In China, breast cancer has become one of the most common malignant tumors in women. Although China is a low incidence country for breast cancer, there are obvious urban-rural differences in the incidence of breast cancer, and the high incidence areas are mainly concentrated in large coastal cities. Therefore, in some coastal cities in China, breast cancer is the most common malignant tumor among women.
Etiological studies have found that breast cancer is the result of multiple risk factors both inside and outside the body. The factors that have been identified include: immediate family member with breast cancer, age at menarche <12 years, age at menopause >55 years, age at first birth ≥35 years, not having children, proliferative disease, atypical hyperplasia, and lobular carcinoma in situ. Although most people have recognized the existence of these risk factors, the lack of adequate attention and proper evaluation is still a common problem.
Among the available risk factors for breast cancer, family history is very important. In general, familial breast cancer can be divided into two types: familial breast cancer, which occurs due to alterations in multiple genes, and hereditary breast cancer, which occurs due to a single genetic variant. Current research suggests that only 5-10% of breast cancers are caused by a genetic mutation. The clinical significance of BRCA2 mutation is similar to that of BRCA2, but it is similar to that of ovarian cancer. The clinical significance of BRCA2 mutations is similar to that of BRCA2, but the correlation with ovarian carcinogenesis is not significant. It is important to note that the majority of women with a family history of breast cancer do not have these genetic qualities and thus their risk is much lower than that of those with a clear genetic predisposition.
Benign breast disease is an important risk factor for breast cancer. An increasing number of clinically asymptomatic women are now undergoing breast biopsies for mammographic abnormalities, creating a larger “high risk” group. In fact, the risk of breast cancer is related to the histologic type of benign breast disease, and it is common to use “non-proliferative” and “proliferative” lesions to distinguish the different risks. Histological examination of clinically detectable breast lumps reveals that about 70% of them are non-proliferative lesions, which have been found not to increase the incidence of breast cancer. The relative risk of breast cancer is increased in hyperplastic lesions, especially in those with lobular or ductal atypia, with a relative risk of 4.0-5.0.
Breast self-examination is a voluntary and conscious part of women’s self-care. It has the advantages of being economical, convenient, rarely time-limited, and non-invasive. There is still controversy about the effectiveness of breast self-examination.
Regular clinical examinations are one of the most effective ways to detect breast cancer at an early stage. It has been found that primary tumors are easily detected by the patient herself, while secondary tumors are more likely to be detected by clinical examination or mammography, which is consistent with the higher percentage of secondary tumors that are lymph node negative and non-invasive. Regular clinical physical examinations after breast cancer surgery are generally: 3-6 months interval within 2 years after surgery; 6 months interval 3-5 years after surgery; 1 year interval more than 5 years after surgery. Physical examinations should include the contralateral breast and be combined with an annual mammogram. Regular checkups are also suitable for other groups at high risk of breast cancer, such as women with lobular carcinoma in situ or atypical hyperplasia lesions, women with a significant family genetic predisposition to breast cancer or those with BRCA 1 or 2 gene mutations, and the interval between checkups is usually six months.
The introduction of color Doppler technology has led to a significant improvement in the accuracy of ultrasound diagnosis of breast lumps in recent years. This is especially true for women who have denser breasts.
Numerous studies have confirmed that mammography is currently the most effective method for early detection of breast cancer. In recent years, with the introduction of molybdenum-rhodium dual target X-ray machines, special films and dark boxes, as well as the integration of fully automated exposure and digital imaging technologies, mammography images have become clearer and easier to perform, creating ideal technical conditions for detecting breast cancer. The direct signs of breast cancer on x-ray mainly include mass nodules and microcalcifications. Malignant masses are often irregular, with burred edges and higher density than the surrounding glands. Microcalcifications are of great clinical importance in the early diagnosis of breast cancer. It has been found that about half of the breast cancers that are not detected in breast screening are detected due to the presence of microcalcifications; and 70% of the detection of intraductal breast cancer is attributed to the detection of microcalcifications on X-ray.
