Finding the Lump

Few discoveries are as terrifying to a woman as finding a lump in her breast. The woman may first notice the irregularity as a small area of thickening, or, she may detect a dimple, a change in contour, or a nipple that is flatter than usual, points in an unusual direction, or produces a discharge.

The next step is having a thorough physical exam. The doctor palpates the breast and performs a mammogram, which is an X-ray scan that pinpoints the location and approximate extent of abnormal tissue. An ultrasound scan might be done to distinguish between a cyst and a tumor. If an area might be cancerous, the next step is a biopsy, in which a very thin needle samples the affected tissue.

Eighty percent of the time, a breast lump is a sign of fibrocystic breast disease, which is benign. It may be a fluid-filled sac of glandular tissue (a cyst) or a solid, fibrous mass of connective tissue (a fibroadenoma). Treatment includes taking vitamin E or synthetic androgens under a doctor's care, or lowering caffeine intake and examining unusual lumps with mammograms or biopsies, because women with fibrocystic breasts are 1.6 times more likely to develop breast cancer than are other women.

Treatment

If biopsied breast cells are cancerous, treatment is usually surgical. A lumpectomy removes a small tumor and some surrounding tissue; a modified mastectomy removes an entire breast; and a radical mastectomy removes the breast and surrounding lymph and muscle tissue. Follow-up treatment varies depending upon the extent of the tumor. If abnormal tissue extends to nearby lymph nodes, chemotherapy and possibly radiation therapy will follow surgery. Chemotherapy is also indicated if a bone scan or other test reveals that the cancer has already spread. This happens in 7% of newly diagnosed cases of breast cancer.

The types of estrogen and progesterone receptors in the cancer cells determine which drugs are used. Some drugs block estrogen or progesterone receptors, which blocks signals that tell the cells to divide. Tumor cells that lack hormone receptors are associated with a poor prognosis. Women with these tumors receive some type of chemotherapy even if the cancer has not spread to adjacent lymph nodes.

Causes of Breast Cancer

A woman who has a close relative who has had breast cancer is at a higher risk of developing the condition than a woman without a family history of breast cancer. Experimental genetic tests can tell whether a woman with a strong family history will develop the inherited form of the illness. This was the case for a young woman whose mother and sister had died of breast cancer. Another sister had recently been diagnosed. Just before she was to undergo breast removal to avoid her feared fate, a genetic test showed that she had not inherited the responsible gene. The woman's cousin, who thought she could not inherit breast cancer because her father was related to the affected family, found that she had indeed inherited the gene. A mammogram revealed a tiny tumor, and surgery saved her life.

Ten percent of all breast cancers are inherited, with the two major responsible genes--called BRCA 1 and BRCA 2--discovered in 1993 and 1994. Researchers are still searching for the environmental triggers of the remaining 90% of cases. One candidate is prolonged exposure to estrogen. The estrogen link was first recognized in the 1970s, when researchers realized that young women who had had their ovaries removed very rarely developed breast cancer. Did their lack of estrogen protect against breast cancer? It appears so.

Prolonged exposure to estrogen can occur in a variety of ways:

Early menarche (first period) and late menopause (last period).

Pesticide residues and other pollutants. These contaminants stimulate cell division like estrogens do. Wildlife populations exposed to environmental estrogens demonstrate reproductive problems, such as infertility, undersized genitalia, and thin eggshells.

Having no children, or having a first child after the age of 30.

Not breast-feeding. Women who do not breast-feed have a higher breast cancer risk than women who do.

Breast Cancer Statistics

Nearly 3 million women in the United States currently have breast cancer. People frequently misunderstand the oft-quoted figure that a woman's lifetime risk of developing breast cancer is 1 in 8, believing that at any given time 1 in 8 U.S. women have breast cancer. This figure, however, refers to the lifetime risk for women who live to be 95.

Statistics indicate that breast cancer is on the rise. The lifetime risk of 1 in 8 was only 1 in 16 in the 1940s. It has increased by 1% a year since then, and by 4% a year since 1987. At least some of that rise is due to more widespread and earlier diagnosis, a result of public health programs to educate women about breast self-exam and mammography. Thanks to these efforts, most women will recover from breast cancer. However, the illness is the second most common cancer in women after lung cancer and causes 46,000 deaths in the United States each year.

Prevention

Health agencies advise mammograms once every two years for women aged 40 to 49, and yearly tests after that. A single baseline mammogram should be taken between age 35 and 40, as a basis of comparison. For a woman with a family history of breast cancer, this timetable is moved up. A mammogram can spot a tumor two years before a woman can feel it.

Thanks to the U.S. government's Women's Health Initiative, begun in 1993, we may soon learn enough about breast cancer to more effectively prevent and treat it. Some 70,000 women are participating in one or both of two investigations: The first study will test the ability of a diet low in fat and high in fruits and vegetables to prevent breast cancer. In the second study, healthy women with family histories of breast cancer are taking daily a drug called tamoxifen. This drug plugs up estrogen receptors in breast cells, preventing cell division.

Another candidate for breast cancer prevention is RU486, the drug used as an abortion pill because it blocks binding of progesterone to its cellular receptors. This action may also prevent breast cancer. Tamoxifen and RU486 are currently being tested as breast cancer treatments too. Tamoxifen, for example, decreases risk of cancer recurrence by 30%.

In addition, at least two dozen substances are being tested for their ability to direct the immune system to fight breast cancer cells. And the Women's Health Initiative is attempting to sort through the various purported environmental causes of breast cancer, including alcohol, pesticides, birth control pills, and electromagnetic fields.

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