Breast Cancer - Symptoms, Diagnosis and Testing

Breast cancer is the most common cancer and what causes the most deaths among women. This text tells about symptoms, self examination and diagnosis of breast cancer.

As breast cancer is a very large topic, we divide it in some texts. This one will address the symptoms, self-examination and diagnosis of breast cancer. If you want to know more information read risk factors and myths of breast cancer.

Breast cancer
Breast cancer


Introduction

Breast cancer is the most common in the USA and leads to more deaths among women - more than 40,000 women die every year due to this disease. Breast cancer is rare before the age of 35, but it is the leading cause of death among women aged from 45 to 55 years.


Although the number of cases has been growing since the 1960s, in recent years the mortality has fallen about 20%. This was only possible due to advances in screening techniques and disclosure to the public of the importance of early diagnosis. The earlier breast cancer is detected and treated, the greater are the chances of complete cure.


Symptoms of breast cancer

The first sign or symptom of breast cancer for most women is the appearance of a nodule (lump) in one breast. A malignant lump is usually hard, irregularly shaped and well adhered to deep planes. A benign nodule is usually rounded, consistency is more elastic and mobile on palpation.

It is worth remembering that the vast majority of lumps in the breast are benign and do not indicate cancer, but only a medical evaluation is able to distinguish them.

Symptoms of breast cancer
Symptoms of breast cancer
 
In addition to the nodules, other findings are important in evaluating a breast and may suggest the presence of a malignancy:
  • The nipple may become more sensitive, changing features, getting bigger, changing shape, reversing into the skin or becoming red and swollen. The secretion of fluids, whether bloody or not, should also attract attention, especially if it occurs in only one breast.
  • Presence of lymph nodes (glands) palpable around the breast and armpit.
  • Appearance of bulging veins around the nipples
  • Changes in the size and shape of a breast, including becoming asymmetric.
  • Changes in skin texture of the breasts, sometimes getting rougher and appearance of orange peel.
  • A rare type of breast cancer called Paget's disease of the breast, manifests itself as a major inflammation of the breast, leaving it red, swollen and very painful. Paget's disease may start as a small lesion around the nipple, sometimes painful, sometimes itchy, like a pimple or mosquito bite that instead of improving, is growing with time.

All signs and symptoms described above can be manifestations of breast cancer, however, in most cases, are not. But as in case of nodules, only a thorough medical evaluation can rule out a malignancy. The existence of more than one of these findings simultaneously, especially in women over 35 years, increases the risk of treating a cancer.


Self-breast examination

The earlier the diagnosis is done, the greater are the chances of successful treatment. The self-breast examination should be performed monthly for small abnormalities that can be detected and as soon as possible to seek medical attention.

This procedure must be performed by all women over the age of 20. At this age cancer is rare, and, therefore, it is ideal time to start the habit of self examination. The breasts are not homogeneous and they have small changes in texture and form that vary from woman to woman. The first few times of self-examination can be frustrating because of lack of understanding of what structures are being palpated, but starting the exam when still young and doing so frequently lead the patient become fully familiar with the particularities of their breasts over time, facilitating detection of any abnormality when they arise.

The presence of silicone implants does not alter the routine of self-examination. The best time for examination is one week after your period, when your breasts are less swollen and tender. For postmenopausal women it is ideal to establish a randomly fixed day of the month to carry out self-examination.

Breast self examination
Breast self examination
 
Steps to perform self-breast examination:
  • Put yourself standing in front of a mirror with your hands on your waist. Observe your breasts. Note their color, size, texture and shape.
  • Raise your arms and observe the breasts front and side. If they are bulky raise them so that the region hidden by the skin can be observed.
  • Lie on your belly up, and with your fingertips gently squeeze the breast. Make small circular movements. Switch the pressure that causes the fingers over the breast. Use your left hand to examine the right breast and right hand to examine the left.
  • Move from top to bottom and from bottom to top in a zigzag fashion, so as to cover the entire length of the breast.
  • This test may be repeated standing while you take a shower because wet skin is easier to examine.

The realization of self-examination of breasts in any way rule out the need for periodic medical evaluation. For those who are familiar with their breasts, an experienced doctor can detect small nodules with much more ease than patients.


Diagnosis of breast cancer

The breast self-examination or clinical examination performed by your doctor are important, but they alone can only diagnose about 10% of breast cancers. Therefore, we indicate the periodic preventive examinations, even when the clinical examination is completely normal.

Mammography


Mammography
Mammography
A mammogram is an exam used for over 40 years for the prevention and diagnosis of breast cancer. It's a simple, basically an X-ray of the breasts.

Annual screening for breast cancer is recommended for all women between 40 and 70 years. In women with a positive family history, especially of the 1st degree, mammography screening should be started from the age of 30.

Whenever possible, try to schedule your mammogram after the end of your period, as the examination may cause some discomfort when performed in the premenstrual period or in their early days.

Digital mammography is slightly superior to conventional mammography in women under the age of 50. Those of 50 years or older have no significant differences in the rate of detection of malignant lesions.

Despite being an excellent examination, mammography is not 100% sensitive and may miss about 15% of tumors. When the cancer is already causing some alteration in the clinical examination, such as a lump papabile, mammography can identify it in more than 95% of cases.

Ultrasonography


As women get older, their breast tissue, rich in mammary glands, is being replaced by fat. A young woman has breasts much denser than an older woman. Dense breasts are not well evaluated by mammography. For this reason, all women under 35 who detect some suspicious palpable mass should perform mammography plus an ultrasound examination of the breasts.

Nuclear magnetic resonance (NMR)


The NMR is a test reserved for women at high risk of breast cancer, including past breast cancer, the presence of the gene mutation BRCA1 and BRCA2 (explained below) or radiation exposure during youth.

MRI is very sensitive but has a high false positive rate, i.e., detect suspicious lesions that ultimately are not malignant.

Breast biopsy


Once identified by imaging studies, the suspicious lesion should be approached for confirmation (histological evaluation of tissue by microscopy). To achieve a sample of the lesion, we resort to biopsy thereof.

There are many biopsy procedures ranging from the introduction of a fine needle aspiration of the contents of the node, even with minor surgery, just an incision in the breast under local anesthesia, to reach the suspicious lesion, removing one in the same piece. A biopsy is considered the gold standard test for the diagnosis of breast cancer.

Genetic testing for breast cancer

There is a clear genetic influence in the development of breast cancer. Up to one third of women with the disease have a positive family history. At least 2 genes have been identified as responsible for hereditary breast cancer. About 10% of cases are caused by mutations in genes called BRC1 and BRC2.

20% of women with mutations in BRC1 develop breast cancer before age 40, and 50% before 50. Women with BRC1 have a 65% risk of developing breast tumors during their lifetime. In BRC2 the risk is 50%.

There are genetic tests for identification of defective genes. Some of the indications for genetic typing are:
  • Patients with breast cancer before age 30
  • More than one relative of the 1st or 2nd degree with breast cancer
  • Breast cancer linked to ovarian cancer
  • Personal or family history of bilateral breast cancer
  • Breast cancer in male relative

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