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Kelompok 1 A.14.1
FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2015
Every second of the 10,000 women in the world are expected to develop breast
cancer each year. Breast cancer is one of the main causes of death from cancer in women
worldwide (Depkes, 2009). Breast cancer is a malignancy of the breast tissue that can be
derived from ductal and lobular epithelium. Breast cancer is one type of cancer is highest
in Indonesia. According to Pathological Registration Based in Indonesia, breast cancer
ranks first with relative frequency of 18.6%. (Data Cancer in Indonesia in 2010,
according to data histopathologic, Registration Agency Cancer Association of Physician
Specialists Pathology Indonesia (IAPI) and the Indonesian Cancer Foundation (ICF),
estimated that the number of events in Indonesia is 12 / 100,000 women, while in the
United States is approximately 92 / 100,000 women with mortality is quite high at 27 /
100,000 or 18% of the deaths were found in women. It may be suffered by the men - men
with a frequency of approximately 1%. In Indonesia, more than 80% of cases are found
to be at an advanced stage, where treatment efforts difficult. Therefore, it needs to be an
understanding of prevention, early diagnosis, curative and palliative treatment and
rehabilitation are good, so that the service can be performed optimally patients
(Kemenkes RI, 2015)
This section describes the stages of breast cancer. The breast cancer stage is based
on the results of testing that is done on the tumor and lymph nodes removed during
surgery and other tests.
b. Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found
in the lobules of the breast. This condition seldom becomes invasive cancer.
Information about LCIS is not included in this summary.
Lobular carcinoma in situ (LCIS). Abnormal cells are found in the lobules of
the breast. Paget disease of the nipple is a condition in which abnormal cells are
found in the nipple only.
2. Stage I
In stage I, cancer has formed. Stage I is divided into stages IA and IB.
a. In stage IA, the tumor is 2 centimeters or smaller. Cancer has not spread
outside the breast.
b. In stage IB, small clusters of breast cancer cells (larger than 0.2 millimeter but
not larger than 2 millimeters) are found in the lymph nodes and either:
3. Stage II
Stage II is divided into stages IIA and IIB.
a. In stage IIA:
o The tumor is larger than 2 centimeters but not larger than 5 centimeters.
Cancer has not spread to the lymph nodes.
o Larger than 2 centimeters but not larger than 5 centimeters. Small clusters
of breast cancer cells (larger than 0.2 millimeter but not larger than 2
millimeters) are found in the lymph nodes; or
o Larger than 2 centimeters but not larger than 5 centimeters. Cancer has
spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the
breastbone (found during a sentinel lymph node biopsy); or
o Larger than 5 centimeters. Cancer has not spread to the lymph nodes.
The tumor is larger than 2 centimeters but not larger than 5 centimeters and small
clusters of cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are
found in the lymph nodes (left panel), or the tumor is larger than 2 centimeters but not
larger than 5 centimeters and cancer is found in 1 to 3 axillary lymph nodes or lymph
nodes near the breastbone (middle panel), or the tumor is larger than 5 centimeters and
has not spread to the lymph nodes (right panel).
4. Stage IIIA
No tumor is found in the breast or the tumor may be any size and cancer is
found in 4 to 9 axillary lymph nodes or lymph nodes near the breastbone (left panel)
or the tumor is larger than 5 centimeters and small clusters of cancer cells (larger than
0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes (middle
panel) or the tumor is larger than 5 centimeters and cancer is found in 1 to 3 axillary
lymph nodes or lymph nodes near the breastbone (right panel).
In stage IIIA:
No tumor is found in the breast or the tumor may be any size. Cancer is found in 4
to 9 axillary lymph nodes or in the lymph nodes near the breastbone (found during
imaging tests or a physical exam); or
The tumor is larger than 5 centimeters. Small clusters of breast cancer cells (larger
than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph
nodes; or
The tumor is larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph
nodes or to the lymph nodes near the breastbone (found during a sentinel lymph
node biopsy).
