It has been suggested that Inflammatory breast cancer be merged into this article or section. (Discuss)

Breast cancer Classification and external resources
Histopathologic image from ductal cell carcinoma in situ (DCIS) of breast. Hematoxylin-eosin stain.
ICD-10	C50.
ICD-9	174-175
OMIM	114480
DiseasesDB	1598
MedlinePlus	000913
eMedicine	med/2808
MeSH	D001943

Typical macroscopic (gross) appearance of the cut surface of a mastectomy specimen containing a cancer (in this case, an invasive ductal carcinoma of the breast, pale area at the center).

Mastectomy specimen containing a very large cancer of the breast (in this case, an invasive ductal carcinoma).

Breast cancer is a cancer that starts in the cells of the breast.^[1] Worldwide, breast cancer is the second most common type of cancer after lung cancer (10.4% of all cancer incidence, both sexes counted)^[2] and the fifth most common cause of cancer death.^[3] Worldwide, breast cancer is by far the most common cancer amongst women, with an incidence rate more than twice that of colorectal cancer and cervical cancer and about three times that of lung cancer. However breast cancer mortality worldwide is just 25% greater than that of lung cancer in women.^[2] In 2005, breast cancer caused 502,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths).^[3] The number of cases worldwide has significantly increased since the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world.^[4][5] Image File history File links Mergefrom. ... Inflammatory breast cancer[1] is an especially aggressive[2] type of breast cancer that can occur in women of any age (and, although extremely rarely, in men). ... Image File history File links Metadata No higher resolution available. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). ... // C00-D48 - Neoplasms (C00-C14) Malignant neoplasms, lip, oral cavity and pharynx (C00) Malignant neoplasm of lip (C01) Malignant neoplasm of base of tongue (C02) Malignant neoplasm of other and unspecified parts of tongue (C03) Malignant neoplasm of gum (C04) Malignant neoplasm of floor of mouth (C05) Malignant neoplasm of... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Mendelian Inheritance in Man project is a database that catalogues all the known diseases with a genetic component, and - when possible - links them to the relevant genes in the human genome. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Medical Subject Headings (MeSH) is a huge controlled vocabulary (or metadata system) for the purpose of indexing journal articles and books in the life sciences. ... Image File history File links Metadata No higher resolution available. ... Image File history File links Metadata No higher resolution available. ... Gross examination or grossing is the process by which pathology specimens are inspected with the naked eye to obtain diagnostic information, while being processed for further microscopic examination. ... In medicine, mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. ... In medicine, mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. ... Cancer is a class of diseases or disorders characterized by uncontrolled division of cells and the ability of these to spread, either by direct growth into adjacent tissue through invasion, or by implantation into distant sites by metastasis (where cancer cells are transported through the bloodstream or lymphatic system). ... Drawing of the structure of cork as it appeared under the microscope to Robert Hooke from Micrographia which is the origin of the word cell being used to describe the smallest unit of a living organism Cells in culture, stained for keratin (red) and DNA (green) The cell is the... For other uses, see Breast (disambiguation). ... Lung cancer is a disease of uncontrolled cell growth in tissues of the lung. ...

The incidence of breast cancer varies greatly around the world being lower in less developed countries and greatest in the more developed countries. In the twelve world regions the annual age standardised incidence per 100,000 women are in Eastern Asia 18, South Central Asia 22, sub-Saharan Africa 22, South-Eastern Asia 26, North Africa and Western Asia 28, South and Central America 42, Eastern Europe 49, Southern Europe 56, Northern Europe 73, Oceania 74, Western Europe 78, and in North America 90.^[6] In the United States the incidence is 141 among white women and 122 among African American women.^[7]

North American women have the highest incidence of breast cancer in the world.^[8] Among women in the U.S., breast cancer is the most common cancer and the second-most common cause of cancer death (after lung cancer).^[8] Women in the U.S. have a 1 in 8 (12.5%) lifetime chance of developing invasive breast cancer and a 1 in 35 (3%) chance of breast cancer causing their death.^[8] In 2007, breast cancer was expected to cause 40,910 deaths in the U.S. (7% of cancer deaths; almost 2% of all deaths).^[9]

In the U.S., both incidence and death rates for breast cancer have been declining in the last few years.^[10][9] Nevertheless, a U.S. study conducted in 2005 by the Society for Women's Health Research indicated that breast cancer remains the most feared disease,^[11] even though heart disease is a much more common cause of death among women.^[12] Society for Womens Health Research Logo The Society for Women’s Health Research (SWHR) is a non-profit organization in the United States whose mission is to improve the health of all women through research, education and advocacy. ... Heart disease is an umbrella term for a number of different diseases which affect the heart and as of 2007 it is the leading cause of death in the United States,[1] and England and Wales. ...

