?
• The most common type of cancer in women in the Jordan and
the second most frequent cause of death from cancer in women
• A disease in which normal cells in the breast begin to change,
grow without control, and no longer die
• Cancer that has not spread is called in situ, meaning “in place”
• Cancer that has spread is called invasive or infiltrating
Scope of Breast Cancer
Dr. Mohammed Tarawneh , Jordan-Amman, 2607/23/15
28 / 4 / 2010
5
Median Age at diagnosis of Female Breast cancer cases in some Arab
Countries
1996
50
1997
50
1998
50
1999
51
2000
51
2001
51
2002
50
2003
49
2004
49
2005
50
2006
51
2007
50
2008
51
53
49.6
51
47.6
51
45
Median Age in Developed Countries
6
49
48
46.4
65 years
Dr.Mohammed Tarawneh-NCDMOH-2010
07/23/15
Ten most common cancers among Jordanian Females,
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
7
Ten most common cancers among Jordanians
( both genders ) 2008
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
8
3606
6235
2332
07/23/15
Dr.Mohammed Tarawneh-NCD4466
MOH-2010
9
Number of registered Female breast cancer cases in Jordan, 1996-2008
X2
Year
1996
1997 1998
1999
2000
2001
2002
2003 2004
2005
2006 2007 2008
Projection !!! Breast Cancer in Jordan will increase by 1.5 every 10 years
Trend of Female breast cancer incidence (ASR) - Jordan
X
X 1.7
Projected
Projected
ASR / 100.000
X
Year
1996
2000
2005
2006
2007
2008
2020
11
Number of Cases
New Cases of Breast Cancer – JNCR- Jordan
Projected
90%
Years
% of female
breast cancer
of all
female cancers
28.5%
32.7%
36.2%
34.8%
35.8%
36.7%
46%
12
Age-Standardized Rate of Female breast
cancer –Jordan -2008- compared with some
countries
3 / 12
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
13
Incidence Rate /100.000 of Female Breast cancer
by Governorates , 2008
Central
North
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
South
14
Percentages of Female Breast Cancer
cases by Governorates -2008
Central
North
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
South
15
% Female Breast Cancer –Jordan as compared with some countries
3
16
Dr.Mohammed Tarawneh-NCDMOH-2010
07/23/15
Age- group
% of Female Breast Cancer cases By Age-group during 1996-2008
17
07/23/15
Dr. Mohammed Tarawneh-NCD-MOH-2010
Percentages of Breast Cancer cases by laterality – 1996-2008
1.4%
4.8%
45.4%
48.4%
07/23/15
Dr.Mohammed Tarawneh-NCDMOH-2010
18
Percentages of Breast cancer cases by Histopathological type- Jordan/2008
All
oth
er
Ad
en
oc
arc
in o
Infilt
ratin
g Lo
bula
r
Medu
lary
1.
4
4.
8
ma
Ty
pe
s
5.
9
Infiltrating Duct Carcinoma IDC
84.
7
IDC%
Lebanon 82.6% 07/23/15
Palestine 78.1%
KuwaitTarawneh-NCD79.4%
KSA 78.9% Oman 60%
Dr.Mohammed
MOH-2010
US SEER (1999-2001 ) 70.2%
Egypt 74%
19
Stages of Breast Cancer in Jordan based on JCR data
Stage 0
2.9%
Stage IV,
13.5%
Stage 0,
0.5%
Stage I
23.2%
Stage 1
6.7%
2007
Stage IV,
12.9%
Stage II
30.5%
Stage II
23.7%
2005
Stage
III
20.4%
9.5%
unknown
Stage 0
3.2%
Stage III
56.2%
Stage I
69%
Stages
111-IV
23.3%
2008
Stage II
28.8%
37.2%
Stage IV,
14.1%
Stage
III
23.1%
7.5%
unknown
20
What is the Structure of the Breast?
