Breast%20cancer Signs and Symptoms

• Refers to both invasive and in situ carcinoma of the breast
• Most common and frequently diagnosed noncutaneous cancer in women

• Highest incidence among all cancers globally
• Fifth leading cause of mortality globally
• Occurs commonly in women >50 years old

• Malignant proliferation of epithelial cells lining the ducts or lobules of the breast
  • Initially limited to a duct or lobule (in situ) without metastasis potential which may progress as time passes and spread in the breast tissue, lymph nodes, or other organs

• Presence of breast nodule, mass, or abscess
  
  • Most common symptom of breast cancer is a new lump or mass in the breast
  • Painless, hard, and irregular mass is more likely to be cancerous, but can also be tender, soft, rounded, or painful
• Breast pain or nipple pain (very rare)
• Nipple discharge
• Nipple retraction
• Presence of breast skin changes (eg peau d’ orange, nipple excoriation, scaling, inflammation, skin tethering, ulceration, abscess)

• History of breast cancer
  
  • Previous history of breast cancer has an increased risk of developing new primary breast cancer
    
    • History of invasive breast cancer, lobular neoplasia (formerly called lobular carcinoma in situ [LCIS]) and ductal carcinoma in situ (DCIS) have the highest risk
    • Lifetime risk at ≥20% based on history of LCIS or atypical ductal hyperplasia (ADH)/atypical lobular hyperplasia (ALH)
  
  
• Previous history of epithelial ovarian or exocrine pancreatic cancer at any age, or prostate cancer at any age with metastatic, intraductal or cribriform histology, those belonging to high- or very high-risk group, or with the following family history: Ashkenazi Jewish ancestry, ≥1 close relative with breast cancer at ≤50 years of age or ovarian, pancreatic, metastatic, or intraductal/cribriform prostate cancer at any age, or ≥2 close relatives with breast or prostate cancer at any age 
• Confirmed biopsy of benign proliferative breast disease
  
  • Breast tissue biopsy showing proliferative disease with and without atypical cells has an elevated risk of developing breast cancer
    
    • Patients with benign breast disease that presents with atypical hyperplasia carry the highest risk
    
    
• History of high-dose radiation exposure
  
  • Multiple exposures of therapeutic radiation to the chest for cancer at an early age (<30 years old) increase the risk of breast cancer
  • Contralateral breast cancer has been shown to develop after high-dose radiation exposure
  • Patients with Hodgkin’s disease receiving radiotherapy at high doses are also at risk
  
  
• Reproductive factors
  • Nulliparity or first full-term pregnancy at age >30 years
    
    • Breastfeeding for >12 months is protective against breast cancer
  • Menarche at age <12 years and menopause at age >55 years
  • Oral contraceptive use before the first full-term pregnancy, combination hormone replacement therapy, and long-term use of unopposed estrogen for >15 years by hysterectomized women have mild increased risk for breast cancer
    
    • Use of low-dose preparations poses a lower risk
    
    
• Advanced age
  
  • Woman ≥35 years with a 5-year risk ≥1.7% for invasive breast cancer assessed using the modified Gail model
    • Modified Gail model calculates the 5-year and lifetime probabilities of developing invasive breast cancer which can be used to identify women at increased risk by evaluating the risk of invasive breast cancer as a function of age, menarche, age at 1st live birth or nulliparity, number of 1st-degree relatives with breast cancer, number of benign breast biopsies, atypical hyperplasia in a previous breast biopsy and race  
  • Risk increases from 40 years old for premenopausal women and 50 years old for postmenopausal women

• Family history of breast cancer
  
  • Increased risk in women with breast cancer among young first-degree relatives
    • Sister has a higher risk than a mother
  • Carriers of BRCA1 and BRCA2 genetic mutations are also at high risk
    
    • Women with these have increased risk of developing other cancers like ovarian cancer
    • Other genes associated with genetic susceptibility to breast cancer include PTEN, TP53, CDH1, STK11, MLH1, MSH2, MSH6, and PMS2; genes currently being investigated include PALB2, CHEK2, ATM, RAD51C, RAD51D, and BRIP1

• Individuals with characteristics for Li-Fraumeni syndrome (LFS) or Cowden syndrome/PTEN hamartoma tumor syndrome testing criteria 
• Breast density: Higher breast density has increased risk
• Lifestyle
  
  • Body mass index of >25 has an increased risk of developing breast cancer with higher death rate
  • Lack of exercise
  • Alcohol consumption (eg beer) of >10 g/day especially in postmenopausal women has increased risk for invasive breast cancer

Risk Factors for Disease Recurrence

• Palpable mass
• Larger mass size
• Higher grade tumors
• Close or involved margins
• Age <50 years
• Presence of lymphovascular space invasion
• Lymph node involvement
• Human epidermal growth factor receptor 2 (HER2) status of the cancer cells
• Proliferative marker Ki67 index