Kanker payudara adalah kanker pada jaringan payudara.

Ini adalah jenis kanker paling umum yang

diderita kaum wanita. Kaum pria juga dapat terserang kanker payudara, walaupun kemungkinannya
lebih kecil dari 1 di antara 1000. Pengobatan yang paling lazim adalah dengan pembedahan dan jika
perlu dilanjutkan dengan kemoterapi maupun radiasi.
1.1. Deinisi 1.1.1. Kanker adalah suatu kondisi dimana sel telah kehilangan pengendalian dan
mekanisme normalnya, sehingga mengalami pertumbuhan yang tidak normal, cepat dan tidak
terkendali. !http"##www.mediasehat.com#utama0$.php% 1.1.&. Kanker payudara !'arcinoma mammae%
adalah suatu penyakit neoplasma yang ganas yang berasal dari parenchyma. Penyakit ini oleh (ord
)ealth *rganization !()*% dimasukkan ke dalam International 'lassiication o Diseases !I'D%
dengan kode nomor 1$ !http"##www.tempo.co.id#medika#arsip#0+&00&#pus,-.htm%
1.&. Patoisiologi 1.&.1. .ransormasi /el,sel kanker dibentuk dari sel,sel normal dalam suatu proses
rumit yang disebut transormasi, yang terdiri dari tahap inisiasi dan promosi. 1.&.1.1. pada tahap inisiasi
terjadi suatu perubahan dalam bahan genetik sel yang memancing sel menjadi ganas. Perubahan dalam
bahan genetik sel ini disebabkan oleh suatu agen yang disebut karsinogen, yang bisa berupa bahan
kimia, 0irus, radiasi !penyinaran% atau sinar matahari. tetapi tidak semua sel memiliki kepekaan yang
sama terhadap suatu karsinogen. kelainan genetik dalam sel atau bahan lainnya yang disebut promotor,
menyebabkan sel lebih rentan terhadap suatu karsinogen. bahkan gangguan isik menahunpun bisa
membuat sel menjadi lebih peka untuk mengalami suatu keganasan. 1.&.1.&. pada tahap promosi, suatu
sel yang telah mengalami inisiasi akan berubah menjadi ganas. /el yang belum melewati tahap inisiasi
tidak akan terpengaruh oleh promosi. karena itu diperlukan beberapa aktor untuk terjadinya keganasan
!gabungan dari sel yang peka dan suatu karsinogen%. 1.&.&. /tadium /tadium penyakit kanker adalah
suatu keadaan dari hasil penilaian dokter saat mendiagnosis suatu penyakit kanker yang diderita
pasiennya, sudah sejauh manakah tingkat penyebaran kanker tersebut baik ke organ atau jaringan
sekitar maupun penyebaran ketempat jauh /tadium hanya dikenal pada tumor ganas atau kanker dan
tidak ada pada tumor jinak. 1ntuk menentukan suatu stadium, harus dilakukan pemeriksaan klinis dan
ditunjang dengan pemeriksaan penunjang lainnya yaitu histopatologi atau P2, rontgen , 1/3, dan bila
memungkinkan dengan '. /can, scintigrai dll. 4anyak sekali cara untuk menentukan stadium, namun
yang paling banyak dianut saat ini adalah stadium kanker berdasarkan klasiikasi sistim .56 yang
direkomendasikan oleh 1I''!International 1nion 2gainst 'ancer dari ()* atau (orld )ealth
*rganization% # 27''!2merican 7oint 'ommittee *n cancer yang disponsori oleh 2merican 'ancer
/ociety dan 2merican 'ollege o /urgeons%. 1.&.&.1. Pada sistim .56 dinilai tiga aktor utama yaitu
8.8 yaitu .umor size atau ukuran tumor , 858 yaitu 5ode atau kelenjar getah bening regional dan 868
yaitu metastasis atau penyebaran jauh. Ketiga aktor .,5,6 dinilai baik secara klinis sebelum
dilakukan operasi , juga sesudah operasi dan dilakukan pemeriksaan histopatologi !P2% . Pada kanker
payudara, penilaian .56 sebagai berikut "
9 . !.umor size%, ukuran tumor "
. 0 " tidak ditemukan tumor primer
. 1 " ukuran tumor diameter & cm atau kurang
. & " ukuran tumor diameter antara &,: cm
. - " ukuran tumor diameter ; : cm
. < " ukuran tumor berapa saja, tetapi sudah ada penyebaran ke kulit atau dinding dada atau
pada keduanya , dapat berupa borok, edema atau bengkak, kulit payudara kemerahan atau ada
benjolan kecil di kulit di luar tumor utama
9 5 !5ode%, kelenjar getah bening regional !kgb% "
5 0 " tidak terdapat metastasis pada kgb regional di ketiak # aksilla
5 1 " ada metastasis ke kgb aksilla yang masih dapat digerakkan
5 & " ada metastasis ke kgb aksilla yang sulit digerakkan
5 - " ada metastasis ke kgb di atas tulang selangka !supracla0icula% atau pada kgb di mammary
interna di dekat tulang sternum
9 6 !6etastasis% , penyebaran jauh "
6 = " metastasis jauh belum dapat dinilai
6 0 " tidak terdapat metastasis jauh
6 1 " terdapat metastasis jauh
1.&.&.&. /etelah masing,masing aktot .,.5,6 didapatkan, ketiga aktor tersebut kemudian digabung
dan didapatkan stadium kanker sebagai berikut "
/tadium 0 " .0 50 60
/tadium 1 " .1 50 60
/tadium II 2 " .0 51 60 # .1 51 60 # .& 50 60
/tadium II 4 " .& 51 60 # .- 50 60
/tadium III 2 " .0 5& 60 # .1 5& 60 # .& 5& 60 # .- 51 60 # .& 5& 60
/tadium III 4 " .< 50 60 # .< 51 60 # .< 5& 60
/tadium III ' " .iap . 5- 60
/tadium I> " .iap .,.iap 5 ,61
1.-. 3ejala Klinis 3ejala klinis kanker payudara dapat berupa 9 benjolan pada payudara 1mumnya
berupa benjolan yang tidak nyeri pada payudara. 4enjolan itu mula,mula kecil, makin lama makin
besar, lalu melekat pada kulit atau menimbulkan perubahan pada kulit payudara atau pada puting susu.
9 erosi atau eksema puting susu Kulit atau puting susu tadi menjadi tertarik ke dalam !retraksi%,
berwarna merah muda atau kecoklat,coklatan sampai menjadi oedema hingga kulit kelihatan seperti
kulit jeruk !peau d?orange%, mengkerut, atau timbul borok !ulkus% pada payudara. 4orok itu makin lama
makin besar dan mendalam sehingga dapat menghancurkan seluruh payudara, sering berbau busuk, dan
mudah berdarah. 9 pendarahan pada puting susu. 9 @asa sakit atau nyeri pada umumnya baru timbul
kalau tumor sudah besar, sudah timbul borok, atau kalau sudah ada metastase ke tulang,tulang. 9
Kemudian timbul pembesaran kelenjar getah bening di ketiak, bengkak !edema% pada lengan, dan
penyebaran kanker ke seluruh tubuh !)andoyo, 1AA0%. Kanker payudara lanjut sangat mudah dikenali
dengan mengetahui kriteria operbilitas )eagensen sebagai berikut" 9 terdapat edema luas pada kulit
payudara !lebih 1#- luas kulit payudara%B 9 adanya nodul satelit pada kulit payudaraB 9 kanker payudara
jenis mastitis karsinimatosaB 9 terdapat model parasternalB 9 terdapat nodul suprakla0ikulaB 9 adanya
edema lenganB 9 adanya metastase jauhB 9 serta terdapat dua dari tanda,tanda locally ad0anced, yaitu
ulserasi kulit, edema kulit, kulit teriksasi pada dinding toraks, kelenjar getah bening aksila berdiameter
lebih &,: cm, dan kelenjar getah bening aksila melekat satu sama lain
1.<. Caktor @esiko 6enurut 6oningkey dan KodimPenyebab spesiik kanker payudara masih belum
diketahui, tetapi terdapat banyak aktor yang diperkirakan mempunyai pengaruh terhadap terjadinya
kanker payudara diantaranya" 1.<.1. Caktor reproduksi Karakteristik reprodukti yang berhubungan
dengan risiko terjadinya kanker payudara adalah nuliparitas, menarche pada umur muda, menopause
pada umur lebih tua, dan kehamilan pertama pada umur tua. @isiko utama kanker payudara adalah
bertambahnya umur. Diperkirakan, periode antara terjadinya haid pertama dengan umur saat kehamilan
pertama merupakan window o initiation perkembangan kanker payudara. /ecara anatomi dan
ungsional, payudara akan mengalami atroi dengan bertambahnya umur. Kurang dari &:D kanker
payudara terjadi pada masa sebelum menopause sehingga diperkirakan awal terjadinya tumor terjadi
jauh sebelum terjadinya perubahan klinis. 1.<.&. Penggunaan hormon )ormon eksogen berhubungan
dengan terjadinya kanker payudara. Eaporan dari )ar0ard /chool o Public )ealth menyatakan bahwa
terdapat peningkatan kanker payudara yang bermakna pada para pengguna terapi estrogen replacement.
/uatu metaanalisis menyatakan bahwa walaupun tidak terdapat risiko kanker payudara pada pengguna
kontrasepsi oral, wanita yang menggunakan obat ini untuk waktu yang lama mempunyai risiko tinggi
untuk mengalami kanker ini sebelum menopause. 1.<.-. Penyakit ibrokistik Pada wanita dengan
adenosis, ibroadenoma, dan ibrosis, tidak ada peningkatan risiko terjadinya kanker payudara. Pada
hiperplasis dan papiloma, risiko sedikit meningkat 1,: sampai & kali. /edangkan pada hiperplasia
atipik, risiko meningkat hingga : kali. 1.<.<. *besitas .erdapat hubungan yang positi antara berat
badan dan bentuk tubuh dengan kanker payudara pada wanita pasca menopause. >ariasi terhadap
kekerapan kanker ini di negara,negara 4arat dan bukan 4arat serta perubahan kekerapan sesudah
migrasi menunjukkan bahwa terdapat pengaruh diet terhadap terjadinya keganasan ini. 1.<.:. Konsumsi
lemak Konsumsi lemak diperkirakan sebagai suatu aktor risiko terjadinya kanker payudara. (illet
dkk., melakukan studi prospekti selama + tahun tentang konsumsi lemak dan serat dalam hubungannya
dengan risiko kanker payudara pada wanita umur -< sampai :A tahun. 1.<.F. @adiasi Gksposur dengan
radiasi ionisasi selama atau sesudah pubertas meningkatkan terjadinya risiko kanker payudara. Dari
beberapa penelitian yang dilakukan disimpulkan bahwa risiko kanker radiasi berhubungan secara linier
dengan dosis dan umur saat terjadinya eksposur. 1.<.$. @iwayat keluarga dan aktor genetik @iwayat
keluarga merupakan komponen yang penting dalam riwayat penderita yang akan dilaksanakan skrining
untuk kanker payudara. .erdapat peningkatan risiko keganasan ini pada wanita yang keluarganya
menderita kanker payudara. Pada studi genetik ditemukan bahwa kanker payudara berhubungan dengan
gen tertentu. 2pabila terdapat 4@'2 1, yaitu suatu gen suseptibilitas kanker payudara, probabilitas
untuk terjadi kanker payudara sebesar F0D pada umur :0 tahun dan sebesar +:D pada umur $0 tahun.
1.:. Pengobatan Kanker 2da beberapa pengobatan kanker payudara yang penerapannya banyak
tergantung pada stadium klinik penyakit !.jindarbumi, 1AA<%, yaitu" 1.:.1. 6astektomi 6astektomi
adalah operasi pengangkatan payudara. 2da - jenis mastektomi !)irshaut H Pressman, 1AA&%" 1.:.1.1.
6odiied @adical 6astectomy, yaitu operasi pengangkatan seluruh payudara, jaringan payudara di
tulang dada, tulang selangka dan tulang iga, serta benjolan di sekitar ketiak. 1.:.1.&. .otal !/imple%
6astectomy, yaitu operasi pengangkatan seluruh payudara saja, tetapi bukan kelenjar di ketiak. 1.:.1.-.
@adical 6astectomy, yaitu operasi pengangkatan sebagian dari payudara. 4iasanya disebut
lumpectomy, yaitu pengangkatan hanya pada jaringan yang mengandung sel kanker, bukan seluruh
payudara. *perasi ini selalu diikuti dengan pemberian radioterapi. 4iasanya lumpectomy
direkomendasikan pada pasien yang besar tumornya kurang dari & cm dan letaknya di pinggir
payudara. 1.:.&. Penyinaran#radiasi Iang dimaksud radiasi adalah proses penyinaran pada daerah yang
terkena kanker dengan menggunakan sinar J dan sinar gamma yang bertujuan membunuh sel kanker
yang masih tersisa di payudara setelah operasi !Denton, 1AAF%. Gek pengobatan ini tubuh menjadi
lemah, nasu makan berkurang, warna kulit di sekitar payudara menjadi hitam, serta )b dan leukosit
cenderung menurun sebagai akibat dari radiasi. 1.:.-. Kemoterapi Kemoterapi adalah proses pemberian
obat,obatan anti kanker dalam bentuk pil cair atau kapsul atau melalui inus yang bertujuan membunuh
sel kanker. .idak hanya sel kanker pada payudara, tapi juga di seluruh tubuh !Denton, 1AAF%. Gek dari
kemoterapi adalah pasien mengalami mual dan muntah serta rambut rontok karena pengaruh obat,
obatan yang diberikan pada saat kemoterapi.
1.F. /trategi Pencegahan Pada prinsipnya, strategi pencegahan dikelompokkan dalam tiga kelompok
besar, yaitu pencegahan pada lingkungan, pada pejamu, dan milestone. )ampir setiap epidemiolog
sepakat bahwa pencegahan yang paling eekti bagi kejadian penyakit tidak menular adalah promosi
kesehatan dan deteksi dini. 4egitu pula pada kanker payudara, pencegahan yang dilakukan antara lain
berupa" 1.F.1. Pencegahan primer Pencegahan primer pada kanker payudara merupakan salah satu
bentuk promosi kesehatan karena dilakukan pada orang yang 8sehat8 melalui upaya menghindarkan diri
dari keterpaparan pada berbagai aktor risiko dan melaksanakan pola hidup sehat. 1.F.&. Pencegahan
sekunder Pencegahan sekunder dilakukan terhadap indi0idu yang memiliki risiko untuk terkena kanker
payudara. /etiap wanita yang normal dan memiliki siklus haid normal merupakan populasi at risk dari
kanker payudara. Pencegahan sekunder dilakukan dengan melakukan deteksi dini. 4eberapa metode
deteksi dini terus mengalami perkembangan. /krining melalui mammograi diklaim memiliki akurasi
A0D dari semua penderita kanker payudara, tetapi keterpaparan terus,menerus pada mammograi pada
wanita yang sehat merupakan salah satu aktor risiko terjadinya kanker payudara. Karena itu, skrining
dengan mammograi tetap dapat dilaksanakan dengan beberapa pertimbangan antara lain" 9 (anita
yang sudah mencapai usia <0 tahun dianjurkan melakukan cancer risk assessement sur0ey. 9 Pada
wanita dengan aktor risiko mendapat rujukan untuk dilakukan mammograi setiap tahun. 9 (anita
normal mendapat rujukan mammograi setiap & tahun sampai mencapai usia :0 tahun. Coster dan
'onstanta menemukan bahwa kematian oleh kanker payudara lebih sedikit pada wanita yang
melakukan pemeriksaan /2D2@I !Pemeriksaan Payudara /endiri% dibandingkan yang tidak. (alaupun
sensiti0itas /2D2@I untuk mendeteksi kanker payudara hanya &FD, bila dikombinasikan dengan
mammograi maka sensiti0itas mendeteksi secara dini menjadi $:D. 1.F.-. Pencegahan .ertier
Pencegahan tertier biasanya diarahkan pada indi0idu yang telah positi menderita kanker payudara.
Penanganan yang tepat penderita kanker payudara sesuai dengan stadiumnya akan dapat mengurangi
kecatatan dan memperpanjang harapan hidup penderita. Pencegahan tertier ini penting untuk
meningkatkan kualitas hidup penderita serta mencegah komplikasi penyakit dan meneruskan
pengobatan. .indakan pengobatan dapat berupa operasi walaupun tidak berpengaruh banyak terhadap
ketahanan hidup penderita. 4ila kanker telah jauh bermetastasis, dilakukan tindakan kemoterapi dengan
sitostatika. Pada stadium tertentu, pengobatan diberikan hanya berupa simptomatik dan dianjurkan
untuk mencari pengobatan alternati.
KANKER PAYUDARA
Fakta dan Angka
6enurut ()* +,AD wanita akan mengalami kanker payudara. Ini menjadikan
kanker payudara sebagai jenis kanker yang paling banyak ditemui pada wanita. /etiap
tahun lebih dari &:0,000 kasus baru kanker payudara terdiagnosa di Gropa dan kurang
lebih 1$:,000 di 2merika /erikat. 6asih menurut ()*, tahun &000 diperkirakan 1,&
juta wanita terdiagnosis kanker payudara dan lebih dari $00,000 meninggal karenanya.
4elum ada data statistik yang akurat di Indonesia, namun data yang terkumpul dari
rumah sakit menunjukkan bahwa kanker payudara menduduki ranking pertama
diantara kanker lainnya pada wanita.
Kanker payudara merupakan penyebab utama kematian pada wanita akibat kanker.
/etiap tahunnya, di 2merika /erikat <<,000 pasien meninggal karena penyakit ini
sedangkan di Gropa lebih dari 1F:,000. /etelah menjalani perawatan, sekitar :0D
pasien mengalami kanker payudara stadium akhir dan hanya bertahan hidup 1+ K -0
bulan.
Penyebab dan Faktor Resiko
Penyebab pasti kanker payudara tidak diketahui. 6eskipun demikian, riset
mengidentiikasi sejumlah aktor yang dapat meningkatkan risiko pada indi0idu
tertentu, yang meliputi"
9 Keluarga yang memiliki riwayat penyakit serupa
9 1sia yang makin bertambah
9 .idak memiliki anak
9 Kehamilan pertama pada usia di atas -0 tahun
9 Periode menstruasi yang lebih lama !menstruasi pertama lebih awal atau
menopause lebih lambat%
9 Caktor hormonal !baik estrogen maupun androgen%.
Dari aktor risiko tersebut di atas, riwayat keluarga serta usia menjadi aktor
terpenting. @iwayat keluarga yang pernah mengalami kanker payudara meningkatkan
resiko berkembangnya penyakit ini. Para peneliti juga menemukan bahwa kerusakan
dua gen yaitu 4@'21 dan 4@'2& dapat meningkatkan risiko wanita terkena kanker
sampai +:D. )al yang menarik, aktor genetik hanya berdampak :,10D dari
terjadinya kanker payudara dan ini menunjukkan bahwa aktor risiko lainnya
memainkan peranan penting.
Pentingnya aktor usia sebagai aktor risiko diperkuat oleh data bahwa $+D kanker
payudara terjadi pada pasien yang berusia lebih dari :0 tahun dan hanya FD pada
pasien yang kurang dari <0 tahun. @ata,rata usia pada saat ditemukannya kanker
adalah F< tahun.
/tudi juga menge0aluasi peranan aktor gaya hidup dalam perkembangan kanker
payudara yang meliputi pestisida, konsumsi alkohol, kegemukan, asupan lemak serta
kurangnya olah isik.
Diagnosis dan Skrining
/ejumlah studi memperlihatkan bahwa deteksi kanker payudara dan serta terapi dini
dapat meningkatkan harapan hidup dan memberikan pilihan terapi lebih banyak pada
pasien.