Because the breast is composed of identical tissues in males and females, breast cancer also occurs in males.^[13][14] Incidences of breast cancer in men are approximately 100 times less common than in women, but men with breast cancer are considered to have the same statistical survival rates as women.^[15]

[edit] Classification

It has been suggested that this section be split into a new article. (Discuss)

Breast cancers are described along four different classification schemes, or groups, each based on different criteria and serving a different purpose: Image File history File links No higher resolution available. ...

• Pathology - A pathologist will categorize each tumor based on its histological (microscopic anatomy) appearance and other criteria. The most common pathologic types of breast cancer are invasive ductal carcinoma, malignant cancer in the breast's ducts, and invasive lobular carcinoma, malignant cancer in the breast's lobules.
• Grade of tumor - The histological grade of a tumor is determined by a pathologist under a microscope. A well-differentiated (low grade) tumor resembles normal tissue. A poorly differentiated (high grade) tumor is composed of disorganized cells and, therefore, does not look like normal tissue. Moderately differentiated (intermediate grade) tumors are somewhere in between.
• Protein & gene expression status - Currently, all breast cancers should be tested for expression, or detectable effect, of the estrogen receptor (ER), progesterone receptor (PR) and HER2/neu proteins. These tests are usually done by immunohistochemistry and are presented in a pathologist's report. The profile of expression of a given tumor helps predict its prognosis, or outlook, and helps an oncologist choose the most appropriate treatment. More genes and/or proteins may be tested in the future.
• Stage of a tumour - The currently accepted staging scheme for breast cancer is the TNM classification.

There are five tumor classification values (Tis, T1, T2, T3 or T4) which depend on the presence or absence of invasive cancer, the dimensions of the invasive cancer, and the presence or absence of invasion outside of the breast (e.g. to the skin of the breast, to the muscle or to the rib cage underneath): A renal cell carcinoma (chromophobe type) viewed on a hematoxylin & eosin stained slide Pathologist redirects here. ... Anatomic pathology is a medical specialty (a branch of pathology) that is concerned with the diagnosis of disease based on the gross, microscopic, and molecular examination of cells and tissues. ... A thin section of lung tissue stained with hematoxylin and eosin. ... Ductal carcinoma can refer to: Infiltrating ductal carcinoma Ductal carcinoma in situ This is a disambiguation page: a list of articles associated with the same title. ... In medicine, malignant is a clinical term that means to be severe and become progressively worse, as in malignant hypertension. ... In anatomy and physiology, a duct is a circumscribed channel leading from an exocrine gland or organ. ... In anatomy, a lobe is a clear anatomical division or extension[1][2] which can be determined without the use of a microscope (at the gross anatomy level. ... The Bloom-Richardson grade (BR grade) is a a histologic grade assigned by pathologists to breast cancers. ... For malignant tumors specifically, see cancer. ... Protein expression is a subcomponent of gene expression. ... Gene expression, or simply expression, is the process by which the inheritable information which comprises a gene, such as the DNA sequence, is made manifest as a physical and biologically functional gene product, such as protein or RNA. Several steps in the gene expression process may be modulated, including the... The estrogen receptor is a receptor for estradiol (the main endogenous estrogen); it is located intracellularly, in parallel with other steroid hormone receptors. ... The progesterone receptor is an intracellular steroid receptor that specifically binds progesterone. ... HER2/neu (also known as ErbB-2) is a member of the epidermal growth factor receptor (EGFR) family and is notable for its role in the pathogenesis of breast cancer and as a target of treatment. ... Immunohistochemistry or IHC refers to the process of localizing proteins in cells of a tissue section exploiting the principle of antibodies binding specifically to antigens in biological tissues. ... Prognosis (older Greek πρόγνωσις, modern Greek πρόγνωση - literally fore-knowing, foreseeing) is a medical term denoting the doctors prediction of how a patients disease will progress, and whether there is chance of recovery. ... See cancer for the biology of the disease, as well as a list of malignant diseases. ... For other uses, see TNM (disambiguation). ...

