(Jrt)
Breast cancer
Breast cancer is a cancer develops from units that produce milk, units ducto-lobulaires breast, mainly in women (remember that man also has a breast atrophied). Breast cancer is a malignant tumor that affects the mammary gland. The malignant cells multiply in a disorderly manner to create a tumor that attacks the healthy surrounding tissue. The tumor cells can spread cancer throughout the body: it said that it "metastasis".
Epidemiology
The risk increases significantly with age between 30 and 60 years and is homogeneous between 60 and 80 years, the average age at diagnosis is 61 years.
There are certain genetic factors predisposing, as well as hormonal factors.
Its impact, however, declined significantly (approximately a little less than 9%) in the USA since 2003 and also in France, which would correspond to less use of hormone replacement for menopause.
Breast cancer in France
* Breast cancer caused an estimated 11 000 deaths in 1997, or 17.8 deaths per 100 000 inhabitants and 7.5% of cancer deaths.
* In 2000, he was diagnosed 41 485 new breast cancers in France.
* In 2005, nearly 50,000 breast cancers that were diagnosed.
* It is the primary cause of death among gynaecological cancers in women in developed countries.
* Less than 10% of breast cancers occur before age 40, 25% occurring before 50 years, nearly half before age 65.
* Breast cancer affects on average one woman in eleven.
* In France, almost 10% of women develop breast cancer. 75% of new cases are diagnosed in women over 50 years and this number is constantly rising: 35 000 in 1995, 42 000 in 2001.
* This increase is explained by many factors:
o an ageing population, the incidence of cancer increases with age;
o widespread screening can diagnose cancers and more earlier. However, detection of cancers diagnosed very slow evolution that might have not been diagnosed nor treated (known as surdiagnostic);
o change in lifestyle. Obesity is such a risk factor for breast cancer;
o the use of hormone replacement therapy treatment of menopause. The impact of this treatment on the increase in breast cancer is recognized the USA and very likely in France
In the world
* In 2002, it was estimated nearly 1.1 million new cases, with over 400 000 deaths from breast cancer. Nearly four million women develop breast cancer (Boyle and Ferley, 2004). As a result of surdiagnostics, the frequency of examinations histological finding a "cancer" breast depends largely on the intensity of screening. The mortality decreased significantly from 90 years in developed countries. It continues to grow in other countries.
The risk factors
it is essentially a cancer of women. It is rare in humans (less than a breast cancer out of 100) but more importantly, the diagnosis is often delayed.
Cancers of the breast to genetic predisposition
5 to 10% of breast cancers are diagnosed breast cancer to genetic predisposition, between 2000 and 4000 people each year and responsible for 550 deaths in 1000 in France.
Features
Most often this type of breast cancer appears in a woman with no particular health problem. Very rarely a woman is carrying a genetic disease known. Remember, however, that breast cancer reached some men, but these cases are fairly rare.
* Several signs can think of a breast cancer genetic predisposition
o young age of the patient (an average of 43 years instead of 60 years in forms noncommunicable)
o Several cases in the family;
o Cancer occurring in both breasts so successive or simultaneous;
o Apparition of a second cancer in the ovary;
o histological type of bone marrow cancer.
Mode of transmission
The mode of transmission is autosomal dominant, it is the transmission of an abnormal gene called "transferred". The presence of a single mutation in the gene sets this woman to a 80% risk of having breast cancer instead of 10% in the absence of change.
The risk for women in a family where there is an abnormal gene depends on the fact that they have inherited or not. If they do not have the gene, their risk is the same as that of other women, whereas if they have inherited the gene, they will have between 70% to 80% chance of actually having breast cancer.
The problem is similar to the risk of ovarian cancer or colon. In some families can be observed all of these cancers among women in the direct line (grandmother, mother, daughter) or with close relatives (aunt, sister, cousin). These cancers occur normally in the first part of their lives.
Genoa in case
Two genes are identified:
* BRCA1 on chromosome 17. More than 500 mutations or sequence variations have already been described.
* BRCA2 on chromosome 13. More than 100 different mutations have been identified.
Only a portion of mutations of these genes increase the risk factor for cancer. The BRCA2 mutations (1 woman in 1460) are found more frequently than mutations in the BRCA1 (1 woman in 1960). These changes entail, in addition to the risk of breast cancer, one in risk of ovarian cancer.
