Radiation Therapy For Early Stage Breast Cancer


Introduction

Breast cancer is the most frequently diagnosed cancer in women worldwide. In the United States, it is the most common cancer (excluding skin cancer) among women. Approximately 250,000 cases of invasive breast cancer are diagnosed each year, with about 40,000 breast cancer deaths. Breast cancer deaths have been declining, likely as a result of a combination of increased awareness, early detection through screening, and modern improvement in cancer therapy over the past couple of decades.[1][2][3]

Etiology

In the United States, about one in eight women will develop breast cancer in her lifetime. The lifetime risk of developing breast cancer is about 12%. Unfortunately, the etiology of most breast cancer cases is unknown; however, many risk factors have been identified. The most important risk factors for breast cancer are female gender and older age. Other significant risk factors include age at menarche, age at menopause, age at first pregnancy, family history, use of exogenous estrogen, alcohol consumption, prior history of chest irradiation, benign proliferative breast disease, mammographic breast density, and genetic mutations. Approximately 10% of breast cancer cases are associated with germline mutations such as BRCA1 and BRCA2. Mutations in BRCA1 and BRCA2 are the most common. Other genetic mutations have been identified to carry mild to moderate risk for breast cancer. BRCA1 mutation carriers have a 55% to 65% lifetime risk of breast cancer while BRCA2 mutation carriers have about a 45% risk. In men, BRCA2 mutations carry a lifetime breast cancer risk of about 7%. BRCA mutations also carry an increased risk for ovarian cancer. BRCA2 mutations carry 10-15% lifetime risk of ovarian cancer. Prophylactic mastectomy significantly reduces the risk of breast cancer. Prophylactic bilateral salpingo-oophorectomy decreases the risk of ovarian and fallopian tube cancers by 80% and breast cancers by 50%.  Majority of breast cancers are diagnosed in women who do not have a family history of breast cancer.  Most breast cancers occur as a result of somatic mutations due to the aging process and environmental factors as opposed to inherited germline mutations.[4][5]

Epidemiology

In 2017, it is estimated that there will about 252,000 new cases of invasive breast cancer diagnosed in the United States along with 63,000 of noninvasive breast cancer (in-situ) cases. About 40,000 women are expected to die, although mortality rates have been declining. In the United States, breast cancer is the second most common cause of cancer-related deaths after lung cancer. Mortality rates are however higher in African Americans compared to whites.  The risk of developing and dying from breast cancer is lower in Asians, Hispanics, and Native Americans.[6][7]

Pathophysiology

Ductal carcinoma in situ (DCIS) comprises 15% to 20% of breast cancer cases. Ductal carcinoma in situ represents cancer cells that have not broken through the basement membrane. One-third of ductal carcinoma in situ can develop invasive disease. Invasive ductal carcinoma is the most common type of breast cancer. Lobular carcinoma carries similar prognosis as ductal carcinoma. Medullary, mucinous, and tubular carcinomas have a better prognosis.

History and Physical

History should include risk factors and gynecologic history. A physical exam is important with attention to breast and regional nodes (tumor, skin or chest wall involvement, nipple changes, axillary and supraclavicular exam). Patients can present with a palpable breast mass, nipple inversion, discharge, or bleeding, or axillary node involvement.

Evaluation

Breast imaging typically begins with mammogram and ultrasound. Breast magnetic resonance imaging (MRI) can be considered for dense breasts, mammographically occult tumors, or if there is the concern for the multifocal or multicentric disease. Additional studies can include computed tomography (CT) of the chest and abdomen, bone scan, magnetic resonance imaging (MRI) of the brain, and positron emission tomography-computed tomography (PET-CT) when indicated. Diagnosis can be obtained through breast biopsy as well as a biopsy of suspicious axillary nodes. Both histologic assessments including a status of estrogen receptor (ER), progesterone receptor (PR), HER2/neu (HER2), and Ki-67 and cancer staging are crucial to helping guide treatment recommendations. Also, Oncotype DX which is a 21 gene RT-PCR assay can be ordered for hormone positive, HER2 negative, node-negative breast tumors to help determine the need for chemotherapy. Lab work includes a complete blood count (CBC), blood chemistries, and liver function tests. Genetic counseling is offered to patients who are at high risk for hereditary breast cancer and fertility counseling if the patient is premenopausal. Distress screening and management addressing psychological, social, and physical needs of the patient are also integral in care of breast cancer patients.[8][9]

Differential Diagnosis

  • Duct ectasia 
  • Ductal carcinoma 
  • Extramedullary acute myeloid leukaemia
  • Hyalinized fibroadenoma
  • Inflammatory carcinoma
  • Mastitis 
  • Radial scar 

Enhancing Healthcare Team Outcomes

Breast cancer still remains a common malignancy in females, and although there are reports that the incidence is declining in certain countries, prompt diagnosis and treatment are necessary to prevent morbidity and mortality. The management of breast cancer is by an interprofessional team that includes an oncologist, surgeon, radiation oncologist, a pathologist, and an oncologic nurse. With a higher emphasis on breast-conserving surgery followed by radiation, many studies report favorable results. Further, many techniques have been developed to deliver radiation to the breast and studies have shown that the risk of recurrence outside the excised lesion is similar whether the whole or partial breast is treated. The treatment of breast cancer continues to evolve, and there are now studies trying to determine the feasibility of delivering radiation intraoperatively. Because breast cancer is a heterogeneous disorder, the key is proper patient selection to achieve the highest cure rates with the least morbidity. [1][13][14](Level V)


Article Details

Article Author

Catherine Kim

Article Editor:

Ozer Algan

Updated:

8/23/2020 5:01:13 PM

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