• Tx - Primary tumor cannot be assessed.
• T0 - No evidence of primary tumor.
• Tis - Carcinoma in situ.
  • Tis(DCIS) - Intracuctal Carcinoma in situ.
  • Tis(LCIS) - Lobular Carcinoma in situ.
  • Tis(Paget's) - Paget's disease of the nipple with no tumor.
• T1 - Tumor 2cm or less in its greatest dimension.
  • T1mic - Microinvasion 0.1cm or less in greatest dimension.
  • T1a - Tumor more then 0.1cm but not more than 0.5cm in its greatest dimension.
  • T1b - Tumor more than 0.5cm but not more than 1.0cm in its greatest dimension.
  • T1c - Tumor more than 1.0cm but not more than 2.0cm in its greatest dimension.
• T2 - Tumor more than 2.0cm but not more than 5.0cm in its greatest dimension.
• T3 - Tumor more than 5cm in its greatest dimension.
• T4 - Tumor of any size with direct extension to (a) chest wall or (b) skin as described below:
  • T4a - Extension to chest wall.
  • T4b - Edema (including peau d'orange) or ulceration of the breast skin, or satellite skin nodules confined to the same breast.
  • T4c - Both T4a and T4b.
  • T4d - Inflammatory breast cancer.

Lymph Node - There are four lymph node classification values (N0, N1, N2 or N3) which depend on the number, size and location of breast cancer cell deposits in lymph nodes. Ductal carcinoma can refer to: Infiltrating ductal carcinoma Ductal carcinoma in situ This is a disambiguation page: a list of articles associated with the same title. ... Pagets disease of the breast, also known as Pagets disease of the nipple, is a condition that outwardly may have the appearance of eczema - with skin changes involving the nipple of the breast. ... This page is about the condition called edema. ... The French term peau dorange means orange skin. It is used in medicine to describe something with the look (orange colour) and texture (dimpled appearance) of an orange peel, for example the skin of the breast in inflammatory breast cancer, or the retina in Pseudoxanthoma elasticum. ... Inflammatory breast cancer[1] is an especially aggressive[2] type of breast cancer that can occur in women of any age (and, although extremely rarely, in men). ... Lymph nodes are components of the lymphatic system. ...

• Nx - regional lymph nodes cannot be assessed. Perhaps due to previous removal.
• N0 - no regional lymph node metastasis.
• N1 - metastasis to movable regional axillary lymph nodes on the same side as the effected breast.
• N2 - metastasis to fixed regional axillary lymph nodes, or metastasis to the internal mammary lymph nodes, on the same side as the effected breast.
• N3 - metastasis to supraclavicular lymph nodes or infraclavicular lymph nodes or metastasis to the internal mammary lymph nodes with metastasis to the axillary lymph nodes.

Metastases - There are two metastatic classification values (M0 or M1) which depend on the presence or absence of breast cancer cells in locations other than the breast and lymph nodes (so-called distant metastases, e.g. to bone, brain, lung). For the musical composition, see Metastasis (Xenakis composition). ...

[edit] Pathologic types

The latest (2003) World Health Organization (WHO) classification of tumors of the breast^[16] recommends the following pathological types: WHO redirects here. ...

The classifications above show that breast cancer is usually, but not always, classified by its histological appearance. Rare variants are defined on the basis of physical exam findings. For example, Inflammatory breast cancer (IBC), a form of ductal carcinoma or malignant cancer in the ducts, is distinguished from other carcinomas by the inflamed appearance of the affected breast.^[17] In the future, some pathologic classifications may be changed. For example, a subset of ductal carcinomas may be re-named basal-like carcinoma (part of the "triple-negative" tumors).^{[citation needed]} Gynecomastia, or gynaecomastia, pronounced is the development of abnormally large mammary glands in males resulting in breast enlargement, which can sometimes cause secretion of milk. ... In medicine, the physical examination or clinical examination is the process by which the physician investigates the body of a patient for signs of disease. ... Inflammatory breast cancer[1] is an especially aggressive[2] type of breast cancer that can occur in women of any age (and, although extremely rarely, in men). ... In medicine, carcinoma is any cancer that arises from epithelial cells. ... An abscess on the skin, showing the redness and swelling characteristic of inflammation. ...

[edit] Signs and symptoms

The first symptom, or subjective sign, of breast cancer is typically a lump that feels different than the surrounding breast tissue. According to the Merck Manual, greater than 80% of breast cancer cases are discovered as a lump by the woman herself.^[18] According to the American Cancer Society (ACS), the first medical sign, or objective indication of breast cancer as detected by a physician, is discovered by mammogram.^[9] Lumps found in lymph nodes located in the armpits^[18] and/or collarbone^{[citation needed]} can also indicate breast cancer. A symptom is a manifestation of a disease, indicating the nature of the disease, which is noticed by the patient. ... The Merck Manual of Diagnosis and Therapy (often referred to simply as The Merck Manual) is one of the worlds most widely used medical textbooks. ... The American Cancer Society (ACS) is the nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy and service. ... In medicine, a sign is a feature of disease as detected by the doctor during physical examination of a patient. ...

Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge. Pain is an unreliable tool in determining the presence of breast cancer, but may be indicative of other breast-related health issues such as mastodynia.^[9][18][19] // Breast Cancer cancerous cells enhabit the breast area causeing damage Breast Pain Also called: fibrocystic breast disease, Chronic cystic mastitis, Diffuse cystic mastopathy, Mammary dysplasia Nipples mastitis Inverted nipple Breast Mammary gland Pagets Disease of Breast Mondors disease Mastalgia Accessory breast Categories: | | | ... Mastalgia, mastodynia or mammalgia are names for a medical symptom that means - pain in the breast (from the Greek masto-, breast and algos, pain). ...

When breast cancer cells invade the dermal lymphatics, small lymph vessels in the skin of the breast, its presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC). Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast, as well as an orange peel texture to the skin referred to as peau d'orange.^[18]

Another reported symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Approximately half of women diagnosed with Paget's also have a lump in the breast.^[20] Pagets disease of the breast, also known as Pagets disease of the nipple, is a condition that outwardly may have the appearance of eczema - with skin changes involving the nipple of the breast. ... In medicine, the term syndrome is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occur together, so that the presence of one feature alerts the physician to the presence of the others. ... For the beetle, see Exema. ...

Occasionally, breast cancer presents as metastatic disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. More common sites of metastasis include bone, liver, lung and brain. Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms. These symptoms are "non-specific," meaning they can also be manifestations of many other illnesses.^[21] Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...

Most symptoms of breast disorder do not turn out to represent underlying breast cancer. Benign breast diseases such as mastitis and fibroadenoma of the breast are more common causes of breast disorder symptoms. The appearance of a new symptom should be taken seriously by both patients and their doctors, because of the possibility of an underlying breast cancer at almost any age.^[22] Mastitis is the inflammation of the mammalian breast caused by the blocking of the milk ducts while the mother is lactating (see breastfeeding). ... Fibroadenoma of the breast is a benign tumor characterized by proliferation of both glandular and stromal elements. ...

[edit] Epidemiology and etiology

Main article: Epidemiology and etiology of breast cancer

Epidemiological risk factors for a disease can provide important clues as to the etiology, or cause, of a disease. The first case-controlled study on breast cancer epidemiology was done by Janet Lane-Claypon, who published a comparative study in 1926 of 500 breast cancer cases and 500 control patients of the same background and lifestyle for the British Ministry of Health.^{[23][verification needed][24]} Epidemiological risk factors for a disease can provide important clues as to the etiology of a disease. ... Epidemiology is the study of factors affecting the health and illness of populations, and serves as the foundation and logic of interventions made in the interest of public health and preventive medicine. ... This article is about the medical term. ... Case-control studies are one type of epidemiological study design. ... Janet Elizabeth Lane-Claypon (1877–1967) was an English physician and one of the founders of the science of epidemiology, pioneering the use of so-called cohort studies and case-control studies. ...

Today, breast cancer, like other forms of cancer, is considered to be the final outcome of multiple environmental and hereditary factors. Some of these factors include:

1. Lesions to DNA such as genetic mutations. Mutations that can lead to breast cancer have been experimentally linked to estrogen exposure.^[25] Beyond the contribution of estrogen, research has implicated viral oncogenesis and the contribution of ionizing radiation in causing genetic mutations.^{[citation needed]}
2. Failure of immune surveillance, a theory in which the immune system removes malignant cells throughout one's life.^[26]
3. Abnormal growth factor signaling in the interaction between stromal cells and epithelial cells can facilitate malignant cell growth. For example, tumors can induce blood vessel growth (angiogenesis) by secreting various growth factors further facilitating cancer growth.^{[citation needed]}
4. Inherited defects in DNA repair genes, such as BRCA1, BRCA2^[27] and p53.^{[citation needed]}

