Breast cancer – what to know?

The incidence of breast cancer varies more than fivefold in different countries around the world. Descendants of immigrants from countries with a low incidence of breast cancer acquire a significantly increased risk of breast cancer corresponding to the new country by the third generation. This undoubtedly indicates the influence of environmental factors and lifestyle on the etiology of breast cancer.

The proportion of genetic burden and the exact proportion of environmental factors are very difficult to establish in most cases of breast cancer. Certain genetic or reproductive risk factors include hereditary mutation of the tumor suppressor gene BRCA1 and BRCA2 (about 5% of all breast cancer patients), first-degree relatives with breast cancer, especially before the age of 40, age at first menstruation as well as at menopause, total duration of the reproductive period, age at first and number of carried pregnancies, as well as obesity in postmenopause. The most certain risk factor in sporadic breast cancer is the length of exposure to endogenous estrogens during life, that is, the average level of estrogen and the number of menstrual cycles during life. Environmental factors modulate the risk of breast cancer worldwide by 5 to 10 times.

In considerations of the formation of sporadic (non-hereditary) forms of breast cancer, which make up 90 – 95% of all cases, significant roles are played by:

– high calorie intake (sugars, fats, proteins) during childhood with low energy expenditure, leading to rapid growth, obesity during childhood and adolescence, and early onset of menstruation;
– alcohol use;
– low vegetable and dietary fiber content in the diet;
– exposure to ionizing radiation before the age of 40;
– smoking before the age of 16 and
– the most significant biological factor in the formation of breast cancer is certainly the duration of exposure to endogenous and exogenous estrogens during life.

Possible protective factors include vitamin C and A, carotenoids, vegetables like kale and cabbage, fiber-rich plant foods, and unsaturated fatty acids from olive oil.

The most significant environmental factor that influences the formation of breast cancer – both protective and highly risky – is diet. Key roles are played by total energy intake, physical activity, the addition of antioxidant substances, and phytoestrogens in the diet. It is known that the incidence of breast cancer is lowest in cultures with a vegetarian diet, that is, the incidence of breast cancer is lowest in societies where the diet contains less fat, especially animal fats, and more vegetables, fruits, grains, and legumes. On the other hand, a high-fat diet in industrial societies where breast cancer is prevalent almost always includes large amounts of unsaturated and partially hydrogenated fats, which are usually associated with high use of refined carbohydrates and insufficient intake of antioxidants, as well as fresh fruits and vegetables.

A very interesting approach of Chinese medicine towards breast cancer reveals that in China, breast cancer is considered a disease caused by melancholy. The feeling of heaviness in the chest prevents good circulation and increases the amount of “mucus,” leading to two conclusions. It is necessary to improve circulation in the chest and reduce the amount of “mucus,” thereby increasing the chances of preventing cancer formation. The easiest way to achieve this is to avoid foods like cheese, chocolate, fried foods, and milk. There are no dairy products in the Chinese diet, and grains and green vegetables prevail.

In preventing breast cancer and preventing recurrence after surgery or radiation due to breast cancer, diet can help in several ways. The basic type of diet recommended here is a vegetarian diet, low in fat. This diet consists of raw foods, such as vegetables, fruits, grains, nuts, and seeds. Some foods are especially medicinal in relation to breast cancer. These include:

– Soy, soy products, and lima beans: Isoflavones and phytoestrogens contained in these foods protect against breast cancer. The low incidence of breast cancer in Japan is mostly attributed to the significant amounts of soy in the daily diet.
– Flaxseed: Flaxseed is rich in omega-3 fatty acids, which have a protective effect on the formation of breast cancer.
– Fish: Salmon, tuna, sardines, mackerel, and herring contain plenty of omega-3 fatty acids.
– Cruciferous vegetables: Vegetables like cabbage, kale, Brussels sprouts, cauliflower, broccoli, and Brussels sprouts contain significant amounts of indole-3-carbinol. The possible mechanism of action of these foods is the change in estrogen metabolism, where the production of 2-OH estradiol increases relative to 4-OH and 16-alpha-OH estradiol.

