Diagnosis and Treatment of Breast Cancer 2.

Lifestyle is becoming increasingly recognized as having risk for breast cancer and smoking and alcohol intake has been related to an increased risk. Now there are a couple of studies that show vigorous exercise, particularly in the teenage years, may markedly decrease the risk for breast cancer.

As I noted there are four cloned genes that we know about that predispose to breast cancer. All of these conferring risk in an autosomally dominant way: BRAC-1, BRAC-2 – these are the breast and ovarian syndromes, ataxia telangiectasia. If the patients are homozygous, they don’t live to a very long life but if they’re heterozygous, they probably do have an increased risk for breast cancer and the importance of identifying these patients are that they are at great risk for risks of radiation and maybe increased surveillance by mammography is a bad thing to do for these patients. It’s a fairly rare thing. P-53 is the Li-Fraumeni syndrome. It’s related to increased incidence of sarcomas and breast cancers and other tumors.

Well, what is the standard screening for breast cancer? Certainly self exam, I think, should be incorporated although sometimes people argue whether studies show that this is useful. The clinical physical exam is of use and the main imaging technique for screening is mammogram. Breast self-exam in a couple of old prospective studies has shown that when used in a consistent way that it will lead to diagnosis of tumors that are more likely to be smaller in the Stage I category and with no positive nodes.

These are the American Cancer Society guidelines for early detection of breast cancer and the NIH has come more into line now with these guidelines. A few years ago they were not so aligned but from age 20-39, clinical breast exam by a physician or nurse every three years and a monthly breast self exam. Age 40 or older, and this is the difference, annual mammography, annual clinical breast exam and monthly breast self exam. Prior to this, the NIH had not recommended mammograms until age 50.

Now, these are for people at standard risk and patients who have a strong family history or look like they may be in a family at great risk, I usually start some sort of surveillance mammography about ten years prior to the onset of maybe the first degree relative that had breast cancer or something like that.

If there is an abnormality on the mammogram or a palpable lesion, what are the biopsy techniques? For mammographic lesions, stereotactic biopsies are very useful. It’s quite accurate in getting the needle right into the lesion on mammogram. Sometimes when you put these wires in for localization, you can be off by quite a bit. That’s why it’s so important to do the specimen mammogram after the excisional biopsy when the wires have been placed.

Fine needle aspirates, I think, are very useful. Particularly if you have a larger lesion you can localize it. To do a fine needle aspirate, you haven’t then been in there surgically and when you have the diagnosis you can concretely sit down and talk about all the surgical options. When people have a localized lesion, I think a fine needle aspirate is a nice way to go. If it’s not positive then you’re going to have to do an excisional biopsy but it often is positive or a needle directed biopsy.

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