5. Stage IIIB
The tumor may be any size and cancer has spread to the chest wall and/or to
the skin of the breast and caused swelling or an ulcer. Cancer may have spread to up
to 9 axillary lymph nodes or the lymph nodes near the breastbone. Cancer that has
spread to the skin of the breast may be inflammatory breast cancer.
In stage IIIB, the tumor may be any size and cancer has spread to the chest
wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer may
have spread to:
Cancer that has spread to the skin of the breast may also be inflammatory
breast cancer. See the section on Inflammatory Breast Cancer for more information.
6. Stage IIIC
No tumor is found in the breast or the tumor may be any size and may have
spread to the chest wall and/or to the skin of the breast and caused swelling or an
ulcer. Also, cancer has spread to 10 or more axillary lymph nodes (left panel); OR to
lymph nodes above or below the collarbone (middle panel); OR to axillary lymph
nodes and lymph nodes near the breastbone (right panel). Cancer that has spread to
the skin of the breast may be inflammatory breast cancer.
In stage IIIC, no tumor is found in the breast or the tumor may be any size.
Cancer may have spread to the skin of the breast and caused swelling or an ulcer
and/or has spread to the chest wall. Also, cancer has spread to:
10 or more axillary lymph nodes.
Cancer that has spread to the skin of the breast may also be inflammatory
breast cancer. See the section on Inflammatory Breast Cancer for more information.
For treatment, stage IIIC breast cancer is divided into operable and inoperable stage
IIIC.
7. Stage IV
The cancer has spread to other parts of the body, most often the bones, lungs,
liver, or brain. In stage IV, cancer has spread to other organs of the body, most often
the bones, lungs, liver, or brain.
D. Risk Factors Breast Cancer
1. Breast cancer risk factors you cannot change
a. Gender
Simply being a woman is the main risk factor for developing breast
cancer. Men can develop breast cancer, but it’s about 100 times more common
among women than men. This is probably because men have less breast tissue, as
well as less of the female hormones estrogen and progesterone, which can
promote breast cancer cell growth.
Aging
Your risk of developing breast cancer goes up as you get older. About 1
out of 8 invasive breast cancers are found in women younger than 45, while about
2 of 3 invasive breast cancers are found in women age 55 or older.
Inheriting certain genes
About 5% to 10% of breast cancer cases are thought to be hereditary,
meaning that they are caused by gene defects (called mutations) passed on from a
parent.
Family history of breast cancer
Breast cancer risk is higher among women whose close blood relatives
have this disease. Having a first-degree relative (mother, sister, or daughter) with
breast cancer about doubles a woman’s risk. Having 2 first-degree relatives
increases her risk about 3-fold. Although the exact risk is not known, women with
a family history of breast cancer in a father or brother also have an increased risk
of breast cancer. Overall, less than 15% of women with breast cancer have a
family member with this disease. This means that most (85%) women who get
breast cancer do not have a family history of this disease.
Personal history of breast cancer
A woman with cancer in one breast has an increased risk of developing a
new cancer in the other breast or in another part of the same breast. (This is
different from a recurrence (return) of the first cancer.) This risk is even higher if
breast cancer was diagnosed at a younger age.
Race and ethnicity
Overall, white women are slightly more likely to develop breast cancer
than are African- American women, but African-American women are more likely
to die of this cancer. In women under 45 years of age, however, breast cancer is
more common in African- American women. Asian, Hispanic, and Native
American women have a lower risk of developing and dying from breast cancer.
2. Next, press your hands firmly on your hips and lean slightly toward your mirror
as you pull your shoulders and elbows forward with a squeezing or hugging
motion. Look for any change in the normal shape of your breasts. Now, bend
forward at the waist, hold your head up and look in the mirror. You may notice
that one breast is larger than the other and this is normal.