The prevalence of these mutations remains low in patients with breast cancer (less than 4% for BRCA1, even if it is double among Ashkenazi Jews)
The probability of developing breast cancer at one carrying a BRCA1 mutation is about 65% before the age of 70 (45% for carriers of a mutation in the BRCA2).
The evolution of cancers carrying BRCA1 mutation is on variable following studies: more serious for some or similar gravity to carry mutations in non-carrier or BCRA2 mutations.
A genetic examination can prove this very high risk, and all relatives must be monitored followed. However, tests of finding a mutant gene can not provide certainty that they are positive.
This act very specialized should be requested for families whose women have a hereditary genetic likely underscored by a consultation of oncogenetics which will establish the pedigree of this family.
Genetic
Any woman may, if it so desires, be granted a genetic counseling whose objective is to determine the risk of cancer is hereditary. If the risk of genetic predisposition is higher than 25% on offers these patients a molecular diagnostics. This molecular research is particularly predictive if we know the mutation in a parent already suffering from breast cancer to genetic predisposition.
Surveillance of women at high risk
Women at risk of genetic predisposition or carrier of a mutation, are followed by clinical monitoring every 6 months from age 20 and annual mammograms from age 30.
Non-fertility or fertility late
Women who had no children, or who had their first pregnancy late (after 30 years) have a significantly increased risk of developing breast cancer, compared to those with at least one child before the age of 30 . These are indeed cycles preceding the first pregnancy completed that appear to be most dangerous for the breast. The pregnancy protects the heart by changing the mammary cells in the direction of greater differentiation. The differentiated cells are less susceptible to carcinogens in particular hormone. Pregnancy is therefore a vaccine conme towards estrogen. The sooner it happens, the better it works.
Obesity and overweight
Obesity, by increasing the amount of fat, increases the rate of blood estrogen via an activation of an enzyme called aromatase. It transforms into effect the type of androgen hormones estrogen.
A recent study showed the increased risk of breast cancer in postmenopausal women according to their weight gain.
Irradiations chest
This risk is now endangered and becomes exceptional, but it was highlighted in women who have undergone numerous radioscopies at the time of pulmonary tuberculosis was widespread.
This risk was also found among Japanese who had been irradiated to non-lethal nuclear explosions at Hiroshima and Nagasaki.
Mastopathies
It is a vague term meaning any disease of the breast. On the reserve generally benign abnormalities that can lead to confusion with a tumor and therefore warrant a levy (biopsy) to identify precisely. Some may promote cancer later and justify regular monitoring.
One aspect dense to mammography, especially if extended, would increase significantly the risk of developing breast cancer.
Sex
A breast cancer in a hundred is found in a man. A stage equal, the prognosis is identical. Nevertheless, the mammary gland in humans is very small, the diagnosis is often late, there are many more cancer found in an advanced stage, accompanied by an attack or plans skin deep (T4).
Screening
It is possible to detect breast cancer when it is still very small (less than one centimeter in diameter) through mammography conducted through regular monitoring. This monitoring will increase the chances of recovery, while receiving treatment less cumbersome and less traumatic than chemotherapy and surgery "mutilating" or removal. Breast cancer is the most common female cancers. It is now the leading cause of cancer mortality in women.
Between 50 and 74 years of age, where women are most exposed to this type of cancer, it is advisable to do a mammogram every two years: it is an effective screening test.
The aim of organised screening of breast cancer is to reduce mortality from breast cancer.
This screening is a risk that surdiagnostic. corresponding to a false-positive woman is regarded as carrying a breast cancer while it is not, thus exposing an unjustified treatment with all the side effects and risks that result . The benefit of this screening must be carefully documented. It is evidenced in particular by a meta-analysis a significant reduction in mortality when screening. These results are, however, criticized.
The current proposal to provide regular mammograms for all women 50 to 75 years in France rely mainly on an expert report prepared in 2001-2 by the Department of Technology Assessment Agency national evaluation and 'accreditation of care. The goal of this report included the recall of recommendations French force. The report concluded that the ineffectiveness of mammography screening is not proven, it should be maintained recommendations in use for breast cancer screening.
