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Source: Michaud LB, Barnett CM, Esteva FJ. Breast Cancer. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th edition. http://accesspharmacy.com/content.aspx?aid=8007809. Accessed July 30, 2012

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  • Malignancy originating from breast tissue

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  • Not completely understood
  • Current evidence supports concept of carcinogenesis as genetically regulated, multistage process.

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  • Carcinogenesis includes initiation, promotion, conversion, and progression.
  • Growth of normal and cancerous cells genetically controlled by balance or imbalance of oncogene, proto-oncogene, and tumor suppressor gene protein products.
    • Multiple genetic mutations required to convert normal cells to cancerous cells.
  • Breast cancer cells often spread undetected by contiguity, lymph channels, and through blood early in course of disease, resulting in metastatic disease after local therapy.
    • Most common metastatic sites:
      • Lymph nodes
      • Skin
      • Bone
      • Liver
      • Lungs
      • Brain

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  • Most common type of cancer
  • Female gender and increasing age 2 variables most strongly associated with occurrence of breast cancer.
    • Median age at diagnosis: between 60 and 65 years of age.
    • Male gender is poor prognostic factor.

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  • Screening programs to detect cancers in asymptomatic women at risk:
    • Breast self-examination
    • Routine screening mammography
  • Pharmacologic risk reduction of breast cancer
    • Selective estrogen receptor modulators (SERMs)
      • Tamoxifen and raloxifene reduce rates of invasive breast cancer in women at high risk.
      • Rates of endometrial cancer and deep vein thromboses higher with tamoxifen.
      • Overall quality of life is similar between two agents.
    • Retinoids
    • Aromatase inhibitors

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  • Endocrine:
    • Early menarche
    • Nulliparity
    • Late age at first birth
    • Hormone replacement therapy
  • Genetic
    • Personal and family history
    • Mutations of tumor suppresser genes [BRCA1 and BRCA2]
  • Environmental (e.g., radiation exposure)
  • See National Cancer Institute risk calculator for interactive risk assessment of multiple factors.

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  • Patients may not have any symptoms; detected in asymptomatic patients through routine screening mammography

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Signs and Symptoms

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  • Painless, palpable lump most common.
  • Less common:
    • Pain
    • Nipple discharge, retraction, or dimpling
    • Skin edema, redness, or warmth
  • Palpable local-regional lymph nodes
  • Systemic metastases symptoms depend on site:
    • Bone pain
    • Difficulty breathing
    • Abdominal pain or enlargement
    • Jaundice
    • Mental status changes

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Means of Confirmation and Diagnosis

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  • Breast biopsy: Core-needle biopsy offers more definitive histologic diagnosis.

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Laboratory Tests

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  • Tumor markers
    • Cancer antigen (CA 27,29)
    • Carcino-embryonic antigen (CEA)
  • Alkaline phosphatase or liver function tests may be elevated in metastatic disease.

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Imaging

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  • Mammography, with or without ultrasound, breast MRI, or both
  • Chest x-ray, chest CT, bone scan, abdominal CT or ultrasound, or MRI for systemic staging

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Diagnostic Procedures

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  • Biopsy
    • Pathologic review
    • Determination of tumor estrogen/progesterone receptor (ER/PR) status and HER2 status
  • Surgery to assure complete removal of abnormal tissue

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Staging

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  • Stage (anatomical extent of disease) based on:
    • Extent and size of primary tumor (T1–4)
    • Presence and ...

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