Diperkirakan A:D wanita yang terdiagnosis pada tahap awal kanker payudara dapat
bertahan hidup lebih dari lima tahun setelah diagnosis sehingga banyak dokter yang
merekomendasikan agar para wanita menjalani LsadariM !periksa payudara sendiri K
saat menstruasi% di rumah secara rutin dan menyarankan dilakukannya pemeriksaan
rutin tahunan untuk mendeteksi benjolan pada payudara. Pada umumnya, kanker
payudara dideteksi oleh penderita sendiri dan biasanya berupa benjolan yang keras
dan kecil. Pada banyak kasus benjolan ini tidak sakit, tapi beberapa wanita mengalami
kanker yang menimbulkan rasa sakit.
/elain tes isik, mamograi tahunan atau dua kali setahun dan 1/3 khusus payudara
disarankan untuk mendeteksi adanya kelainan pada wanita berusia lanjut dan wanita
berisiko tinggi kanker payudara, sebelum terjadi kanker. 7ika benjolan bisa teraba atau
kelainan terdeteksi saat mamograi, biopsi perlu dilakukan untuk mendapatkan
contoh jaringan guna dilakukan tes di bawah mikroskop dan meneliti kemungkinan
adanya tumor.
7ika terdiagnosis kanker, maka perlu dilakukan serangkaian tes seperti status reseptor
hormon pada jaringan yang terkena.
7enis tes yang baru menyertakan juga tes gen )G@& (human epidermal growth factor
receptor-2) untuk tumor. 3en ini berhubungan dengan pertumbuhan sel kanker yang
agresi. Pasien dikatakan )G@&,positi jika pada tumor ditemukan )G@& dalam
jumlah besar. Kanker dengan )G@&,positi dikenal sebagai bentuk agresi dari kanker
payudara dan memiliki perkiraan perjalanan penyakit yang lebih buruk daripada
pasien dengan )G@&,negati. Diperkirakan satu dari empat sampai lima pasien
dengan kanker payudara tahap akhir memiliki )G@&,positi.
Penatalaksanaan Kanker Payudara
Penatalaksanaan kanker payudara dilakukan dengan serangkaian pengobatan meliputi
pembedahan, kemoterapi, terapi hormon, terapi radiasi dan yang terbaru adalah
terapi imunologi !antibodi%. Pengobatan ini ditujukan untuk memusnahkan kanker
atau membatasi perkembangan penyakit serta menghilangkan gejala,gejalanya.
Keberagaman jenis terapi ini mengharuskan terapi dilakukan secara indi0idual.
Pembedahan
.umor primer biasanya dihilangkan dengan pembedahan. Prosedur pembedahan
yang dilakukan pada pasien kanker payudara tergantung pada tahapan penyakit, jenis
tumor, umur dan kondisi kesehatan pasien secara umum. 2hli bedah dapat
mengangkat tumor !lumpectomy%, mengangkat sebagian payudara yang mengandung
sel kanker atau pengangkatan seluruh payudara !mastectomy%. 1ntuk meningkatkan
harapan hidup, pembedahan biasanya diikuti dengan terapi tambahan seperti radiasi,
hormon atau kemoterapi.
Terapi Radiasi
.erapi radiasi dilakukan dengan sinar,J dengan intensitas tinggi untuk membunuh
sel kanker yang tidak terangkat saat pembedahan.
Terapi Hormon
.erapi hormonal dapat menghambat pertumbuhan tumor yang peka hormon dan
dapat dipakai sebagai terapi pendamping setelah pembedahan atau pada stadium
akhir.
Kemoterapi
*bat kemoterapi digunakan baik pada tahap awal ataupun tahap lanjut penyakit
!tidak dapat lagi dilakukan pembedahan%. *bat kemoterapi bisa digunakan secara
tunggal atau dikombinasikan. /alah satu diantaranya adalah Capecitabine dari @oche,
obat anti kanker oral yang diakti0asi oleh enzim yang ada pada sel kanker, sehingga
hanya menyerang sel kanker saja.
Terapi Imunologik
/ekitar 1:,&:D tumor payudara menunjukkan adanya protein pemicu pertumbuhan
atau )G@& secara berlebihan dan untuk pasien seperti ini, trastuzumab, antibodi yang
secara khusus dirancang untuk menyerang )G@& dan menghambat pertumbuhan
tumor, bisa menjadi pilihan terapi. Pasien sebaiknya juga menjalani tes )G@& untuk
menentukan kelayakan terapi dengan trastuzumab.
Mengobati Pasien Pada Tahap Akhir Penyakit
4anyak obat anti kanker yang telah diteliti untuk membantu :0D pasien yang
mengalami kanker tahap akhir dengan tujuan memperbaiki harapan hidup. 6eskipun
demikian, hanya sedikit yang terbukti mampu memperpanjang harapan hidup pada
pasien, diantaranya adalah kombinasi trastuzumab dengan capecitabine. Cokus terapi
pada kanker tahap akhir bersiat paliati !mengurangi rasa sakit%. Dokter berupaya
untuk memperpanjang serta memperbaiki kualitas hidup pasien melalui terapi
hormon, terapi radiasi dan kemoterapi. Pada pasien kanker payudara dengan )G@&,
positi, trastuzumab memberikan harapan untuk pengobatan kanker payudara yang
dipicu oleh )G@&.
NNNNNhttp"##www.hompedin.org#download#kankerpayudara.pd
INTRODUCTION
4reast 'ancer constitutes a major public health issue globally with o0er 1 million new cases diagnosed
annually, resulting in o0er <00,000 annual deaths and about <.< million women li0ing with the disease. It is
the commonest site speciic malignancy aecting women and the most common cause o cancer mortality
in women worldwide.!1B&%
.here is an international#geographical 0ariation in the incidence o 4reast 'ancer.
Incidence rates are higher in the de0eloped countries than in the de0eloping countries and 7apan.
Incidence rates are also higher in urban areas than in the rural areas.
In 2rica, 4reast 'ancer has o0ertaken cer0ical cancer as the commonest malignancy aecting women
and the incidence rates appear to be rising. !-B<% In 5igeria or e=ample, incidence rate has increased
rom 1-.+K1:.- per 100,000 in the 1A+0s, to --.F per 100,000 in 1AA& and 11F per 100,000 in &001. !:%
.hese increases in incidence are due to changes in the demography, socio,economic parameters,
epidemiologic risk actors, better reporting and awareness o the disease. (hile mortality rates are
declining in the de0eloped world !2mericas, 2ustralia and (estern Gurope% as a result o early
diagnosis, screening, and impro0ed cancer treatment programs, the con0erse is true in the de0eloping
world as well as in eastern and central Gurope.!F,+%
4reast cancer and its treatment constitute a great physical, psychosocial and economic challenge in
resource limited societies as ound in 2rica. .he hallmarks o the disease in 2rica are patients
presenting at ad0anced stage, lack o adeOuate mammography screening programs, preponderance o
younger pre,menopausal patients, and a high morbidity and mortality. !-BF%
.his @e0iew is meant to pro0ide practical guidance or the surgeon working in the de0eloping world.
(e ha0e relied on the 'hapter on 4reast 'ancer by 4land et al in /chwartzMs Principles o /urgery, +th
Gdition. !A%
6aterial which is o interest but not immediately applicable has been placed in smaller print. In the
@ecommendations we ha0e ollowed the principles de0eloped in the 4reast )ealth 3lobal Initiati0e.
!10,1&%
2. HISTORY
4reast cancer is one o the oldest known orms o malignancies. .he earliest known documentation on
breast cancer was the /mith /urgical Papyrus !-000,&:00 4.'.% written in 2rica !Ggypt%. It described
+ cases o tumors or ulcers o the breast that were treated by cauterization, with a tool called 8the ire
drill.8 .he writing says about the disease, 8.here is no treatment.8 2t least one o the described cases is
male. .here were ew other historical reerences to breast cancer until the irst century when 'elsus
recognized the rele0ance o operations or early breast cancer.
In the second century, 3alen inscribed his classical clinical obser0ation" 8(e ha0e oten seen in the
breast a tumor e=actly resembling the animal the crab. 7ust as the crab has legs on both sides o his
body, so in this disease the 0eins e=tending out rom the unnatural growth take the shape o a crab?s
legs. (e ha0e oten cured this disease in its early stages, but ater it has reached a large size, no one has
cured it. In all operations we attempt to e=cise the tumor in a circle where it borders on the healthy
tissue.8!1-%
)alsted and 6eyer reported their operations or the local treatment o breast cancer in 1+A<. 4oth
)alsted and 6eyer ad0ocated complete dissection o a=illary lymph node le0els I to III and remo0al o
pectoral muscle along with the breast. 4y demonstrating locoregional control rates ater radical
resection and pro0iding the irst opportunity or cure, these surgeons established radical mastectomy as
state,o,the,art treatment in the early part o the &0th century. Eater in the century, there was a
transition rom the )alsted radical mastectomy to the modiied radical mastectomy !6@6% as the
surgical procedure most reOuently used or breast cancer. .his procedure maintained the en bloc
dissection o the breast and lymph nodes, but let the pectoralis major muscle intact.
.he recognition in the 1A:0s that breast cancer was oten a systemic disease at presentation shited the
management o primary breast cancer away rom a purely surgical approach to a multidisciplinary one
that uses systemic therapy, surgery and radiation. 2s a result surgery or breast cancer may now be
managed with more conser0ati0e and less locally ablati0e procedures such as lumpectomy. .he past
three decades has witnessed an enormous growth in the knowledge and understanding o the basic
science o the disease especially the genetic and molecular basis o the disease.
3. ANATOMY OF THE BREAST
.he breast is a modiied sweat gland and thereore ectodermal in origin. It is present in all mammals
and becomes particularly prominent in emales as the hallmark o pubertal de0elopment. It lies
cushioned in adipose tissue between the subcutaneous at layer and the supericial pectoral ascia. It
e=tends rom the cla0icle abo0e to the upper border o the rectus sheath below and rom the midline to
the posterior a=illary line. It o0erlies the second to the si=th ribs, the pectoralis major, serratus anterior
and the upper part o the rectus sheath. .he area co0ered is wider than the 0isible protuberant breast.
2n a=illary e=tension o the breast !a=illary tail o /pence% always e=ists and its size is proportional to
the total 0olume o the main breast mass. .he inner0ation o the breast is deri0ed rom the anterior
branches o the intercostal ner0es & through F with the nipple recei0ing its inner0ation rom the <th
intercostal ner0e. .he major blood supply, in order o importance, are the internal mammary branches,
the lateral thoracic, and the thoracodorsal perorating 0essels rom the pectoral branch o the
throacoacrominal branch o the a=illary artery, and small intercostals branches. .he 0enous and
lymphatic drainage parallel the blood supply.
.he glandular tissue consists mainly o epithelium, ibrous stroma, and at. .he breast is organized into
roughly &0 lobular units made up o terminal ducts surrounded by at and ibrous tissues and eerent
ductules. .hese terminal ducts coalesce and drain towards the areola orming the 1:,&0 ducts o the
nipple areolar comple=.
.he lymphatic drainage is primarily to the a=illary nodes !$:D%, di0ided into three le0els by the
Pectoralis minor muscle !le0el I nodes lie lateral, le0el II nodes behind and le0el III nodes medial to the
muscle%. 1sually, but with some e=ceptions, lymphatic drainage is progressi0e through these le0els.
Drainage also occurs to the internal mammary chain o lymph nodes which lie in the intercostal spaces,
the supracla0icular nodes, the opposite breast and a=illa, and to the li0er 0ia the rectus abdominis
muscle.
4. EIDEMIO!O"IC RISK FACTORS#ETIO!O"Y
.he precise etiology o breast cancer is largely unknown, but se0eral risk actors ha0e been identiied.
.able 1 lists the known risk actors.!1<%
.he risk actors include"
A$e% .he incidence o breast cancer increases with age and is rare beore the age o &0 years. .he
breast cancer incidence in 'aucasians is highest at age :0,:A, ater menopause, dropping ater age $0.
In 2rica and 2rican,2mericans the peak age incidence is about one decade less, so that the majority
o the patients are pre, menopausal. (hile numerous theories ha0e been proposed to e=plain this
dierence, including age at menarche, time o irst deli0ery, parity, socio,demographic actors, body
mass inde=, and underlying genetic dierence, none are completely satisactory and more research is
needed in this area.!-,:B1:,1$%
Se&% 4reast 'ancer is 100 times more common in women than in men with male breast cancer
accounting or P1D o all breast cancer cases in the 1nited /tates and 0.1D o cancer mortality in men
!1+,&0%.)owe0er in 2rica this situation may be dierent as rom :,1:D o breast cancer in 1ganda
and Qambia may occur in males.!1+B&1,&<%
"e'$rap()* +ar)a,)'n% 2 wide dierence in age adjusted incidence and mortality or breast cancer
e=ists between dierent countries !up to i0e old%. Cigure 1 shows the dierence which may be
e=plained by en0ironmental and genetic actors.!&:,&+%
H'r-'ne#re$nan*y re.a,ed /a*,'r0% .he role o estrogen in the causation o breast cancer has been
e=tensi0ely studied and the general opinion is that estrogen is the primary stimulant or breast epithelial
prolieration. Cactors that increase e=posure to high or prolonged le0el o estrogen are thereore
associated with an increased risk o de0eloping breast cancer !&A,--%. .hese include early menarche,
late menopause, use o contracepti0es and e=ogenous estrogen, nulliparity and increased age at irst
term pregnancy. Induced abortion and spontaneous abortion do not increase the risk. Prolonged
lactation and breast eeding reduce the risk. 2s the li0ing standard and health care acilities in 2rica
impro0e, it is probable that age at menarche will decrease while that o menopause increases. .he
demands or education and a career may increase the number o women who delay childbearing, ha0e
ewer children, use contracepti0es and breast eed or a shorter time. .hese will likely impact on the
increase in the incidence o breast cancer as 2rican countries meet the minimum de0elopment goals.
re+)'u0 Brea0, D)0ea0e% Indi0iduals who ha0e a prior history o in0asi0e carcinoma or ductal
carcinoma in situ ha0e a 0.:D,1D per year risk o de0eloping a new in0asi0e breast carcinoma.
(omen with atypical ductal or lobular hyperplasia ha0e a our to i0e times higher risk o de0eloping
breast cancer. Prolierati0e lesions without atypia, such as moderate hyperplasia and sclerosing
adenosis, are associated with a slightly increased risk !1.:,&D%. *ther common non,prolierati0e
changes such as palpable cysts, ibroadenomas and duct papillomas are not associated with a
signiicantly increased risk. !-<%
En+)r'-en,a. E&p'0ure0" G=posure to ionizing irradiation increases the risk o de0eloping breast
cancer. G=cess breast cancer has been obser0ed in patients gi0en multiple luoroscopies, radiotherapy
or ankylosing spondylitis, )odgkinMs disease, or enlargement o the thymus gland and in sur0i0ors o
the atomic bombings, painters o radium watch aces and J,ray technicians !&+%. Gn0ironmental
e=posures to organic chlorines and other en0ironmental#synthetic estrogens like cosmetics and
phytoestrogens ound in ood ha0e also been postulated to increase the risk, but so ar there are no
conclusi0e e0idence linking organic chlorines to breast cancer. !-1B-:B-F%
!IFESTY!E RISKS
An,(r'p'-e,r)* )nd)*e0 and p(y0)*a. a*,)+),y" )eight, obesity and high body mass
inde= are risk actors especially in post menopausal women. In pre,menopausal women, obesity and
high body mass inde= has an insigniicant but in0erse relationship to breast cancer risk that is reduced
by physical acti0ity. !-$,-A%
D)e,1 A.*'('. and S-'k)n$% 2lcohol and Diets rich in at especially saturated at raises the risk while
smoking does not appear to aect the risk. !<0,<&%
FAMI!Y HISTORY AND "ENETICS
2 amily history o breast cancer increases a woman?s risk o de0eloping the disease. 2 woman is
considered to be at increased risk i the amily member is a irst degree relation with early age o onset
!P age :0%, i both breasts are in0ol0ed, or i she has multiple primary cancers !such as breast and
o0arian cancer%. (omen with one, two, and three or more irst,degree aected relati0es ha0e an
increased breast cancer risk when compared with women who do not ha0e an aected relati0e !risk
ratios 1.+, &.A and -.A, respecti0ely% !<-% /uch women are recommended to begin breast cancer
screening at an age 10 years younger than the age at which the aected relati0e was diagnosed.
)ereditary breast cancer caused by an underlying inherited gene mutation accounts or a small
proportion !:,10D% o all breast cancers. .he majority is accounted or by & germline mutations
4@'2,1 !:0D% and 4@'2,& !-&D%, which are inherited in an autosomal dominant ashion with
0arying penetrance. .hese tumor suppressor genes are important in the processing o D52 damage and
preser0ation o genomic integrity. 4@'2,1 is located on chromosome 1$O while 4@'2,& is located on
chromosome 1-O. !<<% .hey are most commonly ound in the Guropean 2shkenazi 7ewish population
and their descendants, accounting or their relati0ely high pre0alence in the de0eloped world. In Gurope
and 5orth 2merica, 4@'21 is ound in 0.1D o the general population, compared with &0D in the
2shkenazi 7ewish population and is ound in -D o the unselected breast cancer population and in $0D
o women with inherited early,onset breast cancer. !A% 1p to :0,+$D o women carrying a mutated
4@'21 gene de0elop breast cancer during their lietime. @isks or o0arian and prostate cancers are
also increased in carriers o this mutation. 4@'2& mutations are identiied in 10,&0D o amilies at
high risk or breast and o0arian cancers and in only &.$D o women with early,onset breast cancer. .he
lietime risk o de0eloping breast cancer in emale carriers is &:,-0D. 4@'2& is also a risk actor or
male breast cancerB male carriers ha0e a lietime risk o FD or de0eloping the cancer. 4@'2&
mutations are associated with other types o cancers, such as prostate, pancreatic, allopian tube,
bladder, non,)odgkin lymphoma, and basal cell carcinoma.
@isk management strategies or 4@'2,1 and 4@'2,& carriers include"
9 Prophylactic mastectomy and reconstructionB
9 Prophylactic oophorectomy and hormone replacement therapyB
9 Intensi0e sur0eillance or breast and o0arian cancerB and
9 'hemopre0ention using .amo=ien or ralo=iene !post,menopausal women%
In contrast, less is known about genetic mutations as a cause o breast cancer in the non,'aucasian
population. /tudies that ha0e been done o 2rican,2mericans, whose genetic history includes
'aucasians, ha0e identiied 4@'2,1 and ,& mutations but o a dierent pattern.!1$B<:B<F% In nati0e
2ricans, a wide range o 4@'2,1 and 4@'2,& mutations and seOuence 0ariations ha0e been ound
which are uniOue. .his suggests that there may be signiicant dierences in the genetics o hereditary
breast cancer in 2rica.