Spicy, fatty foods, and stimulants such as coffee, black tea, drugs, and alcohol should be avoided. Alcohol is a well-confirmed risk in the formation of breast cancer. Experimentally, it increases cellular proliferation, as well as the number of estrogen receptors (ER alpha) in tumor cells, and the presumed mechanism of action is the increase in endogenous estrogen levels. Alcohol increases the risk of breast cancer, especially in combination with hormonal estrogen therapy, where a significant increase in estrogen levels plays a major role.

A high-fat diet, especially saturated fats, increases the production of free radicals. This increased production of free radicals damages cells, and these cells, in an attempt to regenerate themselves, can become malignant. A particularly harmful combination is a high-fat diet with alcohol and smoking. In contrast to a diet rich in saturated fats, the Mediterranean diet represents a diet rich in unsaturated fatty acids from olive oil in combination with vegetables and fruits, and despite the increased fat intake, it is associated with a low risk of breast cancer. Thus, the risk of breast cancer decreases by about 2% with the substitution of saturated fatty acids with monounsaturated fatty acids, and even 13% with the replacement of saturated fatty acids with polyunsaturated fatty acids.

Increased intake of foods rich in fiber with at least 20 g/day reduces the risk of breast cancer. The presumed mechanism of action is the reduction of intestinal reabsorption of estrogen (enterohepatic recirculation of estrogen) through plant fibers. Not all types of fiber-rich foods have the same protective effect. Green vegetables and grains have the strongest protective effect, while root vegetables are associated with a slightly increased risk of breast cancer. Recommended foods are: wheat germ, rye bread, oatmeal, white beans.

As free radicals promote the formation of cancer and its recurrence, antioxidants in the diet can directly affect the slowdown of free radical formation. There are various protocols for taking antioxidant vitamins to protect breast tissue from the harmful effects of free radicals. Most of these recommendations include the following elements:

– vitamin A (5,000 to 50,000 IU)
– beta carotene (up to 100 mg)
– vitamin B1 (400 mg)
– vitamin B6 (500 mg)
– folic acid (3.2 mg)
– vitamin C (up to 5 g)
– coenzyme Q10 (270 mg)
– flaxseed oil (1 teaspoon)
– melatonin (up to 10 mcg)
– pycnogenol (150 mg)
– aloe vera juice (about 3 dl).

Trace elements play a crucial role in preventing the harmful effects of free radicals. Our body contains some antioxidant proteins such as superoxide dismutase, which neutralizes free radicals produced by oxidation. However, for this enzyme to achieve its antioxidant effect, zinc, copper, and manganese are necessary. The lack of any of them creates conditions for insufficient antioxidant action, resulting in an increased tendency towards breast cancer. Other trace elements significant in preventing breast cancer, which can also be taken additionally, include selenium, chromium, and molybdenum.

The TNM classification is a system proposed by the International Union Against Cancer (UICC – International Union Against Cancer), where T denotes the localization and extent of the primary tumor, N regional lymph nodes, and M means metastasis beyond the regional area.

TNM
Breast Changes

Tis
Ca in situ.

T1
Breast cancer </= 2 cm.

T1a
Breast cancer </= 0.5 cm. T1b Breast cancer > 0.5 cm – 1 cm.

T1c
Breast cancer > 1 cm – 2 cm.

T2
Breast cancer > 2 cm – 5 cm.

T3
Breast cancer > 5 cm.

T4
Presence of pulmonary metastases with or without certain presence of tumor in the genital area.

T4a
Breast cancer spreading to the chest wall.

T4b
Breast cancer affecting the skin: skin edema/ulcerations/satellite nodules on the skin.

T4c
T4a + T4b

T4d
Breast cancer with inflammatory changes.