3. Looking in the mirror, raise your arms and rest your hands behind your head. This
allows you to see the underside of your breasts.
4. Press your nipple, look your nipple if your nipple expel abnormal liquid
5. Raise your left arm. Use the pads of three or four fingers of your right hand to
examine your left breast. Use three levels of pressure (light, medium, and firm)
while moving in a circular motion. Check your breast area using a set pattern. You
can choose (1) lines, (2) circles or (3) wedges.
6. Lines
Beginning at the outer edge of your breast move your fingers downward using a
circular motion until they are below the breast. Then move your fingers slightly
toward the middle and slowly move back up. Go up and down until you go over
the entire breast area.
7. Circle
Beginning at the outer edge of your breast use the flat part of your fingers,
moving in circles slowly around the breast. Gradually make smaller and smaller
circles toward the nipple. Be sure to cover the entire breast and check behind the
nipple.
Wedges
Starting at the outer edge of the breast, move your fingers toward the nipple and back to
the edge. Check your entire breast, covering one wedge-shaped area at a time.
8. Give the special attention on the red area because in that area usually grows tumor.
Limiting consumption of alcohol.
Avoid smoking
Balanced diet
Environmental
Regular exercise and
Occupational health
F. Breast Cancer Test And Treatment
1. Breast Cancer Test
There are many tests and procedures may be used to check for breast cancer:
a. Clinical breast exam (CBE) is an exam of the breast by a doctor or other health
professional. The doctor will carefully feel the breasts and under the arms for lumps
or anything else that seems unusual.
d. MRI (magnetic resonance imaging) is a procedure that uses a magnet, radio waves,
and a computer to make a series of detailed pictures of both breasts.
f. Biopsy is the removal of cells or tissues so they can be viewed under a microscope
by a pathologist to check for signs of cancer. There are four types of biopsy used to
check for breast cancer:
g. Sentinel lymph node biopsy is the removal of the sentinel lymph node during
surgery. The sentinel lymph node is the first lymph node to receive lymphatic
drainage from a tumor and likely spreaded. A radioactive substance and/or blue dye
is injected near the tumor. The substance or dye flows through the lymph ducts to the
lymph nodes. The first lymph node to receive the substance or dye is removed. A
pathologist views the tissue under a microscope to look for cancer cells. If cancer
cells are not found, it may not be necessary to remove more lymph nodes.
a. Surgery
Types of surgery include the following:
1. Breast-conserving surgery is an operation to remove the cancer and some
normal tissue around it, but not the breast itself. Part of the chest wall lining
may also be removed if the cancer is near it.
2. Total mastectomy is surgery to remove the whole breast that has cancer. Some
of the lymph nodes under the arm may be removed and checked for cancer. The
dotted line shows where the entire breast is removed.
3. Modified radical mastectomy is surgery to remove the whole breast that has
cancer, many of the lymph nodes under the arm, the lining over the chest
muscles, and sometimes, part of the chest wall muscles.
Most patients with breast cancer have surgery to remove the cancer.
Chemotherapy may be given before surgery to remove the tumor. When given before
surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that
needs to be removed during surgery. Even if the doctor removes all the cancer that can
be seen at the time of the surgery, some patients may be given radiation therapy,
chemotherapy, or hormone therapy after surgery, to kill any cancer cells that are left. If
a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a
breast’s shape after a mastectomy) may be considered. Breast reconstruction may be
done at the time of the mastectomy or at some time after. The reconstructed breast may
be made with the patient’s own (non-breast) tissue or by using implants filled with
saline or silicone gel.
a. Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or
other types of radiation to kill cancer cells or keep them from growing. There are
two types of radiation therapy. External radiation therapy uses a machine outside
the body to send radiation toward the cancer. External radiation therapy is used to
treat breast cancer. Internal radiation therapy uses a radioactive substance sealed
in needles, seeds, wires, or catheters that are placed directly into or near the
cancer. Late effects of radiation therapy are not common, but may include:
Inflammation of the lung after radiation therapy to the breast, especially
when chemotherapy is given at the same time.