A screening of 206 black outh African women with breast cancer re!ealed " common #$CA% mutations& %'(delA) in e*on
2+ ,%',del, in e*on %%+ and ("'2insC in e*on 2022- A second study of the coding regions of #$CA% and #$CA2 genes from
.0 /igerian patients diagnosed with breast cancer before the age of ,0 years re!ealed 2 no!el #$CA% truncating
mutations+ 0%0102 and %.,2ins)3 four #$CA% missense !ariations3 one #$CA2 truncating mutation+ "0",del,+ pre!iously
unreported in anyone of African descent3 and 20 nontruncating !ariants were detected in #$CA2-,( #$CA% and #$CA2
mutations and se4uence !ariations are potentially significant in cases of early-onset breast cancer within Africa- 5owe!er+
only a small portion of the mutations were protein truncating+ fewer than those obser!ed among white women-(<$)
6ther rare genetic changes that account for predisposition to breast cancer include 7i 8raumeni syndrome (9:(" gene
mutation)+ Cowdens syndrome+ :eutz-;eghers and <uir-9orre syndromes+ Ata*ia 9elangiectasia syndrome (caused by the
A9< gene)- (<+-:1) /ew breast cancer susceptibility genes are being reported and they include the C5=>2 or C5>2
gene+ cytochrome :,(0 genes (C?:%A%+ C?:2@6+ C?:%1)+ glutathione -transferase family ()9<%+ )9:%)+ alcohol and
one-carbon metabolism genes (A@5%C and <958$)+ @/A repair genes (2$CC%+ 2$CC"+ =$CC,A2:8) and genes
encoding cell signaling molecules (:$+ =$+ 9/8alpha or 5:.0)- All these factors contribute to a better understanding of
breast cancer risk but the degree of penetrance of these genes are far less than the #$CA% and #$CA2 genes (<-3:1)
RISK ASSESSMENT
/e0eral statistical models are currently in use in 5orth 2merica to predict the risk o breast cancer,
based on the abo0e risk actors identiied in the 2merican 'aucasian population. .he uni0ersal
applicability o these models can not, howe0er be taken or granted as the data on which they rely on
were generated rom predominantly 2merican 'aucasian population and ha0e not been tested or
2rican women !<-B:&B:-%
9he most prominent statistical models are the )ail and the Claus models- )ail and colleagues de!eloped the most
fre4uently used model+ which incorporates age at menarche+ the number of breast biopsies+ age at first li!e birth+ and the
number of first-degree relati!es with breast cancer- Bt predicts the cumulati!e risk of breast cancer according to decade of
life- 9o calculate breast cancer risk with the )ail model+ a womanCs risk factors are translated into an o!erall risk score by
multiplying her relati!e risks from se!eral categories- 9his risk score is then compared to an adDusted population risk of
breast cancer to determine a womanCs indi!idual risk- A software program incorporating the )ail model is a!ailable from
the /ational Cancer Bnstitute at http&AAbcra-nci-nih-go!Abrc-
Claus and colleagues+ using data from the Cancer and teroid 5ormone tudy+ a case-control study of breast cancer+
de!eloped the other fre4uently used risk-assessment model+ which is based on assumptions about the pre!alence of high-
penetrance breast cancer susceptibility genes- Compared with the )ail model+ the Claus model incorporates more
information about family history+ but e*cludes other risk factors- 9he Claus model pro!ides indi!idual estimates of breast
cancer risk according to decade of life based on knowledge of first- and second-degree relati!es with breast cancer and
their age at diagnosis- $isk factors that are less-consistently associated with breast cancer (diet+ use of oral contracepti!es+
lactation)+ or are rare in the general population (radiation e*posure)+ are not included in either the )ail or Claus risk-
assessment models-(:<)
2. ATHO!O"Y
4reast cancers are deri0ed rom the epithelial cells that line the terminal duct lobular unit. 'ancer cells
that remain within the basement membrane o the elements o the terminal duct lobular unit and the
draining duct are classiied as in situ or non,in0asi0e. 2n in0asi0e breast cancer is one in which there is
dissemination o cancer cells outside the basement membrane o the ducts and lobules into the
surrounding adjacent normal tissue.
C.a00)/)*a,)'n '/ r)-ary Brea0, Can*er
N'n)n+a0)+e Ep),(e.)a. Can*er0
Eobular 'arcinoma in situ !E'I/%
Ductal 'arcinoma in situ !D'I/% or intraductal carcinoma" Papillary, cribriorm, solid and
comedo types
In+a0)+e Ep),(e.)a. Can*er0 3per*en,a$e '/ ,',a.4
In0asi0e lobular carcinoma !10,1:%
In0asi0e ductal carcinoma
In0asi0e ductal carcinoma, !5*/% 5ot *therwise /peciied !:0,$0%
.ubular carcinoma !&,-%
6ucinous or colloid carcinoma !&,-%
6edullary carcinoma !:%
In0asi0e cribriorm !1,-%
In0asi0e papillary !1,&%
2denoid cystic carcinoma !1%
6etaplastic carcinoma !1%
Pagets disease !P1%
M)&ed C'nne*,)+e and Ep),(e.)a. Tu-'r0
Phylloides tumors, benign and malignant
'arcinosarcoma
2ngiosarcoma
a$e,50 d)0ea0e o the breast is a rare maniestation o breast cancer characterized by neoplastic cells in
the epidermis o the nipple areolar comple=. It most commonly presents with eczema o the areola,
bleeding, ulceration, and itching o the nipple. .he diagnosis is oten delayed because o the rare nature
o the condition and conusion with other dermatologic conditions. 4ecause o this, it is recommended
that any ulcerated or irritated lesion on the nipple areolar comple= undergo a punch biopsy under local
anesthesia. .here is an associated cancer elsewhere in the breast in up to +0D o cases.
!CIS originates rom the terminal duct lobular units and only de0elops in the emale breast. It is 1&
times more reOuent in white women than in 2rican 2merican women. In0asi0e breast cancer
subseOuently may de0elop in &: to -:D o women with E'I/ o0er their lietime, and may de0elop in
either breast, regardless o which breast harbored the initial ocus o E'I/
DCIS" predominantly seen in the emale breast, it accounts or :D o male breast cancers. .he risk or
in0asi0e breast cancer is increased nearly i0eold in women with D'I/. .he in0asi0e cancers are
obser0ed in the ipsilateral breast, usually in the same Ouadrant as the D'I/ that was originally detected,
suggesting that D'I/ is an anatomic precursor o in0asi0e ductal carcinoma.
Tu-'r "rade
.he degree o dierentiation o the tumor can be graded by these parameters" tubule ormation, nuclear
pleomorphism, and reOuency o mitoses. .hese are scored rom 1 to -. Cor e=ample, a tumor with
many tubules !the cells are more dierentiated, closer to normal breast tissue and thereore less
aggressi0e% would score 1 whereas a tumor with no tubules would score -. .hese 0alues are combined
and con0erted into three groups" grade I !score -,:%, grade II !scores F and $%, and grade III !scores +
and A%. .his deri0ed histological gradeRoten known as the 4loom and @ichardson grade or the /car,
4loom, and @ichardson grade ater the originators o this systemRis an important predictor o both
disease ree and o0erall sur0i0al. !/ee Prognosis%
S,a$)n$
/taging o 'ancer is an attempt to deine characteristics that would reliably deine tumors based on the
e=tent o the disease. It is useul or choosing treatment options, selection o patients and comparing the
outcome o treatment and clinical trials and or prognosticating. In 2rica, where o0er $0D o breast
cancer patients present late, staging o breast cancer patients can pro0ide re0ealing epidemiological
inormation about opportunities or impro0ing breast cancer screening and management.
.he irst staging method or 4reast 'ancer was proposed by /teinthal, a 3erman Physician in 1A0<,
and since then staging method has been e0ol0ing, with the .56 !.umor, 5ode, 6etastasis% method
being uni0ersally adopted by the 1I'' !.he International 1nion 2gainst 'ancer% and the 2merican
7oint 'ommittee on 'ancer !27''%. .ables & and - show the latest .56 staging or 4reast 'ancer
!27'' classiication !Fth edition or re0ision% !::%, which incorporates both clinical inormation and
changes related to the growing use o new technology !e.g., sentinel lymph node biopsy,
immunohistochemical staining, re0erse transcriptase,polymerase chain reaction%. Patients with bilateral
or multicentric breast cancer are staged according to the size o the largest tumor.
6. DIA"NOSIS
1. E&a-)na,)'n" Garly breast cancer causes no symptoms and is usually painless. .he
commonest symptom is a painless lump in the breast. G=amination o the breast should be
done in such a way to show respect or the pri0acy and comort o the patient. 2 systematic
approach to breast e=amination is important. Initial e=amination should start with the
patient in an upright position with careul 0isual inspection o masses, skin and nipple
changes, and asymmetries. Palpation should be done to include all the breast Ouadrants, the
nipple,areola comple=, the a=illary tail and the a=illa. /imple maneu0ers like stretching the
arms high abo0e the head, tensing the pectoralis muscles may help accentuate asymmetries
and dimpling.
*ther less reOuent presenting signs and symptoms o breast cancer include !1% breast
enlargement or asymmetryB !&% nipple changes, retraction, or discharge, including PagetMs
diseaseB !-% ulceration or erythema o the skin o the breast including inlammatory
carcinomaB !<% an a=illary massB and !:% systemic symptoms such as atigue, cough, ascites
or new musculoskeletal discomort.
&. I-a$)n$" 6ammography, Ductography, 1ltrasonography, 6@I are imaging techniOues
useul in the screening and diagnosis o breast cancer.
Ma--'$rap(y is the most useul test to dierentiate between benign and malignant
lesions and is the one that is recommended or breast cancer screening. /peciic
mammography eatures that suggest a diagnosis o a breast cancer include a solid mass with
or without stellate eatures, asymmetric thickening o breast tissues, and clustered
microcalciications 6ammography may also be used to guide inter0entional procedures,
including needle localization and needle biopsy.
2eromammography techni4ues are identical to those of mammography with the e*ception that the image is
recorded on a *erography plate+ which pro!ides a positi!e rather than a negati!e image @etails of the entire
breast and the soft tissues of the chest wall may be recorded with one e*posure-
@uctography and @uctoscopy
<ammary ductoscopy (<@) is a newly de!eloped endoscopic techni4ue that allows direct !isualization and
biopsy e*amination of the mammary ductal epithelium where most cancers originate- Ehen combined with
ductal la!age and cytology + it may re!eal early carcinoma-(:F-:A) 9he primary indication for ductography
is nipple discharge+ particularly when the fluid contains blood- $adiopa4ue contrast media is inDected into
one or more of the maDor ducts and mammography is performed- Bntraductal papillomas are seen as small
filling defects surrounded by contrast media -Cancers may appear as irregular masses or as multiple
intraluminal filling defects-
U.,ra0'n'$rap(y is an important method o resol0ing eOui0ocal mammography indings,
deining cystic masses, and demonstrating the echogenic Oualities o speciic solid
abnormalities. 1ltrasonography is used to guide ine,needle aspiration biopsy, core,needle
biopsy, and needle localization o breast lesions. It is highly reproducible and has a high
patient acceptance rate, but does not reliably detect lesions that are 1 cm or less in diameter
and when used alone is a poor screening test !F0BF1%
<agnetic $esonance Bmaging is a non in!asi!e+ non radiating imaging techni4ue- Bn the process of
e!aluating <$B as a means of characterizing mammography abnormalities+ additional breast lesions ha!e
been detected- 5owe!er+ in the circumstance of both a negati!e mammogram and a negati!e physical
e*amination+ the probability of a breast cancer being diagnosed by <$B is e*tremely low- 9here is current
interest in using <$B to screen the breasts of high-risk women and of women with a newly diagnosed breast
cancer- Bn the first case+ women with a strong family history of breast cancer or who carry known genetic
mutations re4uire screening at an early age+ but mammography e!aluation is limited because of the increased
breast density in younger women- Bn the second case+ a study of <$B of the contralateral breast in women
with a known breast cancer showed a contralateral breast cancer in (-.F of these women- (F&-F<)
.a)n 78ray0 and B'ne S*an are useul in the detection and diagnosis o metastasis
especially to the bones.
6@I, PG., '. /cans and bone scans are not readily a0ailable in most centers in the
de0eloping world, and when a0ailable, the cost o these procedures makes them 0irtually
unrealistic or many o the patients. 1ltrasonography and J,rays are howe0er readily
a0ailable and many patients will end up with these minimal in0estigations and the standard
history and physical e=amination.
-. B)'p0y
Pathologic diagnosis o a breast lesion can be achie0ed using a number o biopsy
techniOues. (ith a larger biopsy sample, greater accuracy and more inormation are
obtained, but this is at the e=pense o increased in0asi0eness. Ideally, needle biopsies
should be perormed ater imaging to help pre0ent distortions o imaging due to hematoma.
.he 0arious needle biopsy techniOues can be di0ided into two groups
1. Cine needle aspiration will pro0ide cytology which will allow a diagnosis o malignant
cells but will not dierentiate between in situ or in0asi0e disease.
&. .issue biopsy or histology which include .ru cut biopsy, 4iopty cut, 6ammotome.
.hese relati0ely larger tissue samples will allow the diagnosis o in0asi0e 0ersus in situ
cancer.
.able < compares the accuracy o needle biopsy techniOues.
Open B)'p0y 3E&*)0)'n 'r In*)0)'n 9)'p0y4 .he ultimate diagnostic biopsy is open biopsy o a lesion,
normally perormed under general or local anesthetic. *pen e=cisional biopsy should be reser0ed or
lesions or which some doubt remains regarding diagnosis ater less in0asi0e assessment or or benign
lesions that the patient wants remo0ed. 2 wide clearance o the lesion is usually not the goal in
diagnostic biopsies, thus a0oiding unnecessary distortion o the breast. It is also useul or e=cision o
mammographic lesions when percutaneous biopsy has ailed or is eOui0ocal. (here rozen section is
a0ailable, open e=cisional biopsy may be perormed at the same time the as deiniti0e breast cancer
surgery. Incisional biopsy is used only in cases where the lesion is 0ery large and a percutaneous biopsy
has been unsuccessul.
:. SCREENIN"
Annua. screening mammography has been demonstrated to reduce breast cancer mortality among
women older than :0 years by &0 ,-AD. .he beneit in younger women is not yet established. Cor
'aucasian women aged <0K<A, the results o @'.s are consistent in showing no beneits at :K$ years
ater entry, a marginal beneit at 10K1& years, and unknown beneit thereater. .his is primarily because
when used as a screening tool, the detection rate per screened indi0idual is lower because o denser
breasts and an o0erall lower incidence. .he contro0ersy o0er the eecti0eness o screening
mammography among younger women !i.e., <0K<A years% has led to 0arying recommendations about
its use or this age group. In patients with high risk actors a yearly mammography assessment rom the
age o <0 years is ad0isable.!F:,F$%. 'onsidering the younger demographic pattern o 4reast 'ancer in
2rica, it is not clear what role screening mammography should ha0e in 2rica.
*ther methods o early breast cancer screening like /el 4reast G=amination and 'linical 4reast
G=amination ha0e not been demonstrated to impro0e mortality in patientsB rather /4G has resulted in
more breast biopsies due to alse positi0e results, more physician 0isits and apprehension in patients
!F+%. It is pertinent to state that most o the studies that e0aluated the role o /4G and '4G ha0e been
done in de0eloped societies where cancers are small at diagnosis and this may not be rele0ant in 2rica
where the majority o patients present late. Incorporation o 4reast 2wareness programs and health
education into the Primary )ealth 'are o 2rican countries may 0ery well be a useul option to allow
or a diagnosis at an earlier stage. 'ultural attitudes play important roles in the acceptance o screening
programs.!FA%
;. TREATMENT
.reatment strategy will depend on the stage o the disease.
In 0),u Brea0, Can*er !DCIS and !CIS%
!CIS% *bser0ation alone with or without tamo=ien is the preerred option or women diagnosed with
E'I/ because their risk o de0eloping in0asi0e carcinoma is relati0ely low !appro=imately &1D o0er
1: years% and is eOual in both breast..!$0% Collow,up o patients with E'I/ includes physical
e=aminations e0ery F to 1& months or : years and then annually. 2nnual diagnostic mammography is
recommended in patients being ollowed with clinical obser0ation.
DCIS" .reatment options or D'I/ are mastectomy, breast,conser0ing surgery !4'/% plus radiotherapy
or 4'/ alone. .he goal o treatment or D'I/ is to reduce local recurrence, because :0D o the time
that D'I/ recurs it recurs as an in0asi0e cancer. Cactors that may modiy treatment are !1% the grade o
the lesion, with higher,grade lesions more likely to recur in a short timeB !&% the youth o the patient,
with many more years at risk or recurrence and !-% the size o the lesion. Cor years the traditional
surgical management o D'I/ was mastectomy, with or without a=illary dissection. 4reast
conser0ation techniOue and irradiation is now a preerred alternati0e where local breast radiation is
a0ailable. *nly small, low grade D'I/ that has been e=cised with a large margin may be considered or
4'/ alone. 2=illary lymph node staging is discouraged in women with apparent pure D'I/. )owe0er,
a small proportion o patients with apparent pure D'I/ will be ound to ha0e in0asi0e cancer at the
time o their deiniti0e surgical procedure which will reOuire a urther a=illary dissection. !$1% 2ddition
o .amo=ien reduces the risk o de0eloping contralateral breast cancer.!$&B$-%. Collow,up o women
with D'I/ includes a physical e=amination e0ery F months or : years and then annually, as well as
yearly diagnostic mammography.
Ear.y Brea0, Can*er !/tages I and II or .1,-50,1 60%"
/taging or metastatic disease is standard or most patients diagnosed with early breast cancer and
include a chest J,ray, bone scan and ultrasound o the abdomen. I negati0e, treatment intent is
curati0e, and in0ol0e modalities that ight the cancer locally !surgery and radiation% and systemically
!chemotherapy and endocrine therapy%.
!'*'8re$)'na. Trea,-en,%
Eocal treatment reOuires the treatment o the entire breast and the a=illary lymph nodes with surgery,
radiation, or a combination o both. /urgery can be breast conser0ation therapy !4'.% and a=illary
staging !/E54 or a=illary dissection% or simple or total mastectomy with a=illary staging !modiied
radical mastectomy%.
.he surgical procedure or the e=cision o the breast in 4'. goes by se0eral names !Partial
mastectomy, tylectomy, segmental resection, Ouadrantectomy or lumpectomy%.
.he goal o breast,conser0ing surgery is to minimize the risk o local recurrence while lea0ing the
patient with a cosmetically acceptable breast. .he selection o 4'. 0ersus mastectomy depends on the
size o the tumor relati0e to the rest o the breast and the a0ailability o radiation. 4'. and breast
radiation together oers eOui0alent sur0i0al to total mastectomy pro0ided the 4'. remo0es the entire
tumor with negati0e margins.
3enerally a tumor less that 1#< o the breast is amenable to 4'.B anything much larger will result in
signiicant breast distortion ater surgery and radiation.
.he procedure can be done saely with local anesthesia and sedation unless a=illary dissection is part o
the procedure. 2 cur0ilinear incision lying parallel to the nipple,areola comple= is made in the skin
o0erlying the breast cancer. @adial scars are a0oided because o poor cosmetic results. /kin
encompassing any prior biopsy site is e=cised, but skin e=cision is not otherwise necessary. .he breast
cancer is remo0ed with an en0elope o normal,appearing breast tissue. 6eticulous hemostasis is
important because a large hematoma distorts the appearance o the breast and makes re,e=cision and
ollow,up more diicult.
.he e=cised specimen is orientated or the pathologist using sutures, clips, or dyes. 2dditional margins
!superior, inerior, medial, lateral, supericial, and deep% can be taken rom the surgical bed to conirm
complete e=cision o the tumor. .hese si= margins are marked with titanic clips as this may help the
@adiotherapist in planning the boost. In addition, it helps the surgeon to do an adeOuate re,resection i
the margins are not ree o cancer cells at deiniti0e parain,embedded histology sections.
2ttempts to re,appro=imate the ca0ity in the breast should be a0oided, because this will usually distort
the breast contour, which may not be apparent when the patient is supine on the operating table.
/imilarly, drains are not used. 2llowing the ca0ity to ill with serum and ibrin maintains contour in the
early postoperati0e period and helps to a0oid deormity. .he procedure is completed with two,layer
closure o the deep dermis and the subcuticular layer, and a light dressing is used.
.here is no irm consensus on the e=tent o the e=cision or margins reOuired. .he main beneit o 4'.
is preser0ation o body image or the woman, which greatly impro0es her Ouality o lie. /e0eral
randomized controlled trials ha0e shown that 4'. and radiation has a similar sur0i0al ad0antage as
mastectomy as there were no signiicant dierences in the two groups in disease,ree sur0i0al, distant,
disease,ree sur0i0al, or o0erall sur0i0al and e0en in loco regional control.!$<,+0%
'ontraindications to breast conser0ation therapy !4'.% can be di0ided into absolute or relati0e.