N1
Enlarged, mobile axillary lymph nodes.

pN1
Postoperative finding: enlarged mobile axillary lymph nodes.

pN1a
Postoperative finding: micrometastases </= 0.2 cm in enlarged mobile axillary lymph nodes. pN1b Postoperative finding: macrometastases in 1-3 lymph nodes > 0.2 – < 2 cm; or >/= 4 lymph nodes > 0.2 – < 2 cm; or affected lymph node capsule < 2 cm or lymph nodes >/= 2 cm.

N2
Fixed axillary lymph nodes

pN2
Postoperative finding: fixed axillary lymph nodes

N3
Affected lymph nodes along the internal mammary artery.

pN3
Postoperative finding: affected lymph nodes along the internal mammary artery.

M
Distant metastases.

Breast Cancer Treatment

Environmental Factors and Diet | Mastopathy | Mammography and Breast Ultrasound Stages of Breast Cancer | Treatment of Breast Cancer
In treating breast cancer, surgical intervention comes first, where the extent of the intervention depends on the size and spread of the tumor, skin infiltration, tumor mobility relative to the pectoral muscles, and the ratio between tumor size and breast size. Although over 90% of patients are in an operable stage at the time of diagnosis, only in very early stages – Tis and T1 N0 M0 – is the surgical procedure curative. The starting point in choosing the surgical technique is the fact that breast cancer in the clinical stage is already a generalized (disseminated) disease, and the degree of regional lymph node involvement indicates dissemination. Local carcinomatous growth into the depth of the breast tissue and involvement of the large pectoral muscle, as well as the breast nipple, occurs much slower, that is, later compared to lymph node involvement. Hence the trend of limiting the radicalism of surgical intervention in breast cancer and introducing breast-conserving techniques. In this way, by reducing the radicalism of the intervention and individualizing the therapy with the same therapeutic effect, excellent cosmetic results are achieved, reducing the psychological shock associated with the breast cancer diagnosis.

Breast-conserving surgeries include procedures called tumorectomy (lumpectomy), segmentectomy (Wide Excision), quadrantectomy (Wedge Excision), and subcutaneous mastectomy. In all breast-conserving surgeries, lymphadenectomy – removal of lymph nodes from the corresponding axilla – is mandatory. Recently, the “sentinel node” removal technique – the first lymph node receiving the contrast medium injected into the tumor bed – has been applied with very good results. In case of a negative finding, that is, the absence of metastases in the “sentinel node,” the surgical procedure ends with this. Conversely, in case of metastatic involvement of the “sentinel node,” other axillary lymph nodes are also removed. Breast-conserving surgeries are the method of choice in treating precancerous conditions (DCIS and CLIS). Depending on the method chosen and the type of preinvasive breast cancer, additional (adjuvant) procedures will depend. If the postoperative histological finding shows an invasive form of breast cancer, treatment continues obligatorily with radiation – adjuvant radiotherapy. In this case, with negative lymph nodes and T1-2, the tumor bed is irradiated: the breast and chest wall; and if the lymph nodes are positive, it is necessary to irradiate the regional lymphatic pathways as well. In the case of a medial tumor location, the parasternal lymphatic pathways are irradiated, and if the radicalism of the intervention is insufficient, the axilla (axilla) is additionally irradiated.

In advanced stages of breast cancer, unfavorable localization, or disproportion between tumor size and breast size, radical surgery – radical mastectomy – is approached. Here, too, there are several interventions depending on the degree of radicalism. The most commonly used intervention and the standard operation for advanced breast cancer is limited radical mastectomy with axillary lymph node dissection. In this operation, the entire breast and superficial layers of the pectoral fascia with corresponding axillary lymph nodes are removed. Patey’s modified radical mastectomy involves the removal of the entire breast with the removal of the small pectoral muscle and axillary lymph nodes. In classical radical mastectomy Rotter-Halsted, in addition to the breast, the small pectoral muscle, and axillary lymph node dissection, the large pectoral muscle is also removed. In cases of radical mastectomy and stages T1-2, further treatment is not necessary, while in stages T3-4, adjuvant radiation therapy is applied (breast, chest wall). In cases of lymph node involvement, the lymphatic pathways are additionally irradiated.