Although many epidemiological risk factors have been identified, the cause of any individual breast cancer is often unknowable. In other words, epidemiological research informs the patterns of breast cancer incidence across certain populations, but not in a given individual. The primary risk factors that have been identified are sex,^[28] age,^[29] childbearing, hormones,^[30] a high-fat diet,^[31] alcohol intake,^[32][33] obesity,^[34] and environmental factors such as tobacco use, radiation^[27] and shiftwork.^[35] The structure of part of a DNA double helix Deoxyribonucleic acid, or DNA, is a nucleic acid molecule that contains the genetic instructions used in the development and functioning of all known living organisms. ... For linguistic mutation, see Apophony. ... Radiation hazard symbol. ... Growth factor is a protein that acts as a signaling molecule between cells (like cytokines and hormones) that attaches to specific receptors on the surface of a target cell and promotes differentiation and maturation of these cells. ... Stromal Cells Connective tissue cells of an organ found in the loose connective tissue. ... In zootomy, epithelium is a tissue composed of a layer of cells. ... Angiogenesis is the physiological process involving the growth of new blood vessels from pre-existing vessels. ... DNA damage resulting in multiple broken chromosomes DNA repair is a process constantly operating in cells; it is essential to survival because it protects the genome from damage and harmful mutations. ...

No etiology is known for 95% of breast cancer cases, while approximately 5% of new breast cancers are attributable to hereditary syndromes.^[36] In particular, carriers of the breast cancer susceptibility genes, BRCA1 and BRCA2, are at a 30-40% increased risk for breast and ovarian cancer, depending on in which portion of the protein the mutation occurs.^[37]

[edit] Prevention

Lower age of first childbirth (less than 24 years maternal age), having more children (about 7% lowered risk per child), and breastfeeding (4% per breastfeeding year) have all been correlated to lowered breast cancer risk in large studies.^[38] In addition, exercising three times a week for one hour each has been found to lower breast cancer by up to 40%.^{[citation needed]}

[edit] Phytoestrogens and soy

Phytoestrogens such as found in soybeans have been extensively studied in animal and human in-vitro and epidemiological studies. The literature support the following conclusions: Phytoestrogens are chemicals produced by plants that act like estrogens in animal/+human cells and bodies. ... Binomial name Glycine max Soybeans (US) or soya beans (UK) (Glycine max) are a high-protein legume (Family Fabaceae) grown as food for both humans and livestock. ...

1. Plant estrogen intake, such as from soy products, in early adolescence may protect against breast cancer later in life.^[39]
2. Plant estrogen intake later in life is not likely to influence breast cancer incidence either positively or negatively.^[40]

[edit] Folic acid (folate)

Main article: Folic acid#Folic acid and cancer

The factual accuracy of this article is disputed. Please see the relevant discussion on the talk page.(March 2008)

Studies have found that "folate intake counteracts breast cancer risk associated with alcohol consumption"^[41] and "women who drink alcohol and have a high folate intake are not at increased risk of cancer."^[42][43][44] A prospective study of over 17,000 women found that those who consume 40 grams of alcohol (about 3-4 drinks) per day have a higher risk of breast cancer. However, in women who take 200 micrograms of folate (folic acid or Vitamin B9) every day, the risk of breast cancer drops below that of alcohol abstainers.^[45] Folic acid and folate (the anion form) are forms of the water-soluble Vitamin B9. ... Image File history File links Emblem-important. ...

Folate is involved in the synthesis, repair, and functioning of DNA, the body’s genetic map, and a deficiency of folate may result in damage to DNA that may lead to cancer.^[46] In addition to breast cancer, studies have also associated diets low in folate with increased risk of pancreatic, and colon cancer.^[47][48] Pancreatic cancer is a malignant tumor within the pancreatic gland. ...

Foods rich in folate include citrus fruits, citrus juices, dark green leafy vegetables (such as spinach), dried beans, and peas. Vitamin B9 can also be taken in a multivitamin pill. Species & major hybrids Species Citrus maxima - Pomelo Citrus medica - Citron Citrus reticulata - Mandarin & Tangerine Major hybrids Citrus x aurantifolia - Lime Citrus x aurantium - Bitter Orange Citrus x bergamia - Bergamot Citrus x hystrix - Kaffir Lime Citrus x ichangensis - Ichang Lemon Citrus x limon - Lemon Citrus x limonia - Rangpur Citrus x paradisi... Chinese cabbage Swiss chard Leaf vegetables, also called greens or leafy greens, are plant leaves eaten as a vegetable, sometimes accompanied by tender petioles and shoots. ... Binomial name Spinacia oleracea L. Percentages are relative to US recommendations for adults. ... Green beans Bean is a common name for large plant seeds of several genera of Fabaceae (formerly Leguminosae) used for food or feed. ... Binomial name L. Percentages are relative to US recommendations for adults. ...