Arm lymphedema, especially when radiation therapy is given after lymph
node dissection.
In women younger than 45 years who receive radiation therapy to the
chest wall after mastectomy, there may be a higher risk of developing breast
cancer in the other breast.
b. Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of
cancer cells, either by killing the cells or by stopping them from dividing. When
chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter
the bloodstream and can reach cancer cells throughout the body (systemic
chemotherapy). The way of the chemotherapy depends on the type and stage of
the cancer being treated. Systemic chemotherapy is used in the treatment of breast
cancer. Late effects of chemotherapy depend on the drugs used, but may include:
Heart failure.
Blood clots.
Premature menopause.
Second cancer, such as leukemia.
c. Hormone therapy
Hormone therapy is a cancer treatment that removes hormones or blocks
their action and stops cancer cells from growing. Some hormones can cause
certain cancers to grow. If tests show that the cancer cells have places where
hormones can attach (receptors), drugs, surgery, or radiation therapy is used to
reduce the production of hormones or block them from working. The hormone
estrogen, which makes some breast cancers grow, is made mainly by the ovaries.
Treatment to stop the ovaries from making estrogen is called ovarian ablation.
Hormone therapy with tamoxifen is often given to patients with early localized
breast cancer that can be removed by surgery and those with metastatic breast
cancer (cancer that has spread to other parts of the body). Hormone therapy with
an aromatase inhibitor is given to some postmenopausal women who have
hormone receptor–positive breast cancer. Aromatase inhibitors decrease the
body's estrogen by blocking an enzyme called aromatase from turning androgen
into estrogen. Anastrozole and letrozole are two types of aromatase inhibitors.
d. Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances
to identify and attack specific cancer cells without harming normal cells.
Monoclonal antibodies, tyrosine kinase inhibitors, and cyclin-dependent kinase
inhibitors are types of targeted therapies used in the treatment of breast cancer.
Monoclonal antibody therapy is a cancer treatment that uses antibodies made in
the laboratory, from a single type of immune system cell. These antibodies can
identify substances on cancer cells or normal substances that may help cancer
cells grow. The antibodies attach to the substances and kill the cancer cells, block
their growth, or keep them from spreading. Monoclonal antibodies are given by
infusion. They may be used alone or to carry drugs, toxins, or radioactive material
directly to cancer cells. Monoclonal antibodies may be used in combination with
chemotherapy as adjuvant therapy. Tyrosine kinase inhibitors are targeted therapy
drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors
may be used with other anticancer drugs as adjuvant therapy. Cyclin-dependent
kinase inhibitors are targeted therapy drugs that block proteins called cyclin-
dependent kinases, which cause the growth of cancer cells. PARP inhibitors are a
type of targeted therapy that block DNA repair and may cause cancer cells to die.
PARP inhibitor therapy is being studied for the treatment of patients with triple
negative breast cancer or tumors with BRCA1 or BRCA2 mutations. Late effects
of targeted therapy may include heart problems such as heart failure.
There are different types of treatment for patients with breast cancer.
a. Early Stage Breast Cancer (Stage I and Stage II)
Treatment of early-stage breast cancer (stage I and stage II) may include the following:
Modified radical mastectomy.
Breast-conserving surgery followed by radiation therapy. In pregnant women,
radiation therapy is delayed until after the baby is born.
Modified radical mastectomy or breast-conserving surgery during pregnancy
followed by chemotherapy after the first 3 months of pregnancy.
b. Late Stage Breast Cancer (Stage III and Stage IV)
Treatment of late-stage breast cancer (stage III and stage IV) may include the following:
Radiation therapy.
Chemotherapy.
Radiation therapy and chemotherapy should not be given during the first 3 months of
pregnancy.
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