2bsolute contraindications include lack o mammography acilities to ensure all tumors ha0e been
remo0ed, adeOuate pathology acilities to ensure tumor, ree resection margins and#or lack o
radiotherapy acilities.!10B11% *ther contraindications include pregnancy !irst or second trimester
because o the risk o radiotherapy to the etus%, patientMs preerence, diuse suspicious calciications,
inlammatory breast carcinoma, pre0ious radiation to the region, and inability to achie0e negati0e
margins particularly with e=tensi0e intraductal carcinoma !GI'%. @elati0e contraindications also
include two or more gross tumors !multicentric disease% in dierent Ouadrants, tumor greater than : cm
initially or ater neoadju0ant chemotherapy, large tumor,breast ratio or cosmesis, and collagen
0ascular disease.!$<%
In 2rica, many o the actors abo0e make the practice o 4'. diicult and these include lack o
adeOuate diagnostic oncology ser0ices like mammography and surgical pathology, lack o adeOuate
therapeutic oncology ser0ices like radiotherapy, ad0anced stage disease and poor ollow up culture.!:%
.hus the majority o the patients with early breast cancer in 2rica should still undergo total
mastectomy and a=illary clearance.
In a total or simple mastectomy, the patient is placed in the supine position with the ipsilateral arm
e=tended horizontally. 3eneral anesthesia is used. .he incision is in the orm o an ellipse is designed
to include the skin o0erlying the tumor or biopsy scar and the nippleKareola comple=. /uperior and
inerior skin laps are then raised. .he plane between the subcutaneous tissue and breast tissue is not
always ob0ious and is most easily identiied at the medial superior lapB it is thereore easiest to begin
here. .he skin laps must be thin, to ensure that all the breast tissue is remo0ed, and yet enough
subcutaneous at to ensure adeOuate blood supply to the skin. /uperiorly the dissection must include the
tail o /pence laterally. Ineriorly, the dissection ends at the inramammary old. .he entire breast, the
skin ellipse, nipple,areola comple= are then dissected o the pectoralis ascia. .he procedure is
completed with an en bloc e=cision o the a=illary lymph nodes le0el I and II !see description below%.
.he mastectomy site and a=illary nodal basin are then irrigated with saline solution, and meticulous
hemostasis is achie0ed. .he wound is closed with a closed suction drainage bottle i=ed to a catheter
brought out through a separate stab incision.
<odified radical mastectomy can be done alone or in association with breast reconstruction- $econstruction+ using
implants or myocutaneous flaps+ pro!ides many women with an enhanced body image and self-esteem+ and better
psychosocial adDustment+ but it does not impact on the probability of disease recurrence or sur!i!al- ( +13+&) 6ne method
becoming widely used is the skin-sparing mastectomy (<) that conser!es an e*tensi!e section of skin+ as well as the more
recent skin and nipple-sparing mastectomy that preser!es the nipple-areolar comple*- (+--+:)- < is clearly
contraindicated in patients with direct in!ol!ement of the skin by the underlying tumor- /icotine+ pre!ious radiotherapy+
diabetes and obesity increase the risk of skin en!elope ischemia+ skin necrosis and infection-
5owe!er+ the additional cost of reconstruction is an issue especially in resource poor countries-
Trea,-en, '/ ,(e A&)..a
A&)..ary .y-p( n'de d)00e*,)'n 3A!ND4
.he status o a=illary and internal mammary lymph nodes is the most signiicant prognostic actor or
sur0i0al in patients with breast cancer. In breast cancer, the status o a=illary and internal mammary
lymph nodes is the most signiicant prognostic actor or sur0i0al. .he a=illary nodal basin has been the
main target in lymphatic staging in breast cancer because o0er $:D o the lymphatic low rom the
breast is directed to the ipsilateral a=illa. 2=illary clearance !2E5D% has been the gold standard in
a=illary staging in breast cancer, pro0iding 0aluable inormation about the planning o adju0ant
therapy, prognosis and an e=cellent regional disease control as well. @emo0al o 10 or more nodes as
assessed by the pathologist pro0ides accurate inormation about the a=illary nodal status o the patient.
.he most accepted surgical a=illary clearance procedure is a le0el I and II a=illary dissection, detecting
A+.:D o cases with positi0e a=illary nodes. !+F% Gither at the time o mastectomy, or through a
separate incision !i 4'.%, the lateral border o pectoralis major muscle is identiied. .he cla0ipectoral
ascia, e=tending laterally rom the edge o this muscle, is di0ided parallel to the edge o the muscle to
allow entry into the a=illa. .he superior border o the dissection is the lower border o the a=illary 0einB
dissection abo0e the 0ein runs the risk o damage to the brachial ple=us. .he ner0es to latissimus dorsi
!thoracodorsal% and to serratus !long thoracic% are identiied and are the posterior border o the
dissection. .he lateral border is the loor o the a=illa, consisting o skin and subcutaneous tissue.
@etraction o the pectoralis minor muscle medially allows or the remo0al o le0el II nodes. 2ll the
atty tissue within these borders is remo0ed. .he sensory intercostal brachial ner0e runs through the
a=illa and may or may not be preser0ed.
Sen,)ne. n'de 9)'p0y
2lthough long considered the standard management o the a=illa or breast cancer, 25ED is associated
with signiicant arm morbidity !&0,&:D risk o lymphedema% and risk o damage to the a=illary 0ein,
ner0e to the latissimus dorsi and serratus anterior and hypoesthesia o the arm and the thora=. Cor these
reasons, other less in0asi0e but accurate methods ha0e been sought or a=illary staging in breast cancer,
especially in the de0eloped world, where S o patients present with early node negati0e disease .
'linical e=amination o the a=illa and a0ailable diagnostic imaging techniOues like 1/, '. and PD3,
PG. are maniestly inaccurate or a=illary staging.
Eess in0asi0e than 2E5D, sentinel lymph node biopsy !/E54% is now accepted as an alternati0e to
routine 2E5D or the detection o occult lymph node metastases in patients with clinically node,
negati0e breast cancer. !+$B++% /5ED is based on the obser0ation that speciic areas o the breast drain
by way o aerent lymphatics to a speciic LsentinelM node. .his node can be detected by injecting 0ital
blue dye !isosulan blue dye, methylene blue or patent blue > dye% or a radioacti0e suspension !.cAAm
radioisotope labeled colloids%. .he route o injections include intra parenchymal !peri,tumorally%,
intradermal or subareolar.!++B+A%. .he use o 0ital dye is resource eicient !cheaper and less time
consuming% and saer, but may miss non a=illary sites and also carries the risk o anaphylactic reactions
while radioacti0e agents are more e=pensi0e, carries the risk o e=posure to sta, and reOuires that the
hospital ha0e a nuclear medicine department.
.here are i0e principal aims or the e=cision and histopathological analysis o the /5" !1% minimally
in0asi0e assessment o the nodal statusB !&% selection o patients with positi0e /5s or electi0e lymph
node dissection !GE5D% or adju0ant therapyB !-% pre0ention o lymph node dissection and associated
morbidity in /5 negati0e patientsB !<% detection o aberrant or alternati0e lymphatic drainageB !:%
impro0ement o sensiti0ity o histopathological detection o lymph node metastasis.!A0%
Curther surgery o the a=illary nodes now depends on the results o the sentinel lymph,node biopsyRi
negati0e, 2E5D is a0oided. (hile /E54 is becoming widely used in the de0eloped world as a method
to assess the a=illa, 2E5D remains the recommended management or treatment in any hospital that
does not ha0e access to a nuclear medicine department or a dedicated breast pathologist able to use
specialized immunohistochemistry markers.
Rad)',(erapy )n ear.y 9rea0, *an*er% .he aim o radiotherapy to the whole breast ater 4'. is to
establish local control. 5umerous studies ha0e shown reductions in local recurrences rom 1&,-:D to
&,10D at :,10 years. .his compares to local recurrence rates ater mastectomy o :D.!A1% In most
de0eloped countries, the current standard o care or patients with early,stage breast cancer consists o
breast,conser0ing surgery, ollowed by :KF weeksM postoperati0e radiotherapy used on the whole
breast. Probabilities o adeOuate local control rates and good cosmetic results are high with the use o
con0entional ractionation. Patients who cannot recei0e radiation are treated with mastectomy. /ome
recent papers suggest a small sur0i0al ad0antage which was rather oset by the long term to=icity rom
radiotherapy resulting in deaths rom 0ascular and cardiac injuries.!A&%.
ome data support the effecti!eness of an additional dose applied to the tumor bed (i-e-+ boost irradiation) to reduce local
recurrence- 5owe!er+ deli!ery of the boosting dose raises the rate of morbidity+ which reduces cosmetic outcome-
$ecent ad!ances in radiotherapy includes partial breast irradiation using !arious techni4ues such as such as low or high-
dose rate brachytherapy (interstitially or with an intraca!itary balloon)+ conformal e*ternal-beam irradiation (including
intensity modulated radiotherapy)+ and intraoperati!e radiotherapy (=lectron Bntra 6perati!e 9herapy-=7B69)-(1"31,)
<ost reports of partial breast irradiation ha!e pro!ided results much the same as those achie!ed with con!entional e*ternal
beam+ e!en though some caution is needed until the safety and efficacy of such irradiation ha!e been shown in appropriate
patients and analysis of long-term treatment outcomes-(A:-A$)
Sy0,e-)* Trea,-en,
6ore than hal the women with operable breast cancer who recei0e only locoregional treatment die
rom metastatic disease. .his indicates that breast cancer is a systemic disease and that the
micrometastatic process can occur early e0en independently rom lymphatic spread. !$FBA+% .he way to
impro0e sur0i0al is to gi0e these women systemic medical treatment, including endocrine therapy,
chemotherapy, or targeted therapy with trastuzumab along with surgery#radiotherapy.
/ystemic treatment may be gi0en ater !adju0ant% or beore !neoadju0ant, primary, or preoperati0e%
locoregional treatment. 2dju0ant treatment has been shown to be eecti0e in randomized clinical trials,
whereas the e0aluation o neoadju0ant systemic therapy is ongoing.
It is important to realize, especially in the 2rican conte=t, that any systemic therapy including
hormonal therapies, will at least temporarily interrupt child bearing. .he current recommendations o at
least : years o .amo=ien ater diagnosis will signiicantly impact on the ability o a woman to bear
many children. 'hemotherapy will cause most women to stop menstruating and permanent premature
menopause is common. .hese recommendations listed below, based on the culture o the de0eloped
world, may not be acceptable or applicable to 2rican women.
.he choice o systemic adju0ant therapy in early breast cancer will depend on the ollowing actorsB
estrogen !G@%#progesterone !P@% receptor status, menopausal status and o0er,e=pression o )G@&. It
will also depend signiicantly on the risk o recurrence and thereore the potential beneit o the
treatment. 2ny systemic therapy carries with it a risk o to=icity, and can be Ouite e=pensi0e. 2 woman
at high risk o recurrence will beneit signiicantly rom treatment while or a woman at low risk the
beneit will be small yet she will be e=posed to the same to=icity. Cor e=ample, a &0D reduction with
chemotherapy or a patient with a baseline :0D risk o recurrence will result in an absolute reduction to
10D !rom :0D to <0D% where as a woman with a 10D recurrence risk reduces her risk o recurrence
to +D, only a & D absolute reduction. /ome women would not choose chemotherapy or a &D risk
reduction and others might. .he decision to take systemic therapy thereore is thereore 0ery much
dependent on the woman and her understanding o these risks. !AA%
Ad<u+an, end'*r)ne ,(erapy is eecti0e in G@ and# or P@ positi0e tumors. .he most commonly used
endocrine therapy is the /electi0e Gstrogen @eceptor 6odulator !/G@6% .amo=ien, used in
premenopausal women. *ther /G@6 agents like .oremiene and @alo=iene are eOually eecti0e.
.here is strong e0idence to support the superiority o a : year .amo=ien therapy o0er shorter
durations. .amo=ien in addition helps to maintain bone mineral density in post menopausal women
and reduces the risk o de0eloping cancer in the contralateral breast. .he side eects o .amo=ien
include hot lashes, risk o thrombo,embolic disease, endometrial carcinoma and cataracts.
Cor post,menopausal women, third generation selecti0e aromatase inhibitors ha0e been shown in recent
trials to be more eecti0e than .amo=ien and ha0e become the standard o care. G=amples include non
steroidal type !anastrozole and letrozole% and the steroidal type e=emestane. Patients using aromatase
inhibitors ha0e less gynecological symptoms such as endometrial cancer, 0aginal bleeding, and 0aginal
discharges. Cewer cerebro0ascular e0ents and 0enous thromboembolic e0ents were also obser0ed with
patients recei0ing aromatase inhibitors. )owe0er, musculoskeletal eects !arthritis, arthralgia, and#or
myalgia% and bone to=icity !bone ractures% are associated with aromatase inhibitors.
.he combination o endocrine therapy and cytoto=ic chemotherapy pro0ides beneits greater than the
beneits rom either therapy alone. .hey are thereore usually oered seOuentially, with chemotherapy
gi0en right ater surgery, local radiation therapy is then gi0en, and endocrine therapy commenced.
Premenopausal women are gi0en .amo=ien or i0e years. .he optimal duration o the aromatase
inhibitors has not yet been determined and postmenopausal women remain on them indeinitely.
*0arian ablation !e.g., surgical oophorectomy or radiation ablation% or suppression !e.g., use o the
gonadotropin, releasing hormone or luteinizing hormone,releasing hormone analogues% is another
eecti0e way to reduce estrogen in premenopausal women. It can be used as an adju0ant treatment
alone or to induce menopause in 0ery high risk premenopausal women to allow the use o adju0ant
aromatase inhibitors.
C(e-',(erapy% 'hemotherapy has been shown to substantially impro0e the long,term, relapse,ree,
and o0erall sur0i0al in both premenopausal and postmenopausal women up to age $0 years with lymph
node,positi0e and lymph node,negati0e disease irrespecti0e o the hormone receptor status.
.he administration o polychemotherapy !two or more agents% is superior to the administration o
single agents. Cour to si= courses o treatment !-KF months% appear to pro0ide optimal beneit, with the
administration o additional courses adding to to=icity without substantially impro0ing o0erall
outcome. Popular regimes include '6C !cyclophosphamide, methotre=ate,luorouracil% , '2C, 2',
CG'. 2nthracycline based adju0ant therapy !with do=orubicin or epirubicin% result in a small!<,:D% but
statistically signiicant impro0ement in sur0i0al compared with non,anthracycline,containing regimens.
!100%.
9rials using accelerated or dose dense chemotherapy (two weekly inter!al instead of the standard three weeks) with
granulocyte colony stimulating factor ()C8) support to o!ercome the risk of neutropenic sepsis has been demonstrated to
impro!e both disease free sur!i!al and o!erall sur!i!al with fewer neutropenic crises-
9rials using high dose chemotherapy with haemopoietic stem cell rescue on the other hand showed high morbidity and no
benefit from this approach-
Around 20F of breast cancers o!er e*press 5=$2+ and this is associated with an ad!erse prognosis- 9rastuzumab is a
humanised monoclonal antibody directed against the e*ternal domain of the receptor with clinical acti!ity as a single agent
inpatients whose cancers o!er e*press 5=$2-
9rastuzumab in combination with 9a*anes and other drugs ha!e shown considerable impro!ement in metastastic breast
cancer- Bts role in the adDu!ant setting in early breast cancer has been so successful in 5=$2 positi!e breast cancer showing
significant @8 and 6- Gnfortunately+ the cost implication is a drawback to its use in countries with limited resources-
#isphosphonates are drugs that inhibit osteoclast mediated bone resorption induced by tumors- ome adDu!ant trials
indicate that two years of oral clodronate reduces the incidence of bone metastases- 6ne trial showed a small+ but
significant+ impro!ement in o!erall sur!i!al- 8urther trials are underway with clodronate and the newer+ more potent
bisphosphonate zoledronate to define their long term effecti!eness-
9hey are !ery useful in patients taking Aromatase inhibitors because of the risk of bone loss and fractures-
Ad+an*ed Brea0, Can*er 3S,a$e0 III and I=4%
.his includes Eocally 2d0anced 4reast 'ancer !E24'%, metastastic cancer and recurrent cancer. !see
photos%
Photo 1
Photo &
Photo -
Photo <
Photo :
!ABC"
E24' reers to /tage III tumors according to the .56 staging. Eocally ad0anced breast cancer
!E24'% accounts or at least hal o all breast cancers in countries with limited resources and has a
poor prognosis !1&%. Eocally ad0anced tumors include tumours that present with palpable lymph node
metastases, ulcerations, tumors greater than : cm etc.
2 subtype o E24' that deser0es some urther discussion is Inlammatory 4reast 'ancer !I4'%.
Inlammatory breast cancer is a rare but aggressi0e subtype o breast cancer, which historically was
considered uniormly atal. 'linically, inlammatory breast cancer is characterized by the rapid onset o
breast warmth, erythema, and edema !peau dMorange% oten without a well,deined mass.
2long with e=tensi0e breast in0ol0ement, women with inlammatory carcinoma oten ha0e early
in0ol0ement o the a=illary lymph nodes. In general, women with inlammatory breast cancer present at
a younger age are more likely to ha0e metastatic disease at diagnosis, and ha0e shorter sur0i0al than
women with non,inlammatory breast
cancer.!101,10-%
.he management o E24' reOuires a combined modality treatment approach in0ol0ing surgery,
radiotherapy and systemic therapy.
Rad)',(erapy )n !ABC%
@adiotherapy ater 6@6 or mastectomy to the chest wall or a=illa is restricted to patients with high
risk o recurrence. .hese include tumors larger than : cm in ma=imum diameter and those with our or
more in0ol0ed a=illary lymph nodes, those with positi0e surgical margins on resection, and those with
in0ol0ement o the skin or underlying chest wall. !1&% It can also be a 0ery eecti0e local modality in
controlling or shrinking tumors that are not amenable to surgical therapy.
re'pera,)+e and .'*'re$)'na. ,rea,-en,%
.he initial management should be neoadju0ant chemotherapy with Do=orubicin, or
Gpirubicin,based or Paclita=el, or Doceta=el based chemotherapy. Patients with )G@& positi0e tumors
should be considered or preoperati0e chemotherapy incorporating .rastuzumab.
.he ad0antages o neoadju0ant therapy include down staging o the tumor, impro0ing operability o
tumors and increasing the chances o 4'.
Cor patients that respond to neoadju0ant chemotherapy, the ollowing options are recommended
!$1B10<,10+%" modiied radical mastectomy, radiotherapy to the chest wall and supracla0icular nodes
!plus internal mammary nodes i in0ol0ed% with or without delayed breast reconstruction. In those
women with E24' who do not ha0e access to neoadju0ant chemotherapy because o economic
constraints or radiotherapy, mastectomy with node dissection, when easible, may still be considered in
an attempt to achie0e local,regional control. !1&% .he second option is 4'. with surgical a=illary
staging, radiotherapy to the breast, supracla0icular nodes !plus internal mammary nodes i in0ol0ed%.
)owe0er, or patients who ail to respond to preoperati0e chemotherapy, recommended treatment is to
consider additional systemic chemotherapy and#or preoperati0e
radiation.
Ad<u+an, ,rea,-en,%
'hemotherapy should contain an anthracycline. 2cceptable regimens are F cycles o : Cluorouracil,
Do=orubicin, 'yclophosphamide !C2'% or 'yclophosphamide, Gpirubicin, :Cluorouracil !'GC%.
/eOuential addition o .a=anes has also pro0en 0ery eecti0e.
.amo=ien or : years should be recommended to pre, and postmenopausal women whose tumours are
hormone responsi0e.
2romatase inhibitors like Eetrozole, 2nastozole and G=amestane can be used in post menopausal
patients.
/urgical oophorectomy causing o0arian ablation is a 0ery eecti0e therapy in the treatment o locally
ad0anced and metastatic G@ positi0e breast cancer in premenopausal women. .his therapy is one that
would be 0ery easibly applied in 2rica pro0ided that it was acceptable to the woman.
Me,a0,a0,)* and Re*urren, Can*er
.he standard e0aluation procedure or this group o patients includes history and clinical e=amination,
ull blood count, li0er unction test, platelet count , chest J,ray, limited skeletal sur0ey especially o
any long or weight bearing bones that are painul, biopsy o recurrence, e0aluation o hormone receptor
status, ultrasound o the abdomen or '. where a0ailable.