•
The breast is composed mainly of fatty
tissue, which contains a network of
lobes made up of tiny, tube-like
structures called lobules that contain
milk glands
•
Tiny ducts connect the glands, lobules,
and lobes, and carry the milk from the
lobes to the nipple
•
Blood and lymph vessels run
throughout the breast
•
About 90% of all breast cancers
originate in the ducts or lobes of the
breast
Overview
1) Biology of the development of breast cancer
2) Risk factors for breast cancer (in light of biology)
3) Potential for modification of breast cancer risk
Breast Cancer Arises
From The Interaction of
Two Processes
1) The Cancer Formation Process
2) The Process of Development
of the Breast
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Development of the Breast Ductal Tree
Differentiation Occurs With Pregnancy
Birth
2 years
Proliferation
After
Puberty
Proliferation
After
Pregnancy
Proliferation
Differentiation
Cells at Risk Are Analogous
to a Target’s Bull’s-eye
Cells
at
Risk
Cells
at
Risk
Cells
at
Risk
Carcinogens
• A larger number of cells at risk produces a larger
(and easier to hit) bull’s-eye.
Interaction of a Cell at Risk
with a Carcinogen Can Produce
an Initiated Cell
• An initiated cell is the first step
in formation of a tumor
Cells
at
Risk
• For an initiated cell to become a
tumor both the Promotion and
Progression stages have to
occur
• The larger the number of
initiated cells the higher the
breast cancer risk
What Are the Risk Factors
for Breast Cancer?
•
•
•
•
•
•
•
•
•
•
Age
Race
Individual or family history of breast cancer
A history of ovarian cancer
A genetic predisposition (mutations to the BRCA1 or
BRCA2 genes cause 2% to 3% of all breast cancers)
Estrogen exposure
Atypical hyperplasia of the breast
Lobular carcinoma in situ (LCIS)
Lifestyle factors (obesity, lack of exercise, alcohol use)
Radiation
Hereditary Breast Cancer
• About 15% of breast cancers are inherited
• Approximately 80% of hereditary breast cancer is caused by
mutations in the BRCA1 or BRCA2 genes
• Women who inherit a BRCA mutation have a 50% to 85%
chance of developing breast cancer in their lifetime
• Women with especially strong family history may consider
preventive surgery to remove breast tissue and/or
chemoprevention
Risk factors
Age
Adiposity
Gender
Diet
Family
history
Benign breast
disease
Reproductive factors
Endogenous
hormones
Exogenous hormones
Physical
activity
Alcohol
Radiation
Established Risk Factors
for Breast Cancer
Risk Factor
Relative Risk
Age Related
- Age (>50 vs <50 yr)
Reproduction Related
- Age of menarche (<12 vs >14 yr)
- Age of menopause (>55 vs <55 yr)
- Age at first birth (>30 vs < 20 yr)
6.5
1.2-1.5
1.5-2.0
1.3-2.2
Established Risk Factors
for Breast Cancer
Risk Factor
Environment Related
- Exposure to ionizing radiation
Breast Disease
- Breast Biopsy (any finding)
- Atypical hyperplasia
Relative Risk
1.0 - 8.7
1.5 - 1.8
4.0 - 4.4
Age at menarche
Later
age - lower risk
Age 15 vs age 11 gives 30% lower risk
to age 70
Lack of physical activity associated with
earlier menarche
Diet may play a role as might fewer
childhood infections
Menopause
Early
menopause reduces risk
High circulating hormones levels after
menopause increase risk, as does use
of postmenopausal hormones
Anti-estrogens may have a role
– who is target population
– how are they identified, counseled, etc.
– balance risks vs. benefits
Hormonal exposure after
menopause
Obesity
is related to poor survival
Tamoxifen reduces mortality among
women with breast cancer
Tamoxifen and Raloxifene reduce risk of
breast cancer in randomized controlled
trials of breast cancer prevention
Weight and weight gain
Adult
weight gain increases risk of breast
cancer
Relation seen most clearly among
postmenopausal women who never have
used hormones
20 kg gain from age 18 associated with
doubling in risk of breast cancer vs. stable
weight
Physical activity
Evidence
from more than 30 studies
Typical reduction in risk with 4 hours per
week = 20% decrease in risk
Evidence present for pre and postmenopausal women
– Barriers to physical activity include
neighborhood safety, time and family
responsibilities, social pressures
Breast Cancer and Early Detection
• Early diagnosis means a better chance of
successful treatment
• Mammography is the best tool doctors have to
screen for breast cancer
• Many organizations recommend that women obtain
a mammogram each year, starting at the age of 40
• Regular clinical breast examinations and breast
self-examinations are also recommended
• Women are encouraged to discuss the frequency
of screening with their doctors
What Are the Symptoms of Breast Cancer?