Radiation therapy for breast cancer – radiation – serves for locoregional sanitation and is always of an adjuvant or neoadjuvant nature. While radiation is an obligatory part of all breast-conserving surgical procedures in the treatment of breast cancer, after radical surgical interventions, it is applied only in advanced cases: T3-4, or if the lymphatic pathways are involved. The standard dose applied is 40 – 50 Gy, applied fractionally, usually 5×2 Gy per week. Radiation therapy reduces the risk of recurrence in breast-conserving surgical procedures from 40% to 5 – 10%, and in radical surgeries from 15% to 5%. Radiation therapy begins after the surgical wound heals, usually 2 – 4 weeks after surgery. Neoadjuvant radiation is applied in the form of preoperative radiation in inoperable cases to reduce tumor size and allow surgical intervention.

Chemotherapy holds high value in the medicinal treatment of breast cancer. The most commonly applied schemes are the CMF scheme (cyclophosphamide, methotrexate, fluorouracil) when 6 cycles of chemotherapy are applied every 4 weeks, and the AC scheme (adriamycin, cyclophosphamide) in the form of 4 cycles of chemotherapy every 3 weeks. The concept of systemic adjuvant chemotherapy is based on the knowledge that the success of breast cancer treatment depends not only on excellent results from local treatment methods (surgery and radiation) but also on early prevention of disease dissemination. Postoperative polychemotherapy primarily destroys occult micrometastases. Scientific studies indicate that adjuvant chemotherapy is particularly effective in premenopausal breast cancer patients, regardless of receptor status, and in postmenopausal patients with negative receptors.

Breast cancer belongs to hormone-dependent tumors, and endocrine therapy holds a special place in treating advanced forms, recurrences, and metastases. Indications for endocrine therapy derive from the presence of estrogen and progesterone receptors in tumor tissue. About 60 – 70% of breast cancer cases contain estrogen receptors in moderate or high amounts and therefore respond to endocrine – antiestrogen therapy. Ablative and additive hormonal therapies are distinguished. Ablative endocrine therapy involves the removal of the ovaries (ovariectomy) in premenopause. Similar effects are achieved with therapy using GnRH analogs (Zoladex, Enantone) – chemical ovariectomy. Additive hormonal therapy involves the application of appropriate hormonal drugs: antiestrogen hormones (tamoxifen), gestagens, or aromatase inhibitors (chemical adrenalectomy). Antiestrogen therapy (tamoxifen) is applied in all elderly patients (seniors) and receptor-positive patients in postmenopause. Recent scientific papers indicate the superiority of aromatase inhibitors (letrozole) over tamoxifen.

The prognosis of breast cancer depends on the size of the primary tumor, histological type (grading), growth potential, and lymphogenic metastasis. Low-risk patients have a favorable prognosis: in these cases, it is histologically differentiated carcinoma with a high content of receptors. If the carcinoma is morphologically undifferentiated, there is lymphogenic spread (lymphangiosis carcinomatosa), and the receptor content is very low or negative, these are high-risk patients. Unlike other genital carcinomas, given the very slow growth of breast cancer, even 20-35% of patients with untreated breast cancer survive 5 years, and 3 – 5% of patients even 10 years. The most important criterion in breast cancer prognosis is lymph node involvement. If the lymph nodes are negative, 80% of patients survive 5 years, and 65% survive 10 years. The prognosis of breast cancer worsens with the number of lymph nodes affected by metastases, with the critical threshold being 3 – 5 positive nodes.

Text taken from: http://www.poliklinikazdravlje.com/index.php/prehana/2175-prehrana–rak-dojke-i-prehrana-

Bioenergy treatments are very good in the preoperative, and especially in the postoperative period. Bioenergy helps in easier tolerating chemotherapy and improving blood counts.

Franjo Lenac