*thers include bone scans, 6@I, PG., and determination o )G@& status o the tumor. .hese are
howe0er tall orders in countries with limited resources and where there are no medical insurances to
co0er the cost o these in0estigations. Pragmatism is reOuired in this setting.
Trea,-en, '/ !'*a. Re*urren*e
Eocal recurrence can occur in two settingsB post 4'. or 6@6.
Post 6@6 local recurrence should undergo local resection o the recurrence where easible without
unnecessarily endangering the li0es o the patients. In addition, radiotherapy o the in0ol0ed area
should be done i the chest wall was not pre0iously irradiated or i it could be done saely.
Post 4'. patients should undergo a total mastectomy. /ystemic therapy or local recurrence could be
adju0ant chemotherapy or endocrine therapy as in E24'.
Addition of 5yperthermia to radiotherapy has been shown in some trials to cause a statistically significant increase in local
tumor response and greater duration of local control- 9his is howe!er technically demanding and resource intensi!e-
Sy0,e-)* d)0ea0e
/ystemic recurrence and metastatic cancers are incurable, so the goals o therapy are to prolong
sur0i0al, impro0e Ouality o lie with minimal morbidity or to=icity rom the therapy.
6inimally to=ic endocrine therapy is thereore preerred to the use o cytoto=ic therapy whene0er
indicated. Gndocrine therapies are indicated in women with hormone receptor status, bone or sot tissue
disease only and those with limited asymptomatic 0isceral disease. Cor post menopausal women, the
choice is between .amo=ien and aromatase inhibitors, with aromatase inhibitors ha0ing a slight edge
especially in those who ha0e taken anti,estrogen pre0iously.
Cor premenopausal women who are anti,estrogen naT0e, anti,estrogen with or without E)@) agonist is
the preerred choice. *ophorectomy is an e=cellent cheap alternati0e where drugs are not a0ailable.
/ince the majority o 2rican women with breast cancer are hormone receptor negati0e, ew will
beneit rom endocrine therapy, chemotherapy will be the option in most cases.
Premenopausal patients who ha0e taken anti,estrogen pre0iously ha0e a choice o either surgical or
radiotherapeutic oophorectomy or luteinizing hormone,releasing hormone !E)@)% agonists with or
without an antiestrogen.
=ndocrine therapies in postmenopausal women include selecti!e+ nonsteroidal aromatase inhibitors (anastrozole and
letrozole)3 steroidal aromatase inhibitors (e*emestane)3 pure antiestrogens (ful!estrant)3 progestin (megestrol acetate)3
androgens (fluo*ymesterone)3 and high-dose estrogen (ethinyl estradiol)- Bn premenopausal women+ therapies include
75$5 agonists (goserelin and luprolide)3 surgical or radiotherapeutic oophorectomy3 progestin (megestrol acetate)3
androgens (fluo*ymesterone)3 and high-dose estrogen (ethinyl estradiol)-
Chemotherapy is the best option in women with estrogen and progesterone receptor-negati!e tumors+ symptomatic !isceral
metastasis+ or endocrine therapy refractory disease-
9he higher rates of obDecti!e response and longer time to progression of combination chemotherapy are at the e*pense of
increased to*icity with little sur!i!al benefit-
9herefore+ there is no significant ad!antage of combination chemotherapy o!er se4uential single agents-
:referred first-line chemotherapies include se4uential single agents or combination chemotherapy- Among preferred first-
line single agents+ are do*orubicin+ epirubicin+ pegylated liposomal do*orubicin+ paclita*el+ doceta*el+ capecitabine+
!inorelbine (all
category 2A)+ and gemcitabine (category 2#)- Among preferred first-line
combination regimens are cyclophosphamide+ do*orubicin+ and fluorouracil (8ACACA8)3 fluorouracil+ epirubicin+
cyclophosphamide (8=C)3 do*orubicin+ cyclophosphamide (AC)3
epirubicin+ cyclophosphamide (=C)3 do*orubicin in combination with either doceta*el or paclita*el (A9)3
cyclophosphamide+ methotre*ate+ fluorouracil (C<8)3 doceta*el+ capecitabine3 gemcitabine+ paclita*el-
:atients with tumors that are 5=$2-positi!e may deri!e benefit from treatment with trastuzumab as a single agent or in
combination with selected chemotherapeutic agents- 2.F of patients treated with a combination of 9rastuzumab and
do*orubicinAcyclophosphamide chemotherapy de!elop significant cardiac dysfunction making this regime unsafe and
unpopular- !$1)

Trea,-en, '/ C'-p.)*a,)'n0
In 2rica, a good number o women present with ungating# ulcerating masses and many o them are so
ill that they can not undergo surgery or radiotherapy immediately. .he ollowing are some useul
supporti0e measures"
1. Dressing o the wound with honey and metronidazole cleanses and remo0e the odor. .his
measure in addition to the use o neoadju0ant chemotherapy has largely reduced the need
or toilet mastectomy.
&. 'lean malignant ulcers are prone to secondary hemorrhageB topical ormalin is eecti0e
in this setting.
-. Pain is another signiicant problem and this may be due to the disease, therapy or
depression. *ptimal pain management is 0ery crucial to impro0ing the Ouality o lie. I
pain occurs, there should be prompt oral administration o drugs in the ollowing order"
non,opioids !aspirin and paracetamol%B then, as necessary, mild opioids !codeine%B then
strong opioids such as morphine, until the patient is ree o pain. .o calm ears and an=iety,
additional drugs K Uadju0antsV K should be used. .o maintain reedom rom pain, drugs
should be gi0en Uby the clockV, that is e0ery -,F hours, rather than Uon demandV .his three,
step approach !see igure &% o administering the right drug in the right dose at the right
time is ine=pensi0e and +0,A0D eecti0e. /urgical inter0ention on appropriate ner0es may
pro0ide urther pain relie i drugs are not wholly eecti0e.!10A%
<. 2nemia as a result o the disease or chemotherapy is oten under treated and
underestimated in patients. It has a negati0e impact on Ouality o lie and sur0i0al. It will
reOuire blood transusion in some women. .he introduction o recombinant human
erythropoietin !epoetin% has pro0ided an eecti0e and con0enient treatment o anemia
without the risks o blood transusion. Gpoetin is also eecti0e or the pre0ention o anemia
and reduction o transusion reOuirements in patients with a high risk o de0eloping anemia
during chemotherapy.!110,11&%
:. Eymphedema o the arm is a 0ery distressing complication which may occur as a result
o the disease itsel or as a result o surgery or radiotherapy in the treatment
o breast cancer. .reatment options include compression treatments !using compression
bandage or garments and pneumatic compression de0ices%,
therapeutic e=ercises and pharmacotherapy !antibiotics, la0onoids, hyaluronidase, and
selenium%. Diuretics ha0e not been ound useul. !11-B11<%
F. @espiratory distress in ad0anced breast cancer may be as a result o pleural eusion or
deposits in the lungs. 'losed thoracostomy tube drainage with
pleurodesis using .etracycline or 4leomycin is an eecti0e treatment. Eung metastasis can
be treated with steroids inhalers, bronchodilators, diuretics,
an=iolytics, chest physiotherapy and o=ygen.!:%
$. 5eurological complications include cerebral metastases, spinal, leptomeningeal, cranial
and peripheral ner0e metastases.!11:% .reatment includes steroids,
radiotherapy and surgery or localized metastases.
Iounger women with breast cancer are more prone to physical and psychological distress which makes
them ha0e poorer Ouality o lie outcomes. .hese arise as a result o the disease and the complications
o treatment. 3onadal to=icity leading to irregular menses, amenorrhea and premature menopause is
especially disturbing or 2rican patients, the majority o whom are in their reproducti0e age group.
*ther problems like 2lopecia, ertility problems and the cost o treatment may se0erely aect
relationship especially among young couples. In this conte=t, a multi disciplinary approach is important
which will in0ol0e psychologists, social welare#support groups and 0arious ad0ocacy groups where
sur0i0ors o breast cancer can share their e=periences and support one another.!11F,1&0%
>. RO"NOSIS
Na,ura. H)0,'ry" .he natural history o breast cancer in &:0 untreated women re0ealed the ollowing
statisticsB 6edian sur0i0al o untreated breast cancer was &.$ years ater initial diagnosis. .he :, and
10,year sur0i0al rates were 1+.0 and -.FD, respecti0ely. *nly 0.+D sur0i0ed or 1: years or longer.
2utopsy data conirmed that A:D o these women died o breast cancer, while the remaining :D died
o other causes. 2lmost $:D o the women de0eloped ulceration o the breast during the course o the
disease. .he longest sur0i0ing patient died in the nineteenth year ater diagnosis. !1&1%
(ith modern treatment, the :,year sur0i0al rate or stage I patients is A<DB or stage IIa patients, +:DB
and or stage IIb patients, $0D, while or stage IIIa patients the :,year sur0i0al rate is :&DB or stage
IIIb patients, <+DB and or stage I> patients, 1+D.
r'$n'0,)* I)nd)*a,'r0%
Tu-'r 0)?e
Prognosis deteriorates with increasing tumor size, which is an independent predictor o sur0i0al in
node,negati0e patients and correlates with the incidence o nodal metastases.
S,a$)n$
.he status o the a=illary lymph nodes is one o the most useul prognostic indicators or breast cancer,
with a0erage 10,year sur0i0al rates o F0,$0D or node,negati0e patients, dropping to &0,-0D in node,
positi0e patients.
H)0,'pa,('.'$y
9 H)0,'.'$)* ,ype
o 'arcinoma in situ, because it is a prein0asi0e condition, is curable i completely remo0ed,
although 1FD o patients with carcinoma in situ de0elop in0asi0e recurrence ater local
e=cision o ductal carcinoma in situ, usually high grade. /imilarly, 1+D o patients de0elop
in0asi0e recurrence ater lobular carcinoma in situ e=cision.
o (ell,dierentiated in0asi0e cancers ha0e a relati0ely good prognosis i they are tubular,
mucinous, cribriorm, or secretory.
o 6edullary carcinoma is probably o intermediate prognosis, but dierent studies ha0e
used dierent criteria or its deinition.
o In0asi0e ductal and in0asi0e lobular carcinomas ha0e a less a0orable prognosis but are
inluenced hea0ily by other actors.
@ Cy,'.'$)* $rade
o 'ytologic grade is the best predictor o disease prognosis in carcinoma in situ but is
dependent on the grading system used, such as the >an 5uys classiication !high,grade,
low,grade comedo, low,grade noncomedo%.
o .he grading o in0asi0e carcinoma is also important as a prognostic indicator, with higher
grades indicating a worse prognosis. 6icroscopic criteria or grading are shown in .able :.
9 Eympho0ascular" Eymphatic in0asion, 0ascular in0asion, micro0essel Ouantiication, and
lymphoplasmacytic iniltration are associated with a worse prognosis.
9 )ormone receptor status" (ith the aid o gene e=pression studies using D52 microarrays
and immunohistochemistry, se0eral distinct biologic breast cancer subtypes ha0e been
identiied. .hese subtypes dier markedly in prognosis and in the number o potential
therapeutic targets they e=press.
9he intrinsic subtypes include 2 main subtypes of estrogen receptor (=$)Hnegati!e tumors (basal-likeand human epidermal
growth factor receptor-2 positi!eA=$- I5=$2JA=$-K subtype) and at least 2 types of =$L tumors (luminal A and luminal #)-
9he basal like subtype carries poor biologic (worse grade) and clinical prognostic indicators like positi!e a*illary nodes-
9his subtype was found to be more pre!alent in pre-menopausal African HAmerican women compared to post menopausal
African HAmerican women and other races (1&&)9his finding may be one of the reasons why African- American women
with breast cancer ha!e high grade+ late stage tumor and with poor prognosis and poor sur!i!al outcome-
9he similar clinical outcome of nati!e African women with breast cancer may tempt one to e*trapolate these findings seen
in African-American women- 9o lend credence to this fact+ the few studies on hormone receptor status of breast cancer in
nati!e African women show that the maDority of them are =strogen or :rogesterone negati!e (1&--1&:)-
9here are also se!eral other pro!ocati!e parallels between African-American and nati!e African breast cancer patients
which include a younger age distribution and a greater pre!alence of high grade+ estrogen-receptor-negati!e disease
among breast cancer patients in the )hanaian and /igerian populations of western Africa similar to the patterns of breast
cancer reported among African-American women- Eestern African populations ser!ed as the source for most of the sla!e
trade to colonial /orth America+ and therefore share a common ancestry with present-generation African Americans- 9hese
parallels suggest the possible contribution of founder effects-(1F)
5owe!er+ further research needs to be done in this area before reaching any conclusion is reached as the African-
Americans are a heterogeneous group with mi*ed genetic heritage consisting of 5ispanics+ Caucasians and Africans- Bn
addition other socioeconomic factors and en!ironmental factors may contribute to the clinical outcome seen-(1&F31&$)
@ I--un'()0,'*(e-)0,ry
o .he most widely used tests are or the estrogen receptors !G@% and progesterone receptors
!P@%. Immunohistochemistry analysis o heat,treated parain sections has largely
superseded the enzyme,linked immunosorbent assay !GEI/2% ligand,binding assay. G@,
and P@,positi0e status !ie, ;10 mol on GEI/2B ;1: ),score on immunohistochemistry%
predict impro0ed response to endocrine treatment, time to relapse, and o0erall sur0i0al.
o Immunohistochemical positi0ity or c,erb,4& and p:- is associated with a worse
prognosis.
o )G@,& status" .he human epidermal growth actor receptor,& !)G@,&#neu% is a well,
characterized biomarker in the biology o breast carcinoma that has had immediate impact
on clinical medicine. .he positi0e status o )G@,&#neu is associated with a younger age
and se0eral ad0erse prognostic actors, i.e., ad0anced stage, absence o estrogen and
progesterone receptors, metastasis to a=illary lymph nodes, and high nuclear grade. In
addition, women diagnosed with positi0e)G@,&#neu breast carcinoma generally ha0e
relati0e resistance to anthracycline,based chemotherapy, tamo=ien therapy, and ha0e
shorter disease,ree and o0erall sur0i0al. !1&+%
O,(er pr'$n'0,)* )nd)*a,'r0
Ad!ances+ in the knowledge of the molecular mechanisms that influence normal and aberrant cell growth+ ha!e led to the
identification of an increasing number of surrogate biomarkers+ which ha!e been correlated with prognosis or used as
predictors of response to specific treatments- 9hese no!el prognostic markers can be classified as follows&
M 6ncogene products
o #cl-2
o p("
o 5=$-2Aneu
o Cyclin @%
o /m2"
M :roteases
o u:A
o Cathepsin @
o 9enascin C
M <arkers of proliferation - >i-6.
5=$-2Aneu identifies patients with a poor prognosis- 9hese patients are likely to respond to treatment with trastuzumab
(5erceptin)-
9umors positi!e for >i-6. ha!e a high metastatic potential and warrant the possible use of early aggressi!e therapy-
u:A and cathepsin @ identify poor prognosis node-negati!e tumors- Bn these cases+ chemotherapy can be offered-
9he use of gene e*pression profiling to detect breast carcinoma has already shown that the differential e*pression of
specific genes is a more powerful prognostic indicator than traditional determinants such as tumor size and lymph node
status- 9hese molecular assays are awaiting clinical !alidation-
AB. RE=ENTION
/creening as currently practiced can reduce mortality but not incidence, and then only in a particular
age group. 2d0ances in treatment ha0e produced signiicant but modest sur0i0al beneits. 2 better
appreciation o actors important in the etiology o breast cancer would raise the possibility o disease
pre0ention. 'urrently, pre0ention strategies all into two groups" chemopre0ention and surgical
prophyla=is.
C(e-'pre+en,)'n is deined as the systemic use o natural or synthetic chemical agents to re0erse or
suppress the progression o a premalignant lesion to an in0asi0e carcinoma.!1&A%. .amo=ien is
currently the only agent that has been appro0ed clinically or use in women with high risk o
de0eloping cancer. @alo=iene, selenium, retinoids, aromatase inhibitors and cyclo,o=ygenase &
inhibitors reOuire urther clinical in0estigation beore adoption in this conte=t.
Sur$)*a. pr'p(y.a&)0% by either a bilateral mastectomy or oophorectomy, is another a0enue o
pre0ention. /ome studies ha0e demonstrated that women with deinite 4@'21 or 4@'2& mutation
may ha0e an o0erall reduction in their breast cancer risk proile ater such operation.!1-0%
D)e,ary )n,er+en,)'n I speciic dietary actors are ound to be associated with an increased risk o
breast cancer dietary inter0ention will be possible. )owe0er, reduction o dietary intake o such a actor
in whole communities may well be diicult to achie0e without major social and cultural changes.
Dietary at reduction and e=ercise decrease the circulating serum oestradiol le0el, but whether this in
turn leads to a reduction in the incidence o breast carcinoma has not been determined conclusi0ely.
!1-1%
AA. BREAST CANCER AND RE"NANCY
Pregnancy associated breast cancer is deined as breast cancer diagnosed during pregnancy or lactation
or one year post partum. 4reast cancer and pregnancy can be classiied into three main situationsB these
are !a% breast cancer that is detected during the e0olution o pregnancy, !b% breast cancer that is detected
during lactation or postpartum, and !c% pregnancy in patients who ha0e had a pre0ious breast cancer.
'ancer complicates appro=imately 1 per 1000 pregnancies and accounts or one,third o maternal
deaths during gestation. .he pre0alence o breast cancer during pregnancy is increasing due to delayed
onset o childbearing. 4reast cancer is diagnosed in appro=imately 1 in -000 pregnancies. .he
incidence ranges rom 0.$FD to -.+D o breast cancer cases. .he median age o pregnant women
aected with breast cancer is -- years. In a recent re0iew in 5igeria, 1&D o the patients with 4reast
'ancer were pregnant or lactating and $<D were premenopausal , making it the most reOuently
occurring malignancy during pregnancy, along with cancer o the uterine cer0i=.!:% .reatment
decisions or breast cancer patients during pregnancy become most diicult because not only the
mother but also the etus is in0ol0ed. .he inal ad0ice should be based upon the ollowing
considerations" !1% the parentsM decision whether or not to continue with the pregnancy, !&% the period
o pregnancy when the breast cancer is diagnosed, and !-% the stage o the breast cancer.
2 detailed guideline on the management o breast cancer in pregnancy can be ound in the 5''5
'linical Practice 3uidelines in *ncologyW 4reast cancer >.1.&00$ at www.nccn.org.
Garly studies ha0e indicated that the prognosis o breast cancer in pregnancy is 0ery poorB howe0er,
more recent studies with more careul consideration o age and the stage o the disease show no
signiicant dierences. G0idence is lacking that termination o pregnancy changes the outcome o
breast cancer. Pregnancy ater breast cancer does not alter the outcome o treatment. .he ideal inter0al
between treatment or breast cancer and subseOuent pregnancy is unknown. !1-&%
A2. BREAST CANCER IN MA!ES
6ale breast cancer is an uncommon disease although the incidence has increased o0er the past &:
years. Eess than 1D o all breast cancer patients are male. @ates o male breast cancer 0ary widely
between countries" in 1ganda and Qambia the annual incidence rates are :D and 1:D, respecti0ely o
all breast cancer cases. .hese relati0ely high rates ha0e been attributed to endemic inectious diseases
causing li0er damage, leading to hyperestrogenism. 4y contrast, the annual incidence o male breast
cancer in 7apan is less than i0e per million, in parallel with the lower than a0erage incidence o emale
breast cancer in that country. 7ewish men are the only racial group with a higher than a0erage incidence
!&9-#100 000 per year%, irrespecti0e o li0ing in Israel or the 1/2.!1--% @isk actors or 4reast 'ancer
include 3enetic !4@'2&, KlineelterMs syndrome%, Eiestyle !*besity, 2lcohol, Gstrogen intake%, (ork
!)igh ambient temperature, G=haust emissions%, and Disease !.esticular damage, Ei0er damage,
@adiotherapy to chest% .he predominant histological type o disease is in0asi0e ductal, which orms
more than A0D o all male breast tumors.