•
New lumps or a thickening in the breast or under the arm
•
Nipple tenderness, discharge, or physical changes
•
Skin irritation or changes, such as puckers, dimples, or new creases
•
Warm, red, swollen breasts with a rash resembling the skin of an
orange
•
Pain in the breast (usually not a symptom of breast cancer, but should
be reported to a doctor)
•
No visible or obvious symptoms (asymptomatic)
How is Breast Cancer
Evaluated?
• Screening and/or diagnostic mammography
• Ultrasound
• Magnetic Resonance imaging (MRI) scan
• Biopsy is necessary to confirm a diagnosis
• Blood tests are often used to determine if the cancer has spread
outside the breast
• Additional tests may be used to determine stage
Breast Cancer Staging
• Staging is a way of describing a cancer, such as the
depth of the tumor and where it has spread
• Staging is the most important tool doctors have to
determine a patient’s prognosis
• Staging is described by the TNM system: the size of the
Tumor, whether cancer has spread to nearby lymph
Nodes, and whether the cancer has Metastasized
(spread to organs such as the liver or lungs)
• The type of treatment a person receives depends on the
stage of the cancer
Stage 0 Breast Cancer
• Known as “cancer in situ,” meaning the cancer
has not spread past the ducts or lobules of the
breast (the natural boundaries)
• Also called noninvasive cancer
• Ductal carcinoma in situ (DCIS) is the most
common in situ breast cancer
Stage I Breast Cancer
• The tumor is small and has not spread to the
lymph nodes
Stage IIa Breast Cancer
• Stage IIa breast cancer
describes a smaller tumor
that has spread to the
axillary lymph nodes (lymph
nodes under the arm), or a
medium-sized tumor that
has not spread to the axillary
lymph nodes
• Stage IIa may also describe
cancer in the axillary lymph
nodes with no evidence of a
tumor in the breast
Stage IIb Breast Cancer
• Stage IIb breast
cancer describes a
medium-sized tumor
that has spread to the
axillary lymph nodes
• Stage IIb may also
describe a larger
tumor that has not
spread to the axillary
lymph nodes
Stage IIIa Breast Cancer
• Stage IIIa breast cancer describes any size tumor that
has spread to the lymph nodes
Stage IIIb Breast Cancer
• Stage IIIb breast cancer has spread to the chest wall,
or caused swelling or ulceration of the breast, or is
diagnosed as inflammatory breast cancer
Stage IIIc Breast Cancer
• Stage IIIc breast cancer has spread to distant lymph
nodes but has not spread to distant parts of the body
Stage IV Breast Cancer
• Stage IV breast cancer can be any size and has
spread to distant sites in the body, usually the bones,
lungs or liver, or chest wall
Diet, Lifestyle and
Breast Cancer Risk
Vegetables and Fruits
• Eating large amounts of vegetables, in general,
may be linked to a small decrease in breast
cancer risk
• Evidence is stronger for a decrease in risk
with dark green and yellow vegetables
• Vegetables may have a greater effect for
women with a family history of breast cancer
• Eating fruit, in general, is unrelated to breast
cancer risk
• Supplements do not appear to offer the
same protection as food
Anti-cancer Agents in Vegetables & Fruits
Inhibition of Initiation Stage of Cancer Formation
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Anti-cancer Agents in Vegetables & Fruits
Inhibition of Initiation Stage of Cancer Formation
A) Block carcinogen activation
• Flavonoids and isoflavonoids
• Coumarins
• Isothiocyanates in cruciferous vegetables
• Organosulfur compounds in garlic & onions
B) Enhance carcinogen detoxification
• Antioxidants in plants
• Isothiocyanates in cruciferous vegetables
• Organosulfur compounds in garlic & onions
C) Increase DNA repair
• Polyphenols in green tea
• Selenium
Latency Period, 20 years or more
Unspecialize
d
Cell
Initiated
Cell
Initiation
Benign
Tumor
Promotion
Malignant
Tumor
Progression
•Proliferation
•Mutation
•Mutation
•Cancer Gene •Independence •Invade & Spread
Stages of Cancer Formation
Anti-cancer Agents in Fruits & Vegetables
Inhibition of Promotion Stage of Cancer