It has been reported that magnetic resonancer mammography (MRM) has a higher specificity than mammography in the early diagnosis of breast cancer. Especially with contrast enhancement, MRM is quite accurate in identifying benign and malignant breast masses. In general, the blood vessels around benign breast disease are sparse, whereas breast cancer requires a large blood supply when it grows to about 1 cm. The contrast agent enters the blood circulation and concentrates in the area with abundant blood supply, thus causing malignant lesions to show high signal in MRM images. Although MRM can reduce the false-positive rate of breast cancer diagnosis, it still has many limitations to be used as a screening tool for breast cancer. First, MRM is currently more expensive than mammography; in addition, it requires the injection of contrast into the blood vessels, which is an invasive test and therefore not suitable for mass screening.
Nipple discharge is a not so common but important symptom of breast disease, because early breast cancer can be detected in patients with nipple discharge. In the past, methods such as exfoliative cytology and ductal mammography were used to diagnose patients with nipple discharge who had no clinically detectable masses, with the aim of detecting intraductal carcinoma of the breast, but the diagnostic accuracy was not satisfactory. Breast duct endoscopy is a new method developed since the 1990s to diagnose nipple overflow. It involves the insertion of a 0.4mm or 0.75mm inner diameter lighted catheter from the nipple overflow duct orifice and viewing the inside of the breast ducts through a display screen as far as the fifth or sixth level milk duct branch. Ductal endoscopy allows clear visualization of the breast duct wall and luminal secretions, and images of suspicious lesions can be recorded by video or photographic recording. The advantage of ductal endoscopy over cytology or biochemistry is the ability to accurately localize the lesion, which can lead to biopsy of the lesion for further confirmation. Biopsies can be performed using special endoscopic biopsy tools under direct view of the endoscope; the light source of the endoscope can also be used to mark the location of the lesion on the surface of the body to provide accurate localization for surgical biopsy.
However, endoscopic lactoscopy is only suitable for screening of patients with nipple discharge and cannot be extended in routine screening. Also limited by the length of the ductoscope, endoscopy cannot detect lesions in the distal ducts, thus for patients with clinically non-palpable nipple discharge, endoscopy can be used in combination with smear cytology of the discharge and mammography for early detection and diagnosis of breast cancer.
There is no ideal serum tumor marker for breast cancer. Peripheral blood CA153, CA125 and CEA have been studied in the past, but they are not very sensitive and specific for early breast cancer.
The American Cancer Society (ACS) has established the promotion principles for early detection of breast cancer, it includes: 18-39 years old: monthly breast self-examination and 3-yearly clinical physical examination. 40-49 years old: annual clinical physical examination and mammogram, women at high risk should consult with their doctors whether they need to start screening before 40 years old and the interval of mammogram at 40-49 years old. 50 years old and above. Annual clinical checkup and mammogram and monthly breast self-examination.
Currently, the standardized breast cancer treatment plan includes surgery, chemotherapy, radiotherapy, endocrine therapy, targeted therapy and Chinese herbal medicine and other comprehensive treatment means. Surgery has an obvious place in the local treatment of breast cancer. As the familiarity with the biological behavior of breast cancer continues to advance, over the years, the surgical treatment of breast cancer has undergone radical surgery, extended radical surgery and modified radical surgery to the present day “breast preservation” and “axillary preservation” surgeries, and the surgical treatment model has changed from The surgical treatment paradigm has changed from the “maximum tolerable treatment” to the “minimum effective treatment”, and the treatment results are comparable. Individualized treatment in China also takes into account the patient’s financial situation, the medical facilities and the technical level of the medical unit, and the development of a practical individualized plan to ensure compliance and completeness of treatment. In the case of the United States, breast-conserving surgery is the procedure of choice for early-stage breast cancer, but in rural America, surgeons do not follow the breast-conserving treatment proposed by NSABP and prefer to perform total mastectomy because some patients are unable to complete all the standardized treatments. Chemotherapy, endocrine therapy and biologic targeted therapy are important tools in the systemic treatment of breast cancer.