In France, organized screening programs for breast cancer offer all women, from the fifties and up to 74 years, a free mammography examination every two years. A management structure departmental or inter-departmental send to all women 50 to 74 years included an invitation for mammograms every two years. The structure can send an invitation on request (general practitioner or gynaecologist or the woman herself). It must be done by a certified radiologist, a member of the network specializes in screening implemented at the departmental level.
On diagnosis
Before menopause, systematic screening has not proved its effectiveness as suspicious minimal anomalies are common. The drawbacks appear in this case outweigh the benefits, except for women at risk.
Moreover, according to a Swedish study, published in early 2006, the systematic screening of breast cancer would lead to one on diagnosis and treatment unnecessary or would have been expected, which would be the case in almost 10% of cases. The study was to measure in 2001 the rate of breast cancer among women who participated in the test between 1976 and 1986 and who did not continue screening after 74 years - age limit set by the program -- And to compare the group.
The study shows 10% of breast cancer and more among women who received routine screening, while twenty-five years after the start of the trial, the overall rate of breast cancer should have been similar in both groups -- The rate of death in 2001 of women over 80 years are similar groups in rates (60%).
Several assumptions are made:
* Misdiagnosis
* Existence of a slow-growing cancers that do not become symptomatic in the context of a normal life expectancy.
According to the commentary of the study, done by professors Henry Moller, Elisabeth Davies: "The risk of having breast cancer for a woman is 8% during his lifetime, the risk of dying from cancer breast is 2.5%. The screening of 250 women helps prevent 1 death by breast cancer but may also lead to 2 on diagnosing cancers (...) The woman whose death is avoided obtain the full benefits of screening, while women diagnosed 2 pay part of his prize, becoming abused patients with cancer and under treatment. But we do not have the means to predict who are these 3 women. "
However, according to the department of chronic diseases of the french Institute of Health, these analyses should in future help make screening more efficient with the goal to identify cancers that will change those who will remain latent, without jeopardising the benefit of screening itself.
Clinic
The palpation of the breast is part of the annual pelvic exam that should practise any woman early sexual activity. Because of their anatomy, breasts are easy to feel, especially when they are small or medium volume.
At palpation, suspicion is from the discovery of a nodule, which can be detected by palpation from 1 cm in diameter. The irregularity may not be painful, but any recent anomaly is particularly attracting the attention of the patient and his doctor.
Among the irregularities, that the patient can monitor itself:
* A dimple or a ride digging the surface of the breast with a "orange peel";
* A deformation of the nipple, retractant inwards;
* Eczemateux a nipple which turns red, crusty or eroded;
* Mamelonaire flow, especially if it is bloody or black.
The finding of any of these signs should lead to a medical consultation very quickly. However, only the doctor may deem necessary examinations, because all these signs do not meet only in the case of cancers. A nodule may be benign nature:
* When consistency is solid, it may be a adénofibrome which developed in the mammary gland;
* When fluid is likely, it may be a cyst.
Mammography
The doctor may decide to confirm his initial diagnosis by a mammogram. Ultrasound is an examination that can help locate the anomaly to facilitate a levy or recognize whether a cyst fluid, but it can never replace the mammogram. Mammograms, practiced regularly and in the framework of screening programs, can diagnose the disease early enough so that treatment is as conservative as possible and at the same time effective.
Confirmation of the diagnosis
If all the exams still does not permit to ensure a correct diagnosis, and if doubts persist, then it is necessary to consider a sample taken most often by a large needle (trocar) under local anesthesia on an outpatient basis . The levy, or biopsy is often done under guide ultrasound or radiology are called biopsy ultrasound and stereotactic biopsy of the breast. The diagnosis of certainty will be achieved by the study anatomical pathology of the sample.
Salaries
As with all cancers, it is ideally (from a medical point of view) on the surgical removal of the tumor, allowing at the same time to make the diagnosis of certainty. The next problem is to take stock of extension: presence or absence of lymph nodes affected, presence or absence of metastasis.
However mutilation breast is also in general for women to a social and psychological mutilation, breasts are a symbol of femininity among the strongest. Some women may experience this mutilation as a denial of their femininity and thus their personality.
There are also other treatments such as chemotherapy, radiation and hormonal therapy, which in some cases can be used to obtain a decrease of the tumor prior to surgery. The effectiveness and risks of each type of treatment depends on the type of cancer, its extension and terrain.
Read also Tumour
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