Formation
A) Scavenge reactive oxygen species
• Antioxidants in plants
B) Alter proliferation & differentiation
• Phytoestrogens (+/-)
• Retinoids
Phytoestrogens
- Estrogen-like chemicals in plants
- Soy products
High levels of phytoestrogens
Most studied phytoestrogens
- Studies of soy and breast cancer risk in
Asian population are conflicting
- Exposure before puberty may be necessary for
a protective effect
- Concern voiced because of estrogen-like effects
- Area of high interest
Whole Grains and Fiber
- A small decrease in breast cancer risk has
been associated with eating whole grains
- A small decrease in breast cancer risk
may be associated with dietary fiber
- 4 of 5 cohort no association
- 11 of 14 case-control small decrease
- Small decreases in tumors in animals
- Effects on circulating estrogens unclear
Meat and Fish
- Eating meat may be associated with increased
risk of breast cancer
- Women who eat red meat may have a higher
incidence of breast cancer
- Association of eating poultry and breast
cancer risk is unclear
- Most studies saw no association between
eating fish and breast cancer risk
- Studies examining methods of cooking and
doneness show a relationship to breast
cancer risk
Dairy Products
- Studies examining dairy product consumption
and breast cancer risk are conflicting
- Studies of childhood and adolescent
consumption of dairy products and
breast cancer risk are also conflicting
- Dairy products contain conjugated linoleic
acid (CLA) which decreases mammary tumor
formation in rats
Dietary Fat
Contradictory findings
- Positive association (increased risk)
Ecological studies, Animal studies
- Inconclusive association
Case-control studies of women
- No association
Cohort studies of women
Physical Activity
May be associated with decreased breast cancer
risk for women of all ages
Thought to possibly act by changing:
1)Menstrual activity
Exercise may increase age at menarche
2) Body characteristics
Exercise can decrease body fat
3) Hormone levels
Exercise may decrease estrogen levels
Smoking Tobacco
Effect of adult smoking (active & passive) is
unclear
Age beginning smoking may be important
• Heavy smokers below age 20 have a
30% to 80% increase in breast cancer
risk
Cigarette smoke contains numerous
chemical which can initiate and promote
cancer
Breast fluids of smokers contain
chemicals from cigarette smoke
Alcohol Use
• Adult use associated with risk (about 10%
increase for each drink per day)
• All studies have reported impact of early age
alcohol use on breast cancer risk
• About twice the risk of breast cancer for women
below 35 years
• Alcohol use increases estrogen levels
• Adequate folic acid (B vitamin) may decrease risk
in women who have more than 1 drink per day
Obesity
– Associated with decreased premenopausal
breast cancer risk (25% decrease)
• Interferes with regular menstrual cycling
• Less proliferation in breast
– Associated with increased postmenopausal
breast cancer risk (about 200% increase)
• Increases estrogen exposure
• Fat cells form estrogen from other hormones
Modifying the Stages of Cancer Formation
Decrease cells at risk
1) Childbirth
2) Diet?
Eliminate Initiated Cells
1) Childbirth?
2) Diet?
Initiated
Cell
Unspecialize
d
Cell
Initiation
•Mutation
•Cancer Gene
Decrease Initiation Process
1) Minimize Exposures
2) Childbirth
3) Diet
4) Avoid radiation exposure
Benign
Tumor
Promotion
•Proliferation
•Independence
Decrease Promotion Process
1) Decrease estrogenic exposures
2) Childbirth
3) Diet
4) Physical Activity
Prevention
Prevention
today refers mainly to lowering the
risk of disease.
Risk of most chronic diseases can't be totally
eliminated, it can still be significantly reduced.
If everyone in the US led a healthy lifestyle,
80% of the cases of heart disease and
diabetes could be avoided, as could 70% the
cases of stroke and over 50% of cancer.
How is Breast Cancer Treated?
•
Treatment depends on stage of cancer
•
More than one treatment may be used
•
Surgery
•
Radiation therapy
•
Chemotherapy
•
Hormone therapy
•
Targeted therapy
End