<uch rarer tumour types include in!asi!e papillomas and medullary lesions- 7obular carcinoma of the male breast has
been reported not only in men with >linefelterNs syndrome+ but also in genotypically normal men with no pre!ious history of
oestrogen e*posure or gynaecomastia- Bn large studies of male breast cancer+ oestrogen receptor positi!ity has been
reported in more than 10F of tumours+ with 12H16F being progesterone-receptor positi!e-
/ome studies suggested that breast cancer has a worse prognosis in men than in women, but i age,
matched and stage,matched breast cancer is compared, there is no dierence between the se=es
!1+B1-<B1-:%
FUTURE TRENDS AND CONTRO=ERSIES
D)a$n'0)0 and ear.y de,e*,)'n%
e!eral new technologies+ apart from mammography are being e!aluated to impro!e the early detection of breast cancer-
9hese include non ionizing imaging techni4ues like Gltrasonography and <$B- 6ther imaging tools being e!aluated
include scintimammography+ positron emission tomography+ magnetic resonance spectroscopy+ optical imaging+ thermo-
acoustic computed tomography+ microwa!e imaging+ 5all effect imaging etc-
M'.e*u.ar ,ar$e,0 and neC dru$0
HER82
:ertuzumab (also known as 2C,+ 6mnitarg) is a new recombinant humanised monoclonal antibody that also binds the
e*tracellular portion of 5=$2+ which causes steric hindrance and impairs receptor dimerisation- 6ngoing phase-B testing
has shown acti!ity in patients with breast cancer that is either 5=$2-negati!e and trastuzumab-refractory 5=$2-positi!e-
Tyr'0)ne k)na0e1 *y*.)ne01 and pr',e'0'-a
<ost tyrosine-kinase inhibitors are in preclinical in!estigations and only a few ha!e been tested in patients with ad!anced
breast cancer- )efitinib is an inhibitor of the tyrosine kinase of human epidermalgrowth-factor receptor (5=$%) and has
shown some antitumour acti!ity in preclinical studies and a phase BB trial of patients hea!ily pretreated for metastatic breast
cancer-
In0u.)n8.)ke $r'C,( /a*,'r 3I"F4
B)8 is an interesting therapeutic target in breast cancer because its ligands and receptors are often o!ere*pressed and are
implicated in proliferation+ transformation+ and metastasis- 9he B)8 system includes ligands B)8-B and B)8-BB+ receptors
B)8-B$ and B)8-BB$+ and si* known B)8-binding proteins- 9hese binding proteins are promising targets for the
manipulation of endocrine responsi!eness and resistance to 9rastuzumab-
An$)'$ene0)0
#e!acizumab is a recombinant+ humanised monoclonal antibody to !ascular endothelial growth factor that has shown some
efficacy when used alone in phase BB clinical trials-
e!eral anti-angiogenic drugs ha!e been tested for efficacy+ including thalidomide+ endostatin+ angiostatin+ G666'+
G%%2,'+ and cyclo-o*ygenase 2 (C62-2) inhibitors- C62-2 also impro!es the efficacy of
Re*ep,'r0 a0 ,ar$e,0 /'r rad)'nu*.)de0
=fficacy of targeted therapy depends on the biologically rele!ant 4uality and 4uantity of the specific compound- 9his
treatment needs to reach the target efficiently and accurately and e*ert a selecti!e therapeutic effect- 9he de!elopment of
biomarkers to assess in-!i!o responses and the ability to use such biomarkers as targets for specific radionuclide treatment
represent great challenges in cancer medicine-
IN SITU AB!ATION
Bn situ ablation of the primary tumour has been suggested as an alternati!e to surgery- 9here are preliminary reports on
methods using cryosurgery+ or coagulating with heat+
deli!ered by a laser fiberoptic techni4ue -
E56 EB77 :=$86$< #$=A9 G$)=$?O
Eithin the ne*t decade the number of patients undergoing a*illary surgery will diminish as a result of impro!ed staging by
sentinel node biopsy- A greater part of the patients will ha!e only breast resection+ and these operations can be performed
as day-case surgery+ e!en under local anaesthesia- 9he surgical challenges during the ne*t decade will be immediate breast
reconstruction and !arious oncoplastic procedures- 9herefore breast surgery will increasingly be performed by plastic
surgeons- )eneral surgeons will not be so interested in carrying out all the other rather undemanding breast procedures-
(1-F)
C'n,r'+er0)e0
%- $ele!ance-
2- 9he place of post mastectomy radiotherapy in early breast cancer especially in women with 9% +92 and one to three
positi!e lymph nodes-
"- e4uencing of post mastectomy radiotherapy and breast reconstruction(1-$)
,- 9he impact of mammographic screening in reduction of mortality in breast cancer
A4. CONC!USION
6anagement o breast cancer is a major challenge in resource limited countries.
Gorts should be geared towards early diagnosis, prompt and standardized treatment to reduce the
burden o ad0anced disease in 2rican women, majority o who are worse hit in the most producti0e
part o their lie time.
*ur knowledge about breast cancer is e0ol0ing, but is still limited with respect to its etiology and
biology, and with respect to its eatures in indi0idual countries and
cultures.
Curther research is needed to understand the role o genetics and en0ironment in the etiology o breast
cancer in 2rica.
A2. RECOMMENDATIONS
In high,resource countries, e0idence,based guidelines outlining optimal approaches to early detection,
diagnosis, and treatment o breast cancer ha0e been deined and
disseminated. .hese guidelines unortunately are not applicable in countries with resource constraints
as they are not economically easible or culturally appropriate.
.he ollowing recommendations might be considered appropriate in the resource,poor countries o
2rica. Collowing the 4reast )ealth 3lobal Initiati0e we ha0e stratiied the recommendations into
Ba0)*1 !)-),ed1 En(an*ed and Ma&)-a.. 31081&D1-+4
De/)n),)'n '/ S,ra,)/)*a,)'n ,er-0
9 Ba0)* .e+e.R'ore resources or undamental ser0ices absolutely necessary or any breast health care
system to unction. 4y deinition, a health care system lacking any basic,le0el resource would be
unable to pro0ide breast cancer care to its patient population. 4asic,le0el ser0ices are typically applied
in a single clinical interaction.
9 !)-),ed .e+e.R/econd,tier resources or ser0ices that produce major impro0ements in outcome, such
as increased sur0i0al, but which are attainable with limited inancial means and modest inrastructure.
Eimited,le0el ser0ices may in0ol0e single or multiple clinical interactions.
9 En(an*ed .e+e.R.hird,tier resources or ser0ices that are optional but important. Gnhanced,le0el
resources may produce minor impro0ements in outcome but increase the number and Ouality o
therapeutic options and patient choice.
9 Ma&)-a. .e+e.R)igh,le0el resources or ser0ices that may be used in some high,resource countries,
but nonetheless should be considered lower priority than those in the basic, limited, or enhanced
categories on the basis o cost or impracticality or limited,resource en0ironments. In order to be
useul, ma=imal,le0el resources typically depend on the e=istence and unctionality o all lower,le0el
resources.
@ecommendations are presented in tabular orm and are reproduced with permission rom the 4)3I.
*ur own recommendations include"
1.Garly Detection and Diagnosis" Possible less resource,intensi0e methods or earlier diagnosis o
breast cancer like education in breast awareness, training in breast sel,e=amination !4/G%, regular
clinical breast e=amination !'4G% by e=perienced personnel and diagnostic ultrasound may be the
option in resource limited countries as mammography screening may be resource intensi0e. !FA%
&. .o impro0e breast pathological capacity and ser0ices in 2rica, the ollowing approaches may be
e=ploredB including training pathologists, establishing pathology ser0ices in centralized acilities, and
organizing international pathology ser0ices. In particular it is important that estrogen and progesterone
receptor status o tumors be identiied.
-. 2s staging is crucial to treatment decisions and prognosis, a thorough clinical e0aluation ater the
diagnosis o breast cancer to check or clinically ob0ious indications o metastases to the lymph nodes
and other areas is crucial. In addition, tests to assess the presence o metastases to the lungs, li0er, and
bone pro0ide 0aluable inormation, i a0ailable. )ormone receptor testing o pathology specimens
should be part o the pathology ser0ices
<. 6ore training or surgeons in 4'. and /entinel node biopsy.
2disa 2deyinka 'harles 6D,C(2'/, CI'/
Director, @esidency .raining Program
2bia /tate 1ni0ersity .eaching )ospital
2ba, 5igeria
2le=andra 6. Gasson, 6/c , 6D , C@'/', C2'/
2ssistant Proessor, Department o /urgery
3eneral /urgery and /urgical *ncology
6ount /inai )ospital and Princess 6argaret )ospital
F10 1ni0ersity 20enue .oronto , *ntario 6:3 &6A
Re/eren*e !)0,
!1% >eronesi 1, 4oyle P, 3oldhirsch 2, *recchia @, >iale 3, >eronesi 1, et al. 4reast cancer.Xsee
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&00&. '2" a 'ancer 7ournal or 'linicians &00: 6arB::!&%"$<,10+.
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incidence in /outh 2rica. X@e0iewY X1F resY. 7ournal o 'linical *ncology &001 /ep 1:B1A!1+
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a re0iew o disease presentation and detection strategies. X@e0iewY X<< resY. Gastern
6editerranean )ealth 7ournal &00- 6ayBA!-%"<<+,F-.
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X$< resY. (est 2rican 7ournal o 6edicine &000 7ulB1A!-%"1$A,A1.
!F% 2desunkanmi 2@, Eawal **, 2delusola K2, Durosimi 62, 2desunkanmi 2@K, Eawal
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!$% )isham 25, Iip '), )isham 25, Iip '). *0er0iew o breast cancer in 6alaysian women"
a problem with late diagnosis. 2sian 7ournal o /urgery &00< 2prB&$!&%"1-0,-.
!+% Parkin D6, 4ray C, Cerlay 7, Pisani P, Parkin D6, 4ray C, et al. 3lobal cancer statistics,
&00&. '2" a 'ancer 7ournal or 'linicians &00: 6arB::!&%"$<,10+.
!A% Kirby I.4land ea. .he 4reast. /chwartz?s Principles o /urgery +th edition. &00$.
@e .ype" 3eneric
!10% 2nderson 4*, /hyyan @, Gniu 2, /mith @2, Iip '), 4ese 5/, et al. 4reast 'ancer in
Eimited,@esource 'ountries" 2n *0er0iew o the 4reast )ealth 3lobal Initiati0e &00:
3uidelines. .he 4reast 7ournal &00FB1&!s1%"/-,/1:.
!11% Gniu 2, 'arlson @(, 2ziz Q, 4ines 7, )ortobagyi 35, 4ese 5/, et al. 4reast 'ancer in
Eimited,@esource 'ountries" .reatment and 2llocation o @esources. .he 4reast 7ournal
&00FB1&!s1%"/-+,/:-.
!1&% @obert (.'arlson 6Z4*26@'62GG6@76@@E6Z66a3/6P. .reatment o 4reast
'ancer in
'ountries with Eimited @esources. .he 4reast 7ournal A, F$,$<. &00-.
@e .ype" 3eneric
!1-% 4reasted 7). .he Gdwin /mith /urgical Papyrus. 'lassics o 6ed Eib. >ol III., <0:. 1A-0.
'hicago, 1ni0ersity o 'hicago Press.
@e .ype" 3eneric
!1<% 6cPherson K, /teel '6, Di=on 76, 6cPherson K, /teel '6, Di=on 76. 24' o breast
diseases. 4reast cancer,epidemiology, risk actors, and genetics.Xsee commentY. X@e0iewY X1F
resY. 467 &000 /ep AB-&1!$&F1%"F&<,+.
!1:% Ijaduola .3, /mith G4, Ijaduola .3, /mith G4. Pattern o breast cancer among white,
2merican, 2rican,2merican, and nonimmigrant west,2rican women. X@e0iewY X<: resY.
7ournal o the 5ational 6edical 2ssociation 1AA+ /epBA0!A%":<$,:1.
!1F% 5ewman E2, 5ewman E2. 4reast cancer in 2rican,2merican women. X@e0iewY X11$
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!1$% Polite 45, *lopade *I, Polite 45, *lopade *I. 4reast cancer and race" a rising tide does
not lit all boats eOually. X@e0iewY X&1 resY. Perspecti0es in 4iology H 6edicine &00:B<+!1
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!1+% Centiman I/, CourOuet 2, )ortobagyi 35, Centiman I/, CourOuet 2, )ortobagyi 35. 6ale
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a case report and re0iew o the literature. X@e0iewY X-A resY. 'hirurgia Italiana &00:
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!&0% (eiss 7@, 6oysich K4, /wede ), (eiss 7@, 6oysich K4, /wede ). Gpidemiology o
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!&1% *kobia 65, *sime 1, *kobia 65, *sime 1. 'linicopathological study o carcinoma o
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!&&% Kidmas 2., 1gwu 4., 6anasseh 25, Iya D, *paluwa 2/, Kidmas 2., et al. 6ale breast
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!&-% /ano D, Dao 4, Eankoande 7, .oure 4, /akande 4, .raore //, et al. X6ale breast cancer in
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!&<% Eoeler I7, Eoeler I7. 6ale breast cancer.XcommentY. 4ritish 7ournal o /urgery 1AA$
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!&:% 4ray C, 6c'arron P, Parkin D6, 4ray C, 6c'arron P, Parkin D6. .he changing global
patterns o emale breast cancer incidence and mortality. X@e0iewY X+: resY. 4reast 'ancer
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!&F% 'olditz 32, 'olditz 32. Gpidemiology and pre0ention o breast cancer. X@e0iewY X<F
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!&$% )ortobagyi 35, de la 3arza /7, Pritchard K, 2madori D, )aidinger @, )udis '2, et al.
.he global breast cancer burden" 0ariations in epidemiology and sur0i0al. X@e0iewY X$+ resY.
'linical 4reast 'ancer &00: DecBF!:%"-A1,<01.
!&+% 6ac6ahon 4, 6ac6ahon 4. Gpidemiology and the causes o breast cancer. X@e0iewY X<F
resY. International 7ournal o 'ancer &00F 6ay 1:B11+!10%"&-$-,+.
!&A% 4asu 2, @owan 43, 4asu 2, @owan 43. 3enes related to estrogen action in reproduction
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!-0% 'olditz 32, 'olditz 32. Gstrogen, estrogen plus progestin therapy, and risk o breast
cancer. X@e0iewY X-A resY. 'linical 'ancer @esearch &00: 7an 1:B11!& Pt &%"A0As,1$s.
!-1% Darbre PD, Darbre PD. Gn0ironmental oestrogens, cosmetics and breast cancer. X@e0iewY
X1:A resY. 4est Practice H @esearch 'linical Gndocrinology H 6etabolism &00F
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!-&% Kristensen >5, /orlie ., 3eisler 7, Eangerod 2, Ioshimura 5, Karesen @, et al. 3ene
e=pression proiling o breast cancer in relation to estrogen receptor status and estrogen,
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!--% *kobia 65, 4unker '), *kobia 65, 4unker '). Gstrogen metabolism and breast cancer
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!-<% /anten @7, 6ansel @, /anten @7, 6ansel @. 4enign breast disorders. X@e0iewY X+A resY.
5ew Gngland 7ournal o 6edicine &00: 7ul &1B-:-!-%"&$:,+:.
!-:% 3ikas PD, 6ansield E, 6okbel K, 3ikas PD, 6ansield E, 6okbel K. Do underarm
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!-F% /ae /, Papineni /, /ae /, Papineni /. .he role o =enoestrogenic compounds in the
de0elopment o breast cancer. X@e0iewY XF$ resY. .rends in Pharmacological /ciences &00F
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!-$% Criedenreich '6, Criedenreich '6. Physical acti0ity and breast cancer risk" the eect o
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!-+% Eorincz 26, /ukumar /, Eorincz 26, /ukumar /. 6olecular links between obesity and
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!-A% Kaur ., Qhang QC, Kaur ., Qhang QC. *besity, breast cancer and the role o
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!<0% Dumitrescu @3, /hields P3, Dumitrescu @3, /hields P3. .he etiology o alcohol,induced
breast cancer. X@e0iewY X&0: resY. 2lcohol &00: 2prB-:!-%"&1-,&:.
!<1% 5agata ', 6izoue ., .anaka K, .suji I, (akai K, Inoue 6, et al. .obacco smoking and
breast cancer risk" an e0aluation based on a systematic re0iew o epidemiological e0idence
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&00F 7unB-F!F%"-+$,A<.
!<&% .subura 2, 1ehara 5, Kiyozuka I, /hikata 5, .subura 2, 1ehara 5, et al. Dietary actors
modiying breast cancer risk and relation to time o intake. X@e0iewY X10+ resY. 7ournal o
6ammary 3land 4iology H 5eoplasia &00: 7anB10!1%"+$,100.
!<-% Dumitrescu @3, 'otarla I, Dumitrescu @3, 'otarla I. 1nderstanding breast cancer risk ,,
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&00: 7anBA!1%"&0+,&1.
!<<% 4uchholz .2, (u J, )ussain 2, .ucker /E, 6ills 34, )aty 4, et al. G0idence o
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International 7ournal o 'ancer &00& Ceb 10BA$!:%"::$,F1.
!<:% 5anda @ /E'/C7/E2Ceal. 3enetic testing in an ethnically di0erse cohort o high,risk
women" a comparati0e analysis o 4@'21 and 4@'2& mutations in 2merican amilies o
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!<F% Kean,'owdin @ /CJEP'.D/Deal. 4@'21 0ariants in a amily study o 2rican,
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X@e0iewY X$A resY. 4reast 'ancer @esearch H .reatment &00: CebB+A!-%"&A$,-0<.
!<A% @ubinstein (/, @ubinstein (/. )ereditary breast cancer in 7ews. X@e0iewY X110 resY.
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!:0% /mith KE, @obson 6G, /mith KE, @obson 6G. 1pdate on hereditary breast cancer.
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!:$% Eeris ', 6okbel K, Eeris ', 6okbel K. .he role o mammary ductoscopy in the
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X@e0iewY X1+ resY. Postgraduate 6edicine 1A-- 7un &0B11+!&%"&$,+.
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!F$% @etsky 6, Demicheli @, )rushesky (, @etsky 6, Demicheli @, )rushesky (. 4reast
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Practice &00: /epB:<!A%"+0-,<.
!FA% /mith @2, 'alei 6, 2lbert 1/, 'hen .)), Duy /(, Cranceschi D, et al. 4reast 'ancer
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&00FB1&!s1%"/1F,/&F.
!$0% 4radley /7 (D4DE. 2lternati0es in the surgical
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!$1% @obert (.'arlson et al. 5''5\ Practice 3uidelines
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!$&% *li0otto I, Ee0ine 6, /teering 'ommittee on 'linical Practice 3uidelines or the 'are and
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3uidelines or the 'are and .reatment o 4reast 'ancer. 'linical practice guidelines or the care
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&001 update%. X@e0iewY X+ resY. '627 'anadian 6edical 2ssociation 7ournal &001 *ct
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!$-% /chwartz 3C, /olin E7, *li0otto I2, Grnster >E, Pressman PI, /chwartz 3C, et al.
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!$F% 3uarneri >, 'onte PC, 3uarneri >, 'onte PC. .he curability o breast cancer and the
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!$+% Cisher 4 2/47eal. .wenty,year ollow,up o
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!$A% >eronesi 1 '56Eeal. .wenty,year ollowup
o a randomized study comparing breast conser0ing surgery with
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!+0% Garly 4reast 'ancer .rialists? 'ollaborati0e 3roup. Gect o
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!+1% .achi 6, Iamada 2, .achi 6, Iamada 2. 'hoice o laps or breast reconstruction.
X@e0iewY X:$ resY. International 7ournal o 'linical *ncology &00: *ctB10!:%"&+A,A$.
