Screening:
Screening is performed on healthy individuals to detect common diseases that threaten human life and, importantly, are treatable, especially in early stages. In breast cancer, due to its high prevalence among women and because early diagnosis allows for effective treatment and disease control, screening holds special importance.

One of the screening methods in some countries is breast self-examination, which requires proper training but is not universally accepted by all scientific centers. Currently, screening is primarily done through imaging techniques, which include:

Mammography: Mammography is performed for two purposes:

  • Screening Mammography: This is done for early detection of disease in women who do not have symptoms. It is recommended starting at age 40, every 1-2 years, and annually from age 50. For individuals at higher risk of breast cancer, mammography screening may begin at younger ages.
  • Diagnostic Mammography: This is performed when a patient presents with a suspicious breast lump or when other examinations reveal signs of cancer disease.

Tomosynthesis (3D Mammography):
This technique provides high-resolution three-dimensional images of breast tissue and is especially useful for women with dense breast tissue. The radiation dose is equivalent to standard mammography.

Automated Breast Ultrasound:
A newer method for examining breast tissue using ultrasound, providing high-resolution 3D images for the physician.

In Iran, the current recommendation is to start mammography screening at age 40 for women. However, in individuals with a high risk of breast cancer, such as those with a strong family history, screening may begin earlier based on the physician’s advice.

Benign Breast Diseases:

Breast Cysts and Fibrocystic Disease:
Breast cysts are fluid-filled cavities that can range in size from a few millimeters to several centimeters. These cysts may be palpable or even painful, but they generally do not increase the risk of breast cancer and are mostly managed with simple, non-surgical treatments.
Fibrocystic disease is a common benign breast disorder that sometimes presents with breast firmness and pain. These changes can be controlled with reassurance, anxiety reduction, and simple treatments.

Benign Masses:
The majority of these masses do not carry a higher risk of developing into cancer compared to normal breast cells, but monitoring and care by a physician are necessary. If needed, needle biopsy and sometimes surgical removal of the mass may be performed.

Idiopathic Granulomatous Mastitis (IGM):

IGM is a chronic, benign inflammatory disease of the breast tissue that is rare in most populations worldwide. It is generally observed in women with a history of childbirth and breastfeeding. The etiology of this disease remains unclear, although the role of immune system reactions is evident.
Clinically, the disease manifests as one or several swollen, red, and painful inflammatory masses in a single breast, and only rarely occurs bilaterally. During its course, skin erythema and multiple ulcerations with cream-colored or greenish discharge may appear. The condition usually subsides and becomes inactive after several months; however, in some cases, symptoms may persist for several years.
In a proportion of patients, additional symptoms such as joint pain or erythematous skin rashes, particularly on the lower legs, may develop. Occasionally, the disease becomes severe, leading to multiple non-infectious fluid collections in the breast that cause significant pain and discomfort. It is important to note that these secretions are not infectious, the masses are not malignant in nature, and the risk of breast cancer in affected patients is equivalent to that of the general population.
Diagnosis is based on clinical examination and ultimately confirmed by core needle biopsy of the lesion with pathological assessment. It is crucial to distinguish IGM from inflammatory breast cancers.
Treatment ranges from routine care and simple anti-inflammatory agents to corticosteroid therapy, and in some cases, surgical intervention with drainage of distressing secretions. Nevertheless, in the majority of cases, the disease follows a self-limiting course, resolving spontaneously without the need for prolonged pharmacological therapy or surgical procedures.

Breast Cancer

Breast cancer results from the growth of malignant cells in the breast, forming a cancerous tumor. It’s important to note that benign tumors are not cancer and do not spread to other parts of the body, whereas malignant (invasive) cancer cells, especially in advanced stages, can invade surrounding breast tissue or spread to distant parts of the body.

Breast cancer is the most common cancer among women, and in most cases, it is of the carcinoma type. It may be non-invasive (in situ) and confined to the glandular tissue of the breast, which means it cannot spread to other parts of the body. However, invasive carcinomas can infiltrate surrounding tissues and, in advanced stages, spread via the lymphatic system to the axillary lymph nodes, or through the bloodstream to organs such as the lungs, liver, bones, or brain.

Prevalence in Iran:

Although the incidence of breast cancer in Iran is lower than in some developed countries, with approximately more than 10,000 new cases annually, it remains the most common cancer among Iranian women. This highlights the need for effective screening and timely treatment programs.

Risk Factors:

Personal Factors:

  • Female gender
  • Obesity
  • Alcohol consumption

Reproductive Factors:

  • Early menstruation
  • Late menopause
  • Long-term use of oral contraceptives
  • First pregnancy after age 35
  • Long-term hormone replacement therapy after menopause

Genetic and Familial Factors:

Individuals carrying genes that predispose them to breast cancer have a higher lifetime risk. In these cases, based on the physician’s assessment, preventive measures such as medications or preventive mastectomy may be recommended.