[edit] Avoiding exposure to secondhand tobacco smoke

Breathing secondhand smoke increases breast cancer risk by 70% in younger, primarily pre-menopausal women. The California Environmental Protection Agency has concluded that passive smoking causes breast cancer^[49] and the US Surgeon General^[50] has concluded that the evidence is "suggestive," one step below causal. There is some evidence that exposure to tobacco smoke is most problematic between puberty and first childbirth. The reason that breast tissue appears most sensitive to chemical carcinogens in this phase is that breast cells are not fully differentiated until lactation.^[51] Tobacco smoking is the act of smoking tobacco products, especially cigarettes and cigars. ... The California Environmental Protection Agency (Cal/EPA) was created in 1991 by Governor Pete Wilson, through an executive order. ... Surgeon General can have several different meanings. ...

[edit] Oophorectomy and mastectomy

Prophylactic oophorectomy (removal of ovaries), in high-risk individuals, when child-bearing is complete, reduces the risk of developing breast cancer by 60%, as well as reducing the risk of developing ovarian cancer by 96%.^[52] Oophorectomy is the surgical removal of the ovaries of a female animal. ...

[edit] Medications

Hormonal therapy has been used for chemoprevention in individuals at high risk for breast cancer. In 2002, a clinical practice guideline by the US Preventive Services Task Force (USPSTF) recommended that "clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention" with a grade B recommendation.^{[53][verification needed][54][55]} Hormonal therapy is one of the major modalities of medical treatment for cancer, others being cytotoxic chemotherapy and targeted therapy (biotherapeutics). ... Clinical practice guidelines are collections of practical information for use by doctors and other medical professionals. ... According to the Agency for Healthcare Research Quality, US Preventive Services Task Force is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. ...

[edit] Selective estrogen receptor modulators (SERMs)

The guidelines^[clarify] were based on studies of SERMs from the MORE, BCPT P-1, and Italian trials. In the MORE trial, the relative risk reduction for raloxifene was 76%.^[56] The P-1 preventative study demonstrated that tamoxifen can prevent breast cancer in high-risk individuals. The relative risk reduction was up to 50% of new breast cancers, though the cancers prevented were more likely estrogen-receptor positive (this is analogous to the effect of finasteride on the prevention of prostate cancer, in which only low-grade prostate cancers were prevented).^[57][58] The Italian trial showed benefit from tamoxifen.^[59] Selective estrogen receptor modulators (SERMs) is a class of medication that acts on the estrogen receptor. ... The relative risk reduction is a measure used in epidemiology. ... Finasteride (marketed as Proscar, Propecia, Fincar, Finpecia, Finax, Finast, Finara, Finalo, Prosteride, Gefina, Finasterid IVAX) is an antiandrogen which acts by inhibiting type II 5-alpha reductase, the enzyme that converts testosterone to dihydrotestosterone (DHT). ... HRPC redirects here. ...

Additional randomized controlled trials have been published since the guidelines. The IBIS trial found benefit from tamoxifen.^[60] In 2006, the NSABP STAR trial demonstrated that raloxifene had equal efficacy in preventing breast cancer compared with tamoxifen, but that there were fewer side effects with raloxifene.^[61] The RUTH Trial concluded that "benefits of raloxifene in reducing the risks of invasive breast cancer and vertebral fracture should be weighed against the increased risks of venous thromboembolism and fatal stroke".^[62] On September 14, 2007, the US Food and Drug Administration approved raloxifene (Evista) to prevent invasive breast cancer in postmenopausal women.^[63] A randomized controlled trial (RCT) is a form of clinical trial, or scientific procedure used in the testing of the efficacy of medicine, used because of its record of reliability. ... is the 257th day of the year (258th in leap years) in the Gregorian calendar. ... The United States Food and Drug Administration is the government agency responsible for regulating food, dietary supplements, drugs, cosmetics, medical devices, biologics and blood products in the United States. ... Raloxifene is an oral selective estrogen receptor modulator which is used in the prevention of osteoporosis in postmenopausal women. ...

[edit] Screening

Main article: Breast cancer screening

Breast cancer screening is an attempt to find unsuspected cancers. The most common screening methods are self and clinical breast exams, x-ray mammography, and breast Magnetic resonance imaging (MRI) Breast cancer is cancer of breast tissue. ...

[edit] X-ray mammography

Mammography is still the modality of choice for screening of early breast cancer, since it is relatively fast, reasonably accurate, and widely available in developed countries.