!+&% .aylor '(, )organ K, Dodwell D, .aylor '(, )organ K, Dodwell D. *ncological aspects
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!+<% 'hagpar 24, 'hagpar 24. 2d0ances in the management o localized breast cancer" an
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!+:% @ainsbury @6, @ainsbury @6. /kin,sparing mastectomy. X@e0iewY X<+ resY. 4ritish
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!+F% Pickren )( @72)7. 6odiication o con0entional mastectomy" a detailed study o lymph
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!A0% /chulze ., 4embenek 2, /chlag P6, /chulze ., 4embenek 2, /chlag P6. /entinel lymph
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cancer. X@e0iewY X&+ resY. 2nnals o *ncology &00:B1F /uppl &"ii1$0,ii1$-.
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resY. /eminars in @adiation *ncology &00: 2prB1:!&%"$F,+-.
!A<% *recchia @, Euini 2, >eronesi P, 'iocca 6, Cranzetti /, 3atti 3, et al. Glectron
intraoperati0e treatment in patients with early,stage breast cancer" data update. X@e0iewY X<F
resY. G=pert @e0iew o 2nticancer .herapy &00F 2prBF!<%"F0:,11.
!A:% 2rthur D(, 6orris 66, >icini C2, 2rthur D(, 6orris 66, >icini C2. 4reast cancer"
new radiation treatment options. X@e0iewY X&F resY. *ncology !)untington% 1F-F
5o0B1+!1-%"1F&1,A.
!AF% >icini C2, 2rthur D(, >icini C2, 2rthur D(. 4reast brachytherapy" 5orth 2merican
e=perience. X@e0iewY X&+ resY. /eminars in @adiation *ncology &00: 2prB1:!&%"10+,1:.
!A$% Keisch 6G, Keisch 6G. 2ccelerated partial breast irradiation" the case or current use.
X@e0iewY X-1 resY. 4reast 'ancer @esearch &00:B$!-%"10F,A.
!A+% /mith I, 'hua /, /mith I, 'hua /. 6edical treatment o early breast cancer. I" adju0ant
treatment. X@e0iewY X0 resY. 467 &00F 7an $B--&!$:-&%"-<,$.
!AA% KD 6iller 3/. 'hemotherapy or early and ad0anced breast cancer . 'ancer o the 4reast
:th edition, F:A,F+$Glse0ier /cience /t Eouis . &00$. Glse0ier /cience /t Eouis .
@e .ype" 3eneric
!100% /mith I, 'hua /, /mith I, 'hua /. 6edical treatment o early breast cancer. III"
chemotherapy. X@e0iewY X0 resY. 467 &00F 7an &1B--&!$:-<%"1F1,&.
!101% 'ariati 6, nett,4ritton .6, Pinder /G, Purushotham 2D, 'ariati 6, nett,4ritton .6, et
al. 8Inlammatory8 breast cancer. X@e0iewY X+1 resY. /urgical *ncology &00: 5o0B1<!-%"1--,
<-.
!10&% 'ristoanilli 6, 4uzdar 21, )ortobagyi 35, 'ristoanilli 6, 4uzdar 21, )ortobagyi
35. 1pdate on the management o inlammatory breast cancer. X@e0iewY XF1 resY. *ncologist
&00-B+!&%"1<1,+.
!10-% 3iordano /), )ortobagyi 35, 3iordano /), )ortobagyi 35. Inlammatory breast
cancer" clinical progress and the main problems that must be addressed. X@e0iewY X-1 resY.
4reast 'ancer @esearch &00-B:!F%"&+<,+.
!10<% 2pelstaedt 7P, 2pelstaedt 7P. Eocally ad0anced breast cancer in de0eloping countries"
the place o surgery. X@e0iewY XFA resY. (orld 7ournal o /urgery &00- 2ugB&$!+%"A1$,&0.
!10:% /henkier ., (eir E, Ee0ine 6, *li0otto I, (helan ., @eyno E, et al. 'linical practice
guidelines or the care and treatment o breast cancer" 1:. .reatment or women with stage III
or locally ad0anced breast cancer.Xsee commentY. X@e0iewY X$- resY. '627 'anadian 6edical
2ssociation 7ournal &00< 6ar 1FB1$0!F%"A+-,A<.
!10F% 3iordano /), 3iordano /). 1pdate on locally ad0anced breast cancer. X@e0iewY X10:
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!10$% 3iordano /), )ortobagyi 35, 3iordano /), )ortobagyi 35. Inlammatory breast
cancer" clinical progress and the main problems that must be addressed. X@e0iewY X-1 resY.
4reast 'ancer @esearch &00-B:!F%"&+<,+.
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neoadju0ant therapy or breast cancer" the potential and the Ouestions. X@e0iewY XA0 resY.
/urgical 'linics o 5orth 2merica &00- 2ugB+-!<%"A<-,$1.
!10A% (orld )ealth *rganization 3. /ymptom relie in terminal illness. 1AA+.
@e .ype" 3eneric
!110% Eeonard @', 1ntch 6, >on KC, Eeonard @', 1ntch 6, >on Koch C. 6anagement o
anaemia in patients with breast cancer" role o epoetin. X@e0iewY X$- resY. 2nnals o *ncology
&00: 6ayB1F!:%"+1$,&<.
!111% 4arrett,Eee P, 4okemeyer ', 3ascon P, 5ortier 7(, /chneider 6, /chrij0ers D, et al.
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insights based on results rom the Guropean 'ancer 2nemia /ur0ey. *ncologist &00:
*ctB10!A%"$<-,:$.
!11&% /chwartzberg E/, Iee EK, /enecal C6, 'haru >, .omita D, (allace 7, et al. 2
randomized comparison o e0ery,&,week darbepoetin ala and weekly epoetin ala or the
treatment o chemotherapy,induced anemia in patients with breast, lung, or gynecologic cancer.
*ncologist &00<BA!F%"FAF,$0$.
!11-% Kligman E, (ong @K, 7ohnston 6, Eaetsch 5/, Kligman E, (ong @K/, et al. .he
treatment o lymphedema related to breast cancer" a systematic re0iew and e0idence summary.
X@e0iewY X-0 resY. /upporti0e 'are in 'ancer &00< 7unB1&!F%"<&1,-1.
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5o0B+0!11%"1<+0,<.
!11:% (eil @7, Palmieri D', 4ronder 7E, /tark 26, /teeg P/, (eil @7, et al. 4reast cancer
metastasis to the central ner0ous system. X@e0iewY XFA resY. 2merican 7ournal o Pathology
&00: *ctB1F$!<%"A1-,&0.
!11F% Knob 6., Knob 6.. .he inluence o endocrine eects o adju0ant therapy on Ouality
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CebB11!&%"AF,110.
!11$% Gdwards 23, )ailey /, 6a=well 6, Gdwards 23K, )ailey /, 6a=well 6. Psychological
inter0entions or women with metastatic breast cancer.Xsee commentY. X@e0iewY X$1 resY.
'ochrane Database o /ystematic @e0iews &00<B!&%"'D00<&:-.
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467 1AA< Dec 1$B-0A!FAFA%"1F<A,:&.
!11A% 6osher 'G, no,4urg /, 6osher 'G, no,4urg /. 2 re0iew o age dierences in
psychological adjustment to breast cancer. X@e0iewY X:F resY. 7ournal o Psychosocial
*ncology &00:B&-!&,-%"101,1<.
!1&0% (alker E3, Gremin *, (alker E3, Gremin *. Psychological assessment and inter0ention"
uture prospects or women with breast cancer. X@e0iewY X<: resY. /eminars in /urgical
*ncology 1AAF 7anB1&!1%"$F,+-.
!1&1% 4loom )73 @()G. 5atural history o untreated breast cancer !1+0:,1A--%" 'omparison
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4ritish 6edical 7ournal.
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!1&&% Eisa 2.'arey et al. @ace, 4reast 'ancer /ubtypes, and /ur0i0al
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!1&-% 6bonde 6P, 2mir ), /chwartz,2lbiez @, 2kslen E2, Kitinya 75, 6bonde 6P, et al.
G=pression o estrogen and progesterone receptors in carcinomas o the emale breast in
.anzania. *ncology @eports &000 6arB$!&%"&$$,+-.
!1&<% 5yagol 7, 5yong?o 2, 4yakika 4, 6uchiri E, 'occo 6, de /anti 66, et al. @outine
assessment o hormonal receptor and her,&#neu status underscores the need or more therapeutic
targets in Kenyan women with breast cancer. 2nalytical H ]uantitati0e 'ytology H )istology
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!1&F% 'ary 3ross. 5ew @esearch /uggests 2ccess, 3enetic Dierences
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!1&+% 2zadeh ../tark et al. @ace 6odiies the 2ssociation between 4reast
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Positi0e /tatus or )G@,&#neu. 'ancer 10< # 10, &1+A,&1AF. &00:.
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!1&A% )oussami 5, 'uzick 7, Di=on 76, )oussami 5, 'uzick 7, Di=on 76. .he pre0ention,
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!1-0% @./.Prichard 2DK)4DG(6a57*. .he pre0ention o breast cancer. 4ritish 7ournal o
/urgery B " A0, $$&,$+-. &00-.
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6ale breast cancer. X@e0iewY X1<& resY. Eancet &00F Ceb 1+B-F$!A:10%":A:,F0<.
!1-<% 3iordano /), 3iordano /). 2 re0iew o the diagnosis and management o male breast
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!1-:% Krause (, Krause (. 6ale breast cancer,,an andrological disease" risk actors and
diagnosis. X@e0iewY X101 resY. 2ndrologia &00< DecB-F!F%"-<F,:<.
!1-F% 0on /K, 0on /mitten K. /urgical management o breast cancer in the uture. X@e0iewY X&$
resY. 2cta *ncologica &000B-A!-%"<-$,A.
!1-$% 4uchholz .2, /trom G2, Perkins 3), 6c5eese 6D, 4uchholz .2, /trom G2, et al.
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!1-+% 2nderson 4*, Iip '), @amsey /D, 4engoa @, 4raun /, Citch 6, et al. 4reast 'ancer in
Eimited,@esource 'ountries" )ealth 'are /ystems and Public Policy. .he 4reast 7ournal
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Kanker Payudara, Momok bagi Setiap Wanita
Jumat, 29 Sep 2000 17:16:36
Pdperi, Jakarta ! Payudara inda" dambaan #anita$ %amun, tentu a&a de'inii inda" ini men&adi angat re(ati'$
Sebab, tak ada parameter yang menentukan inda" atau tidaknya epaang payudara$ %un ata ega(anya,
)u"an memang men*iptakan tubu" #anita dengan ega(a keinda"annya, erta 'ungi!'unginya yang "akiki$
+egitu pu(a dengan payudara$ ,iana(a" etiap anak manuia menikmati detik!detik pertama -raa. dunia$ /aa
yang dinikmati dari pan*aran air uu ibu$ +egitu tingginya peng"argaan pada air uu ini, e"ingga da(am
ba"aa -u'i. kerap diebut ebagai -ungai ke"idupan.$
%amun terkadang diba(ik keinda"an itu, )u"an menye(ipkan *obaan$ 0roninya, e(ain men&adikan tubu" #anita
tidak menarik, *obaan itu &uga dapat mengakibatkan kematian, e"ingga eringka(i men&adi momok menakutkan
bagi #anita$ 1obaan itu bernama Kanker Payudara$ ,an traginya, pada #anita, 'rekueni Kanker Payudara
ternyata menempati peringkat kedua ete(a" kanker (e"er ra"im 2er3ik4$
Menurut ,r 0dra( ,ar#i, Kepa(a )im Kanker Payudara dan Kanker Ku(it dari /uma" Sakit Kanker ,"armai,
Kanker Payudara ada(a" uatu penyakit neop(ama yang i'atnya gana$ 5a( ini diebabkan pertumbu"an yang
tidak terkenda(i dari e(!e( ke(en&ar uu yang terdiri dari a(uran ke(en&ar uu dan tempat produki air uu$
Penyebabnya, peruba"an truktur genetik dari e( terebut, 'aktor (ingkungan, pri(aku, konumi makanan,
konumi obat!obatan, 3iru, e"ingga pada ak"irnya dapat mengakibatkan kematian bagi penderitanya$
-Penyakit itu bera#a( dari beruba"nya e( norma( men&adi abnorma($ 6ntuk men&adi kanker, terdiri dari tiga
ta"ap$ )a"ap pertama iniiai atau peruba"an di da(am e( itu endiri$ ,a(am ta"ap ini, terkadang e( bia
kemba(i men&adi norma($ %amun e( yang tidak kemba(i norma( ber(an&ut ke ta"ap promoi$ ,i ta"ap promoi ini
ada 'aktor!'aktor pen*etu, mia(nya (emak, inar mata"ari, 'aktor (ingkungan dan ebagainya$ Proe di ta"ap
promoi "ingga men&adi e( kanker memakan #aktu yang *ukup (ama, ini(a" yang diebut ta"ap pro(i'erai.
papar ,r 0dra( yang di temui pdperi$*o$id di kediamannya bi(angan Menteng, Jakarta, Senin 227894$
,r 0dra( menamba"kan, e( kanker terebut akan tumbu" teru dan me(akukan penyebaran ke ke(en&ar geta"
bening regiona( 2ketiak4, (a(u menu&u pembu(u" dara"$ ,engan bantuan pembu(u" dara", e( ber"enti dan
menyebar di a(a" atu organ tubu"$ Mia(nya paru!paru, otak, tu(ang, (e3er atau "ati$ 9kibatnya, &ika 'ungi
organ tubu" tadi beruba", dapat menimbu(kan kematian$
Stadium da(am Kanker Payudara, menurut dokter ke(a"iran Padang 7: ta"un i(am ini, di(i"at dari peni(aian
tingkat k(ini eperti bearnya tumor gana 2kanker4, ada tidaknya ke(en&ar geta" bening di ketiak, dan ada atau
tidaknya penyebaran di organ!organ tubu" yang (ain$ Stadium itu diebut dengan parameter )%M atau )umor,
%odu 2ke(en&ar geta" bening4, dan Metatai 2penyebaran &au"4$
;emak +erkore(ai kuat
+erdaarkan pene(itian ,r 0dra( dan rekan!rekan e&a#atnya dari berbagai diip(in 2Pato(ogi 9natomi,
<pidemo(ogi, =i>i4 ?aku(ta Kedokteran 6ni3erita 0ndoneia erta tim dari Jepang, diketa"ui, mengkonumi
(emak e*ara ber(ebi"an ternyata punya kore(ai kuat pada ter&adinya kanker payudara$ 5a( ini diketa"ui ete(a"
me(akukan pene(itian ter"adap 600 reponden$
?aktor!'aktor riiko tinggi kanker payudara (ainnya ia(a" #anita umur di ata :0 ta"un yang tidak mempunyai
anak, #anita yang mempunyai anak pertama pada umur 37 ta"un, #anita yang tidak ka#in, menar*"e (ebi" dini
2diba#a" 1: ta"un4, menopaue yang (ambat, ri#ayat trauma pada payudara, berat badan renda", *enderung
obeita, "ubungan ke(uarga dengan penderita kanker payudara 2&a(an ibu4, &um(a" ke"ami(an renda", dan
maa menyuui yang ingkat atau tidak menyuui$
-+erdaarkan pene(itian kita, yang pa(ing berpengaru" ada(a" maa(a" makanan tinggi (emak$ ;a(u maa(a"
"ormona( orang yang tidak menyuui, erta orang yang tidak punya anak$ Se(ain itu ada 'aktor keturunan &a(an
ibu, enta" kakak perempuan yang kena Kanker Payudara, atau adik perempuannya, ibu, audara perempuan
ibu, nenek, epupu, riiko mereka yang tumbu" pada ke(uarga yang punya ri#ayat Kanker Payudara ini ada(a"
10 peren,. kata ,r 0dra($
6niknya, ternyata pria pun dapat menderita kanker payudara$ 5a( ini berkaitan dengan 'aktor "ormona($
-Perentae Kanker Payudara pada pria ada(a" atu peren,. u&ar ,r 0dra($ -%a", untuk (aki!(aki "ubungan
antara KP, dipengaru"i o(e" adanya peruba"an metabo(ime "ormona( yaitu eterogen, di mana didapatkan
penurunan etrone dan peningkatan etrio( da(am dara",. u&ar dokter yang &uga men&adi Konu(tan Senior
+eda" @nko(ogi 2payudara, (e"er A kepa(a, ku(it dan &aringan (unak di /S6P% 1iptomangunkuumo erta /S
Kanker ,"armai terebut$
5a( (ain yang &uga unik ada(a", 'aktor riiko Kanker Payudara di tiap!tiap negara angat ber3ariai dan
tergantung dari "ai( pene(itian yang te(a" di(akukan pada popu(ai di tempat terebut$ Mia(nya, 'aktor (emak
tinggi ternyata &uga men&adi penyebab igni'ikan Kanker Payudara bagi beberapa negara yang memang
mayorita mayarakatnya mengkonumi makanan (emak tinggi$ Mia(nya 9merika Serikat, 9utra(ia dan
+e(anda$
Seba(iknya, di 9merika Se(atan dan 9ia, Kanker Payudara mempunyai iniden yang renda"$ ,iperkirakan,
Jepang dan 0ndoneia mempunyai iniden yang renda"$ Wa(au di 0ndoneia inidennya termauk renda",
namun berdaarkan ur3ei ruma" tangga pada beberapa /uma" Sakit dan pen*atatan "ai( pemerikaan
pato(ogi, 'rekueni Kanker Payudara menempati peringkat nomor dua ete(a" kanker (e"er ra"im 2er3ik4$
,apat ,iembu"kan
,r 0dra( ,ar#iPada tadium dini, ebenarnya Kanker Payudara dapat diembu"kan$ Sayangnya, di 0ndoneia,
biaanya penderita datang da(am kondii tadium (an&ut 270 peren4$ 9kibatnya, penanganan Kanker Payudara
"anya berkiar pada tu&uan 3a(iati' atau meringankan ge&a(anya a&a$ 5a( ini(a" yang menyebabkan iniden,
morbidita erta angka kematian 2morta(ita4 mai" tetap tinggi$ Pada"a( &ika ebe(umnya ada upaya
pen*ega"an primer dan deteki dini atau pen*ega"an ekunder, bo(e" &adi angka!angka itu dapat ditekan$
+erdaarkan pene(itian yang di(akukan ,r 0dra( dan rekan!rekan, konep daar pen*ega"an primer ini me(iputi:
B Men*ega" terpaparnya ubtani yang menyebabkan riiko ter&adinya Kanker Payudara, mia(nya meruba"
kebiaaan "idup 2(i'ety(e4 konumi tinggi (emak$
B Menggunakan proteki ter"adap ba"an karinogenik 2tumbu"an gana yang beraa( dari e(!e( epite(4,
mia(nya memakai proteki ter"adap radiai$
B Menggunakan ba"an yang dapat men*ega" proe karinogenik, mia(nya memakai ba"an antipro(i'erati'
untuk men*ega" proe Kanker Payudara, *onto" pemberian )amoCi'en 2preparat antieterogen4$ Pemberian
)amoCi'en ini perna" di(akukan pada 16 ribu #anita e*ara propekti' dan a*ak$
Sementara itu, pen*ega"an ekunder atau diebut &uga krining8deteki dini, dianggap ebagai upaya pa(ing
raiona( untuk menurunkan angka kematian akibat Kanker Payudara$ Pene(itian krining ini di(akukan pertama
ka(i o(e" 5ea(t" 0nuran*e P(an o' =reater %e# Dork ta"un 1963, "ai(nya mampu menurunkan angka kematian
antara 20 "ingga 27 peren pada ke(ompok umur (ebi" dari 70 ta"un$
1ara pemerikaan untuk pe(akanaan krining terdiri dari pemerikaan k(ini payudara o(e" tenaga kee"atan,
mia(nya peia(i beda", dokter umum, pera#at yang ter(ati"$ Pemerikaan payudara endiri 2S9,9/04$
Pemerikaan penun&ang atau mamogra'i$
Mendeteki dini kanker payudara bia di(akukan dengan *ara:
B Pemerikaan payudara endiri 2S9,9/04 e&ak uia 20 ta"un$
B Pemerikaan berka(a o(e" dokter etiap dua "ingga tiga ta"un pada uia 20 "ingga :0 ta"un$
B Pemerikaan berka(a o(e" dokter etiap ta"un ete(a" beruia 37 ta"un$
B Mamogra'i atu "ingga dua ka(i pada uia 37 "ingga :9 ta"un$ 2 mamogra'i E pemerikaan radiodiagnotik
k"uu dengan mempergunakan teknik 'oto -o't tiue. pada payudara$4$
B Mamogra'i etiap ta"un ete(a" beruia 70 ta"un$
Pemerikaan Payudara Sendiri atau S9,9/0 diangap ebagai *ara termura", aman, dan eder"ana$ Meki
demikian pemerikaan ini "aru(a" berdaarkan petun&uk dan pedoman yang te(a" ada$ ,engan S9,9/0, bukan
tidak mungkin akan (ebi" banyak Kanker Payudara tadium dini yang dapat dideteki$ Sayangnya, S9,9/0
diangap mai" be(um e'ekti'$ 5a( ini dikarenakan ketakutan dan ke*emaan da(am meng"adapi kenyataan,
erta mai" edikitnya #anita yang memakai *ara tet ini 2ekitar 17 "ingga 30 peren4$ Se(ain itu pema"aman
S9,9/0 e*ara tekni mai" be(um dikuaai$
9da beberapa tanda kanker payudara dini yaitu:
B +en&o(an dengan bata tidak tega$
B Koniteni kera$
B )idak akit$
B 9da *ekungan pada ku(it di ata tumor$
B 9da bagian ku(it yang ter(i"at eperti ku(it &eruk 2pour dF orange4$
B Koreng dan kemera"an pada ku(it$
B Pembearan geta" bening di ketiak dan di ata tu(ang e(angka$
9ndaipun Kanker Payudara uda" menyerang, berbagai pengobatan dapat ditempu"$ Daitu operai, radiai
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Miteri Kanker Payudara
G Januari 2007
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kau baru ditemukan di berbagai negara berkembang dan kurang (ebi" 372$000 paien meningga( karena
penyakit ini$ Sayangnya ampai aat ini penyebab kanker payudara mai" be(um diketa"ui$
Siapa Sa&a yang /entan /eikoJ
%amun ada beberapa "a( yang dapat meningkatkan reiko kanker payudara, antara (ain uia, ri#ayat
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kanker payudara yang beruia 30!an$ @(e" karena itu &ika 9nda termauk go(ongan yang bereiko tinggi, meki
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temukan ebaiknya egera konu(taikan ke dokter untuk men*ega" "a(!"a( yang tidak diinginkan$ Se(ain itu
per"atikan ku(it payudara, apaka" pembu(u" 3ena!nya emakin ter(i"atJ 9paka" ku(it di ekitar puting men&adi
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per"atikan ukuran dan poii payudara$ +i(a ukurannya menge*i( atau poii yang atu (ebi" renda" daripada
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minta(a" ru&ukan untuk me(akukan mammogram$ Jika ada peruba"an #arna pada payudara, minta pu(a ru&ukan
untuk biopy$ Jika ge&a(a!ge&a(a tetap ada tanpa adanya diagnoa penyebabnya, minta pendapat kedua atau
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Kanker payudara adalah kanker pada jaringan payudara. Ini adalah jenis kanker paling umum yang
diderita kaum wanita. Kaum pria juga dapat terserang kanker payudara, walaupun kemungkinannya
lebih kecil dari 1 di antara 1000. Pengobatan yang paling lazim adalah dengan pembedahan dan jika
perlu dilanjutkan dengan kemoterapi maupun radiasi.