However, the more treatment the better and the more expensive the better, but the individualized treatment should be arranged according to the patient’s specific conditions, such as the early stage of the disease, whether the lymph nodes are metastatic, age, whether the patient is menopausal, whether the patient is receptor positive or not, and whether the patient is overexpressed Her-2, in order to minimize the recurrence and metastasis and improve the survival rate. This is the only way to minimize recurrence and metastasis, increase survival rate and improve quality of life.
Some physicians simply understand that the use of all kinds of treatment measures is considered comprehensive treatment. In fact, the team spirit of comprehensive treatment should be brought into play, and physicians in surgery, radiotherapy, chemotherapy, pathology and diagnostic imaging should pay attention to the rational design of the overall treatment plan and the organic cooperation among various therapies, so as to break the situation of separate treatment departments and strengthen the overall concept. At present, surgery is still an important tool for breast cancer treatment, as well as for judging prognosis and evaluating efficacy. Surgeons should take up the burden of organizing and coordinating comprehensive breast cancer treatment. Surgery, chemotherapy, radiotherapy, endocrine therapy, and biologic therapy will continue to seek their respective positions and values in the integrated treatment, so that patients can obtain the best treatment results.
The integrated treatment model is based on “evidence-based medicine” and is based on prospective large-scale randomized trials. Medical practice has demonstrated that standardized comprehensive treatment can improve DFS and OS, reduce the extent of surgery, improve outcomes, maintain upper extremity function, and improve quality of life. Immediate breast reconstruction (stage I breast reconstruction) is feasible for patients who are eligible, and is divided into breast reconstruction with implant placement and breast reconstruction with autologous tissue. Recent studies have shown that breast reconstruction does not affect the survival rate of breast cancer, but postoperative radiotherapy will increase the complications of breast reconstruction surgery, such as contracture of the prosthesis envelope, so the immediate breast reconstruction of breast cancer surgery mostly chooses the method of autologous tissue reconstruction.
Among many flap donors, the Transverse Rectus Abdominis Myocutaneous (TRAM) flap is highly valued because of its abundant tissue volume, stable and reliable blood supply, and concealed donor scar. The Deep Inferior Epigastric Perforator (DIEP) is a development based on the free TRAM and is more commonly used in larger medical centers in Europe and the United States. If less breast tissue is removed, the breast can also be reconstructed using a nearby latissimus dorsi muscle flap. Endocrine therapy is indicated for patients with positive ER and/or PR and is not usually used in conjunction with chemotherapy. Tamoxifen (TAM) is a widely used endocrine therapy for premenopausal and postmenopausal patients for 5 to 10 years; however, long-term use may increase the incidence of side effects such as thromboembolism and endometrial cancer.
In recent years a new generation of aromatase inhibitors anastrozole (anastrozole, Reninde), letrozole, and exemestane have entered the clinic, challenging TAM. The results of prospective randomized trials have shown that adjuvant endocrine therapy for postmenopausal receptor-positive early-stage breast cancer with aromatase inhibitors is superior to TAM, and postoperative adjuvant endocrine therapy can be an alternative to chemotherapy for postmenopausal receptor-positive breast cancer with tumors <2 cm, grade I cell differentiation, and no metastasis in lymph nodes. Since endocrine therapy has fewer side effects, is convenient to take, and has definite efficacy, it has a broad space for development in the comprehensive treatment of breast cancer.
Herceptin (Herceptin) is an anti-HER2 (c-erbB-2) monoclonal antibody that acts on the HER2-Neu surface protein of breast cancer cells, interfering with the biological behavior of cancer cells and inhibiting their growth. biologic behavior and inhibit the proliferation of cancer cells. Biologically targeted therapies are expected to advance the development of comprehensive breast cancer treatment. The rapid development of molecular biology of breast cancer has gradually revealed the biological characteristics of tumors and promoted the development of comprehensive breast cancer treatment. Molecular targeted therapy is a new anti-tumor modality that acts on multiple links, and its high specificity of treatment and low toxic side effects may become the most promising tumor treatment in the future.