Due to the high incidence of breast cancer among older women, screening is now recommended in many countries. Recommended screening methods include breast self-examination and mammography. Mammography has been estimated to reduce breast cancer-related mortality by 20-30%.^[64] Routine (annual) mammography of women older than age 40 or 50 is recommended by numerous organizations as a screening method to diagnose early breast cancer and has demonstrated a protective effect in multiple clinical trials.^[65] The evidence in favor of mammographic screening comes from eight randomized clinical trials from the 1960s through 1980s. Many of these trials have been criticised for methodological errors, and the results were summarized in a review article published in 1993.^[66] Breast self-examination (BSE) is an easy but unreliable method for finding possible breast cancer. ... Mammography. ...

Improvements in mortality due to screening are hard to measure; similar difficulty exists in measuring the impact of Pap smear testing on cervical cancer, though worldwide, the impact of that test is likely enormous. Nationwide mortality due to cancer before and after the institution of a screening test is a surrogate indicator about the effectiveness of screening, and results of mammography are favorable. The pap smear as we know it is an invention of Dr. Georgios Papanikolaou (1883-1962), an American of Greek birth, the father of cytopathology. ... Cervical cancer is a malignant cancer of the cervix. ...

Normal (left) versus cancerous (right) mammography image.

The U.S. National Cancer Institute recommends screening mammography every one to two years beginning at age 40.^[67] In the UK, women are invited for screening once every three years beginning at age 50. Women with one or more first-degree relatives (mother, sister, daughter) with premenopausal breast cancer should begin screening at an earlier age. It is usually suggested to start screening at an age that is 10 years less than the age at which the relative was diagnosed with breast cancer. Image File history File links Mammo_breast_cancer. ... Image File history File links Mammo_breast_cancer. ... The National Cancer Institute (NCI) is part of the United States Federal governments National Institutes of Health. ...

A clinical practice guideline by the US Preventive Services Task Force recommended "screening mammography, with or without clinical breast examination (CBE), every 1 to 2 years for women aged 40 and older."^[68] The Task Force gave a grade B recommendation.^{[53][verification needed]}

In 2005, 67.9% of all U.S. women age 40–64 had a mammogram in the past two years (74.5% of women with private health insurance, 56.1% of women with Medicaid insurance, 38.1% of currently uninsured women, and 32.9% of women uninsured for > 12 months).^[69] The term health insurance is generally used to describe a form of insurance that pays for medical expenses. ... Medicaid is the US health insurance program for individuals and families with low incomes and resources. ... Health care in the United States is provided by many separate legal entities. ...

[edit] Criticisms of screening mammography

Several scientific groups however have expressed concern about the public's perceptions of the benefits of breast screening.^[70] In 2001, a controversial review published in The Lancet claimed that "there is no reliable evidence that screening for breast cancer reduces mortality".^[71][72]The Cochrane Collaboration concluded, "for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. It is thus not clear whether screening does more good than harm."^[73] The Lancet is one of the oldest and most respected peer-reviewed medical journals in the world, published weekly by Elsevier, part of Reed Elsevier. ...

False positives are a major problem of mammographic breast cancer screening. Data reported in the UK Million Woman Study indicates that if 134 mammograms are performed, 20 women will be called back for suspicious findings, and four biopsies will be necessary, to diagnose one cancer. Recall rates are higher in the U.S. than in the UK.^[74] The contribution of mammography to the early diagnosis of cancer is controversial, and for those found with benign lesions, mammography can create a high psychological and financial cost.

[edit] Mammography in women less than 50 years old

Part of the difficulty in interpreting mammograms in younger women stems from the problem of breast density. Radiographically, a dense breast has a preponderance of glandular tissue, and younger age or estrogen hormone replacement therapy contribute to mammographic breast density. After menopause, the breast glandular tissue gradually is replaced by fatty tissue, making mammographic interpretation much more accurate. Some authors speculate that part of the contribution of estrogen hormone replacement therapy to breast cancer mortality arises from the issue of increased mammographic breast density. Breast density is an independent adverse prognostic factor on breast cancer prognosis. Estriol. ... Hormone replacement therapy (HRT) is a system of medical treatment for perimenopausal and postmenopausal women, based on the assumption that it may prevent discomfort and health problems caused by diminished circulating estrogen hormones. ...

A systematic review by the American College of Physicians concluded "Although few women 50 years of age or older have risks from mammography that outweigh the benefits, the evidence suggests that more women 40 to 49 years of age have such risks".^[75]. Systematic reviews are named as the highest level of medical evidence, by evidence based medicine professionals. ... The American College of Physicians (ACP) is a national organization of doctors of internal medicine (internists), physicians who specialize in the prevention, detection and treatment of illnesses in adults. ...