1.1. Deinisi 1.1.1. Kanker adalah suatu kondisi dimana sel telah kehilangan pengendalian dan
mekanisme normalnya, sehingga mengalami pertumbuhan yang tidak normal, cepat dan tidak
terkendali. !http"##www.mediasehat.com#utama0$.php% 1.1.&. Kanker payudara !'arcinoma mammae%
adalah suatu penyakit neoplasma yang ganas yang berasal dari parenchyma. Penyakit ini oleh (ord
)ealth *rganization !()*% dimasukkan ke dalam International 'lassiication o Diseases !I'D%
dengan kode nomor 1$ !http"##www.tempo.co.id#medika#arsip#0+&00&#pus,-.htm%
1.&. Patoisiologi 1.&.1. .ransormasi /el,sel kanker dibentuk dari sel,sel normal dalam suatu proses
rumit yang disebut transormasi, yang terdiri dari tahap inisiasi dan promosi. 1.&.1.1. pada tahap inisiasi
terjadi suatu perubahan dalam bahan genetik sel yang memancing sel menjadi ganas. Perubahan dalam
bahan genetik sel ini disebabkan oleh suatu agen yang disebut karsinogen, yang bisa berupa bahan
kimia, 0irus, radiasi !penyinaran% atau sinar matahari. tetapi tidak semua sel memiliki kepekaan yang
sama terhadap suatu karsinogen. kelainan genetik dalam sel atau bahan lainnya yang disebut promotor,
menyebabkan sel lebih rentan terhadap suatu karsinogen. bahkan gangguan isik menahunpun bisa
membuat sel menjadi lebih peka untuk mengalami suatu keganasan. 1.&.1.&. pada tahap promosi, suatu
sel yang telah mengalami inisiasi akan berubah menjadi ganas. /el yang belum melewati tahap inisiasi
tidak akan terpengaruh oleh promosi. karena itu diperlukan beberapa aktor untuk terjadinya keganasan
!gabungan dari sel yang peka dan suatu karsinogen%. 1.&.&. /tadium /tadium penyakit kanker adalah
suatu keadaan dari hasil penilaian dokter saat mendiagnosis suatu penyakit kanker yang diderita
pasiennya, sudah sejauh manakah tingkat penyebaran kanker tersebut baik ke organ atau jaringan
sekitar maupun penyebaran ketempat jauh /tadium hanya dikenal pada tumor ganas atau kanker dan
tidak ada pada tumor jinak. 1ntuk menentukan suatu stadium, harus dilakukan pemeriksaan klinis dan
ditunjang dengan pemeriksaan penunjang lainnya yaitu histopatologi atau P2, rontgen , 1/3, dan bila
memungkinkan dengan '. /can, scintigrai dll. 4anyak sekali cara untuk menentukan stadium, namun
yang paling banyak dianut saat ini adalah stadium kanker berdasarkan klasiikasi sistim .56 yang
direkomendasikan oleh 1I''!International 1nion 2gainst 'ancer dari ()* atau (orld )ealth
*rganization% # 27''!2merican 7oint 'ommittee *n cancer yang disponsori oleh 2merican 'ancer
/ociety dan 2merican 'ollege o /urgeons%. 1.&.&.1. Pada sistim .56 dinilai tiga aktor utama yaitu
8.8 yaitu .umor size atau ukuran tumor , 858 yaitu 5ode atau kelenjar getah bening regional dan 868
yaitu metastasis atau penyebaran jauh. Ketiga aktor .,5,6 dinilai baik secara klinis sebelum
dilakukan operasi , juga sesudah operasi dan dilakukan pemeriksaan histopatologi !P2% . Pada kanker
payudara, penilaian .56 sebagai berikut "
9 . !.umor size%, ukuran tumor "
. 0 " tidak ditemukan tumor primer
. 1 " ukuran tumor diameter & cm atau kurang
. & " ukuran tumor diameter antara &,: cm
. - " ukuran tumor diameter ; : cm
. < " ukuran tumor berapa saja, tetapi sudah ada penyebaran ke kulit atau dinding dada atau
pada keduanya , dapat berupa borok, edema atau bengkak, kulit payudara kemerahan atau ada
benjolan kecil di kulit di luar tumor utama
9 5 !5ode%, kelenjar getah bening regional !kgb% "
5 0 " tidak terdapat metastasis pada kgb regional di ketiak # aksilla
5 1 " ada metastasis ke kgb aksilla yang masih dapat digerakkan
5 & " ada metastasis ke kgb aksilla yang sulit digerakkan
5 - " ada metastasis ke kgb di atas tulang selangka !supracla0icula% atau pada kgb di mammary
interna di dekat tulang sternum
9 6 !6etastasis% , penyebaran jauh "
6 = " metastasis jauh belum dapat dinilai
6 0 " tidak terdapat metastasis jauh
6 1 " terdapat metastasis jauh
1.&.&.&. /etelah masing,masing aktot .,.5,6 didapatkan, ketiga aktor tersebut kemudian digabung
dan didapatkan stadium kanker sebagai berikut "
/tadium 0 " .0 50 60
/tadium 1 " .1 50 60
/tadium II 2 " .0 51 60 # .1 51 60 # .& 50 60
/tadium II 4 " .& 51 60 # .- 50 60
/tadium III 2 " .0 5& 60 # .1 5& 60 # .& 5& 60 # .- 51 60 # .& 5& 60
/tadium III 4 " .< 50 60 # .< 51 60 # .< 5& 60
/tadium III ' " .iap . 5- 60
/tadium I> " .iap .,.iap 5 ,61
1.-. 3ejala Klinis 3ejala klinis kanker payudara dapat berupa 9 benjolan pada payudara 1mumnya
berupa benjolan yang tidak nyeri pada payudara. 4enjolan itu mula,mula kecil, makin lama makin
besar, lalu melekat pada kulit atau menimbulkan perubahan pada kulit payudara atau pada puting susu.
9 erosi atau eksema puting susu Kulit atau puting susu tadi menjadi tertarik ke dalam !retraksi%,
berwarna merah muda atau kecoklat,coklatan sampai menjadi oedema hingga kulit kelihatan seperti
kulit jeruk !peau d?orange%, mengkerut, atau timbul borok !ulkus% pada payudara. 4orok itu makin lama
makin besar dan mendalam sehingga dapat menghancurkan seluruh payudara, sering berbau busuk, dan
mudah berdarah. 9 pendarahan pada puting susu. 9 @asa sakit atau nyeri pada umumnya baru timbul
kalau tumor sudah besar, sudah timbul borok, atau kalau sudah ada metastase ke tulang,tulang. 9
Kemudian timbul pembesaran kelenjar getah bening di ketiak, bengkak !edema% pada lengan, dan
penyebaran kanker ke seluruh tubuh !)andoyo, 1AA0%. Kanker payudara lanjut sangat mudah dikenali
dengan mengetahui kriteria operbilitas )eagensen sebagai berikut" 9 terdapat edema luas pada kulit
payudara !lebih 1#- luas kulit payudara%B 9 adanya nodul satelit pada kulit payudaraB 9 kanker payudara
jenis mastitis karsinimatosaB 9 terdapat model parasternalB 9 terdapat nodul suprakla0ikulaB 9 adanya
edema lenganB 9 adanya metastase jauhB 9 serta terdapat dua dari tanda,tanda locally ad0anced, yaitu
ulserasi kulit, edema kulit, kulit teriksasi pada dinding toraks, kelenjar getah bening aksila berdiameter
lebih &,: cm, dan kelenjar getah bening aksila melekat satu sama lain
1.<. Caktor @esiko 6enurut 6oningkey dan KodimPenyebab spesiik kanker payudara masih belum
diketahui, tetapi terdapat banyak aktor yang diperkirakan mempunyai pengaruh terhadap terjadinya
kanker payudara diantaranya" 1.<.1. Caktor reproduksi Karakteristik reprodukti yang berhubungan
dengan risiko terjadinya kanker payudara adalah nuliparitas, menarche pada umur muda, menopause
pada umur lebih tua, dan kehamilan pertama pada umur tua. @isiko utama kanker payudara adalah
bertambahnya umur. Diperkirakan, periode antara terjadinya haid pertama dengan umur saat kehamilan
pertama merupakan window o initiation perkembangan kanker payudara. /ecara anatomi dan
ungsional, payudara akan mengalami atroi dengan bertambahnya umur. Kurang dari &:D kanker
payudara terjadi pada masa sebelum menopause sehingga diperkirakan awal terjadinya tumor terjadi
jauh sebelum terjadinya perubahan klinis. 1.<.&. Penggunaan hormon )ormon eksogen berhubungan
dengan terjadinya kanker payudara. Eaporan dari )ar0ard /chool o Public )ealth menyatakan bahwa
terdapat peningkatan kanker payudara yang bermakna pada para pengguna terapi estrogen replacement.
/uatu metaanalisis menyatakan bahwa walaupun tidak terdapat risiko kanker payudara pada pengguna
kontrasepsi oral, wanita yang menggunakan obat ini untuk waktu yang lama mempunyai risiko tinggi
untuk mengalami kanker ini sebelum menopause. 1.<.-. Penyakit ibrokistik Pada wanita dengan
adenosis, ibroadenoma, dan ibrosis, tidak ada peningkatan risiko terjadinya kanker payudara. Pada
hiperplasis dan papiloma, risiko sedikit meningkat 1,: sampai & kali. /edangkan pada hiperplasia
atipik, risiko meningkat hingga : kali. 1.<.<. *besitas .erdapat hubungan yang positi antara berat
badan dan bentuk tubuh dengan kanker payudara pada wanita pasca menopause. >ariasi terhadap
kekerapan kanker ini di negara,negara 4arat dan bukan 4arat serta perubahan kekerapan sesudah
migrasi menunjukkan bahwa terdapat pengaruh diet terhadap terjadinya keganasan ini. 1.<.:. Konsumsi
lemak Konsumsi lemak diperkirakan sebagai suatu aktor risiko terjadinya kanker payudara. (illet
dkk., melakukan studi prospekti selama + tahun tentang konsumsi lemak dan serat dalam hubungannya
dengan risiko kanker payudara pada wanita umur -< sampai :A tahun. 1.<.F. @adiasi Gksposur dengan
radiasi ionisasi selama atau sesudah pubertas meningkatkan terjadinya risiko kanker payudara. Dari
beberapa penelitian yang dilakukan disimpulkan bahwa risiko kanker radiasi berhubungan secara linier
dengan dosis dan umur saat terjadinya eksposur. 1.<.$. @iwayat keluarga dan aktor genetik @iwayat
keluarga merupakan komponen yang penting dalam riwayat penderita yang akan dilaksanakan skrining
untuk kanker payudara. .erdapat peningkatan risiko keganasan ini pada wanita yang keluarganya
menderita kanker payudara. Pada studi genetik ditemukan bahwa kanker payudara berhubungan dengan
gen tertentu. 2pabila terdapat 4@'2 1, yaitu suatu gen suseptibilitas kanker payudara, probabilitas
untuk terjadi kanker payudara sebesar F0D pada umur :0 tahun dan sebesar +:D pada umur $0 tahun.
1.:. Pengobatan Kanker 2da beberapa pengobatan kanker payudara yang penerapannya banyak
tergantung pada stadium klinik penyakit !.jindarbumi, 1AA<%, yaitu" 1.:.1. 6astektomi 6astektomi
adalah operasi pengangkatan payudara. 2da - jenis mastektomi !)irshaut H Pressman, 1AA&%" 1.:.1.1.
6odiied @adical 6astectomy, yaitu operasi pengangkatan seluruh payudara, jaringan payudara di
tulang dada, tulang selangka dan tulang iga, serta benjolan di sekitar ketiak. 1.:.1.&. .otal !/imple%
6astectomy, yaitu operasi pengangkatan seluruh payudara saja, tetapi bukan kelenjar di ketiak. 1.:.1.-.
@adical 6astectomy, yaitu operasi pengangkatan sebagian dari payudara. 4iasanya disebut
lumpectomy, yaitu pengangkatan hanya pada jaringan yang mengandung sel kanker, bukan seluruh
payudara. *perasi ini selalu diikuti dengan pemberian radioterapi. 4iasanya lumpectomy
direkomendasikan pada pasien yang besar tumornya kurang dari & cm dan letaknya di pinggir
payudara. 1.:.&. Penyinaran#radiasi Iang dimaksud radiasi adalah proses penyinaran pada daerah yang
terkena kanker dengan menggunakan sinar J dan sinar gamma yang bertujuan membunuh sel kanker
yang masih tersisa di payudara setelah operasi !Denton, 1AAF%. Gek pengobatan ini tubuh menjadi
lemah, nasu makan berkurang, warna kulit di sekitar payudara menjadi hitam, serta )b dan leukosit
cenderung menurun sebagai akibat dari radiasi. 1.:.-. Kemoterapi Kemoterapi adalah proses pemberian
obat,obatan anti kanker dalam bentuk pil cair atau kapsul atau melalui inus yang bertujuan membunuh
sel kanker. .idak hanya sel kanker pada payudara, tapi juga di seluruh tubuh !Denton, 1AAF%. Gek dari
kemoterapi adalah pasien mengalami mual dan muntah serta rambut rontok karena pengaruh obat,
obatan yang diberikan pada saat kemoterapi.
1.F. /trategi Pencegahan Pada prinsipnya, strategi pencegahan dikelompokkan dalam tiga kelompok
besar, yaitu pencegahan pada lingkungan, pada pejamu, dan milestone. )ampir setiap epidemiolog
sepakat bahwa pencegahan yang paling eekti bagi kejadian penyakit tidak menular adalah promosi
kesehatan dan deteksi dini. 4egitu pula pada kanker payudara, pencegahan yang dilakukan antara lain
berupa" 1.F.1. Pencegahan primer Pencegahan primer pada kanker payudara merupakan salah satu
bentuk promosi kesehatan karena dilakukan pada orang yang 8sehat8 melalui upaya menghindarkan diri
dari keterpaparan pada berbagai aktor risiko dan melaksanakan pola hidup sehat. 1.F.&. Pencegahan
sekunder Pencegahan sekunder dilakukan terhadap indi0idu yang memiliki risiko untuk terkena kanker
payudara. /etiap wanita yang normal dan memiliki siklus haid normal merupakan populasi at risk dari
kanker payudara. Pencegahan sekunder dilakukan dengan melakukan deteksi dini. 4eberapa metode
deteksi dini terus mengalami perkembangan. /krining melalui mammograi diklaim memiliki akurasi
A0D dari semua penderita kanker payudara, tetapi keterpaparan terus,menerus pada mammograi pada
wanita yang sehat merupakan salah satu aktor risiko terjadinya kanker payudara. Karena itu, skrining
dengan mammograi tetap dapat dilaksanakan dengan beberapa pertimbangan antara lain" 9 (anita
yang sudah mencapai usia <0 tahun dianjurkan melakukan cancer risk assessement sur0ey. 9 Pada
wanita dengan aktor risiko mendapat rujukan untuk dilakukan mammograi setiap tahun. 9 (anita
normal mendapat rujukan mammograi setiap & tahun sampai mencapai usia :0 tahun. Coster dan
'onstanta menemukan bahwa kematian oleh kanker payudara lebih sedikit pada wanita yang
melakukan pemeriksaan /2D2@I !Pemeriksaan Payudara /endiri% dibandingkan yang tidak. (alaupun
sensiti0itas /2D2@I untuk mendeteksi kanker payudara hanya &FD, bila dikombinasikan dengan
mammograi maka sensiti0itas mendeteksi secara dini menjadi $:D. 1.F.-. Pencegahan .ertier
Pencegahan tertier biasanya diarahkan pada indi0idu yang telah positi menderita kanker payudara.
Penanganan yang tepat penderita kanker payudara sesuai dengan stadiumnya akan dapat mengurangi
kecatatan dan memperpanjang harapan hidup penderita. Pencegahan tertier ini penting untuk
meningkatkan kualitas hidup penderita serta mencegah komplikasi penyakit dan meneruskan
pengobatan. .indakan pengobatan dapat berupa operasi walaupun tidak berpengaruh banyak terhadap
ketahanan hidup penderita. 4ila kanker telah jauh bermetastasis, dilakukan tindakan kemoterapi dengan
sitostatika. Pada stadium tertentu, pengobatan diberikan hanya berupa simptomatik dan dianjurkan
untuk mencari pengobatan alternati.
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