Types of Breast Cancer:

Carcinoma In Situ (DCIS):

These are non-invasive cancers confined to the ducts or lobules of the breast. They require local treatment only and typically do not require systemic therapies like chemotherapy.

Paget’s Disease of the Breast:

A rare, non-invasive cancer limited to the nipple and sometimes areola, often presenting with redness, scaling, or itching of the nipple.

Invasive Breast Cancers:

The most common type is Invasive Ductal Carcinoma (IDC). Other less common types include:

  • Invasive Lobular Carcinoma
  • Medullary Carcinoma
  • Mucinous Carcinoma
  • Tubular Carcinoma
  • Papillary Carcinoma

Signs and Symptoms of Breast Cancer:

Breast cancer may present without symptoms and be detected through screening (e.g., mammography) at early stages. However, it may also manifest with:

  • A palpable lump
  • Dimpling or retraction in part of the breast
  • Swelling or orange peel appearance of the breast skin
  • Skin ulceration
  • Spontaneous bloody nipple discharge

In some cases, the first sign may be a palpable mass in the underarm, due to lymph node involvement. Rarely, the first symptom could be a metastasis to organs such as the bones, liver, lungs, or brain.

Diagnosis:

Imaging:

  • Mammography is crucial in both screening and diagnosing breast cancer. It uses low-dose X-rays and does not increase cancer risk. When done at recommended intervals, it helps detect a significant number of breast cancers in early stages.
  • Ultrasound uses sound waves to visualize breast tissue.
  • MRI offers a dynamic and more detailed image of the breast, useful for evaluating suspicious lesions.
  • PET scan (PET-mammo) is a newer imaging method with limited applications in breast cancer but can be valuable in specific cases.

Each imaging method has its own benefits and limitations, and should be used as recommended by a physician.

Biopsy:

Today, breast cancer is mainly diagnosed using needle biopsy under local anesthesia. The collected tissue is examined microscopically by a pathologist, and the results guide treatment decisions.

Blood Analysis:

This involves checking peripheral blood for genetic fragments or tumor markers. While promising, this method has limited current use in breast cancer diagnostics.

Treatment of Breast Cancer:

Effective treatment requires a multidisciplinary team including specialists in surgery, radiology, pathology, oncology, and radiation therapy.

Early diagnosis allows for broader treatment options and better outcomes.

Surgical Treatment:

Breast Surgery:

Surgery is a standard treatment in most stages of breast cancer. Depending on the situation, part of the breast (lumpectomy) or the entire breast (mastectomy) may be removed.

  • Breast-Conserving Surgery (Oncoplastic Surgery): The tumor and a margin of healthy tissue are removed, and immediate reconstruction is done using the remaining breast tissue.
  • Mastectomy: Complete removal of breast tissue.

Axillary Lymph Node Surgery:

If underarm lymph nodes are affected, they are removed during breast surgery. However, if imaging and physical exams show no signs of lymph node involvement, the sentinel lymph node biopsy technique may be used. If the sentinel node is clear, further lymph node removal can be avoided, helping prevent arm lymphedema.

Systemic Therapy:

Systemic therapy targets cancer cells throughout the body to prevent the growth of any that may have spread. It includes:

  • Chemotherapy
  • Hormone Therapy
  • Targeted Therapy (e.g., HER2 inhibitors)

Radiation Therapy (Radiotherapy):

This treatment uses radioactive energy to destroy cancer cells in targeted tissues. Applications include:

  • After breast-conserving surgery (to the remaining breast tissue)
  • To the chest wall and lymph node regions after mastectomy
  • To distant organs such as bone or brain if metastases are present

Radiotherapy can be:

  • External: Radiation delivered from outside the body
  • Internal (brachytherapy): Radiation delivered from a radioactive source placed inside the breast tissue—either during surgery (IORT) or postoperatively.

Male Breast Cancer

In men, the breasts are not fully developed and consist of small glands located beneath the areola and nipple, surrounded by fatty tissue. This tissue structure can, however, develop breast cancer.
Although breast cancer in men is rare, awareness about it is also low. As a result, it is often diagnosed in advanced stages. As with all cancers, early detection and timely treatment are crucial for a favorable prognosis.

Clinical Signs:

Breast cancer in men may be asymptomatic in its early stages, but the following changes may be warning signs:

  • A palpable lump in the breast
  • A lump under the armpit
  • Dimpling or retraction of the breast skin; inversion of the nipple
  • Redness, irritation, or skin ulceration
  • Nipple discharge (clear or bloody)

Diagnosis:

Imaging techniques such as mammography, ultrasound, and if needed, MRI, are used for evaluation. However, definitive diagnosis is made through needle biopsy of the suspicious tissue.

Treatment:

Treatment may include:

  • Surgery
  • Chemotherapy
  • Radiotherapy
  • And, if necessary, hormonal therapy

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