A report released November 27, 2007 by the Journal of the National Cancer Institute showed that the formula doctors use to calculate a woman's risk of breast cancer underestimates the danger for black women most of the time and especially for those age 50 and older — the age when they are most likely to benefit from screening tests and protective drugs, according to the first major reassessment of the widely used tool.^[76]

[edit] Enhancements to mammography

CAD is especially established in US and the Netherlands. It is used in addition to the human evaluation of the diagnostician.

[edit] Breast MRI

Magnetic resonance imaging (MRI) has been shown to detect cancers not visible on mammograms, but has long been regarded to have disadvantages. For example, although it is 27-36% more sensitive, it is less specific than mammography.^[77] As a result, MRI studies will have more false positives (up to 5%), which may have undesirable financial and psychological costs. It is also a relatively expensive procedure, and one which requires the intravenous injection of a chemical agent (from which there are side effects, potentially serious in a small number of people) to be effective. Proposed indications for using MRI for screening include:^[78] MRI redirects here. ... Type I errors (or α error, or false positive) and type II errors (β error, or a false negative) are two terms used to describe statistical errors. ...

• Strong family history of breast cancer
• Patients with BRCA-1 or BRCA-2 tumour suppressor gene mutations
• Evaluation of women with breast implants
• History of previous lumpectomy or breast biopsy surgeries
• Axillary metastasis with an unknown primary tumor
• Very dense or scarred breast tissue

However, two studies published in 2007 demonstrated the strengths of MRI-based screening:

• In March 2007, an article published in the New England Journal of Medicine demonstrated that in 3.1% of patients with breast cancer, whose contralateral breast was clinically and mammographically tumor-free, MRI could detect breast cancer. Sensitivity for detection of breast cancer in this study was 91%, specificity 88%.^[79]

• In August 2007, an article published in The Lancet compared MRI breast cancer screening to conventional mammographic screening in 7,319 women. MRI screening was highly more sensitive (97% in the MRI group vs. 56% in the mammography group) in recognizing early high-grade Ductal Carcinoma in situ (DCIS), the most important precursor of invasive carcinoma. Despite the high sensitivity, MRI screening had a positive predictive value of 52%, which is totally accepted for cancer screening tests.^[80] The author of a comment published in the same issue of The Lancet concludes that "MRI outperforms mammography in tumour detection and diagnosis."^[81]

The New England Journal of Medicine (New Engl J Med or NEJM) is a peer-reviewed medical journal published by the Massachusetts Medical Society. ... It has been suggested that Human Anatomical Terms be merged into this article or section. ... The sensitivity of a binary classification test or algorithm, such as a blood test to determine if a person has a certain disease, or an automated system to detect faulty products in a factory, is a parameter that expresses something about the tests performance. ... The specificity is a statistical measure of how well a binary classification test correctly identifies the negative cases, or those cases that do not meet the condition under study. ... The positive predictive value is the proportion of patients with positive test results who are correctly diagnosed. ...

[edit] Breast self-exam

Breast self-examination (BSE) was widely discussed in the 1990s as a useful modality for detecting breast cancer at an earlier stage of presentation. A large clinical trial in China reduced enthusiasm for breast self-exam. In the trial, reported in the Journal of the National Cancer Institute first in 1997 and updated in 2002, 132,979 female Chinese factory workers were taught by nurses at their factories to perform monthly breast self-exam, while 133,085 other workers were not taught self-exam. The women taught self-exam tended to detect more breast nodules, but their breast cancer mortality rate was no different from that of women in the control group. In other words, women taught breast self-exam were mostly likely to detect benign breast disease, but were just as likely to die of breast cancer.^[82] In 2003, the American Cancer Society relegated structured BSE to an 'optional' method of detecting breast cancer, citing self awareness as more important than structured self exams based on recent research.^[27] Breast self-examination (BSE) is an easy but unreliable method for finding possible breast cancer. ... The American Cancer Society (ACS) is the nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy and service. ...

[edit] Genetic testing

A clinical practice guideline by the US Preventive Services Task Force :^[68]

• "recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2)" The Task Force gave a grade D recommendation.^{[53][verification needed]}
• "recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing." The Task Force gave a grade B recommendation.^{[53][verification needed]}

The Task Force noted that about 2% of women have family histories that indicate increased risk as defined by: Genetic counsel