Introduction: What is breast cancer? Breast cancer will strike one in every eight American women. This makes it the most common cancer in woman. Approximately 200, 000 women are diagnosed with breast cancer each year. Of that number, 40, 000 will die from breast cancer each year.

(Journal of Environmental Health 2003) Breast cancer is just one type of cancer. Cancerous cells are cells that grow without the normal system of controls placed upon them. Breast cancer develops from the mammary ducts 80% of the time. The other 20% of the time the cancer develops from the lobules of the breasts.

While breast cancer may occur in men, this paper will primarily focus on breast cancer in women. Breast cancer is 100 times more likely to affect women as it is men. There are two forms of breast cancer, invasive cancer and carcinoma in situ. (Dimensions of Human Sexuality, Shriver, S.

2002) Invasive cancer is the more serious form of breast cancer. Invasive cancer develops when some abnormal cells from the interior of the lobules or ducts rupture out into the breast tissue surrounding the lobules. Once these cells are free, they may travel into the lymphatic and vascular system where they have access to virtually all other areas of the body. These cells are especially fond of migrating to the liver, bones, and lungs. (Dimensions of Human Sexuality, Shriver, S. 2002) In contrast, carcinoma in situ are a cluster of abnormal breast tissue cells that develop inside of the lobules of the breast.

These do not travel to other areas. In situ translates to mean 'in place'. The cancer cells associated with Carcinoma in situ are not considered completely cancerous. They don't possess the capability to travel outside the breast tissues. However, they are considered a precancerous condition.

They may eventually develop into an invasive form of cancer or just raise the risk of developing invasive cancer. (Susan G. Komen Breast Cancer Foundation, 2003) This paper will cover the following aspects of breast cancer: Breast anatomy and physiology, Risk factors, Hormonal relationships with breast cancer, Early detection / screening , Treatment options currently available, and the unique Psychological Impact that breast cancer creates for women. Breast Structure: Anatomy, Physiology, Neurologic Control, Vascular Supply The breasts, also called mammary glands, exist in both females and males. However, in men they are not developed unless certain abnormal hormonal changes take place.

The breasts in women vary somewhat in size and shape. Basically the breasts are located off to the sides of the sternum, on the front of the chest wall between the second and sixth ribs. (Anatomy of the Human Body, Gray, H. ) During puberty hormonal changes cause the breasts to begin to develop and mature. This stimulation comes from the release of estrogen from the anterior pituitary. The base of each breast lies on top of the pectoralis major, obliques extern us, and serratus anterior muscles and extends up into the axillary region.

On the external surface of the breast, between the 4 th and 5 th ribs is the nipple. The nipple is made up of contractile muscle fibers and is capable of becoming firm and erect when stimulated. The color of the nipple can range from a light pink to brown. At the tip of the nipple there are up to twenty tiny openings from the lactiferous ducts. The circular area surrounding the nipple is called the areola.

The color of the areola may also range from a light pink to a dark brown. During pregnancy the areola will darken. Imbedded in the areola are areolar glands which give the areola a slightly bumpy appearance. These glands secrete an oily kind of substance that acts as a skin protector during breast feeding. (Textbook of Medical Physiology, Guyton, 2000) The breast tissue itself is a series of lobules and mammary ducts that form a pattern similar to clusters of grapes. The lobules are round sacs that produce milk.

The ducts are the passageways that transport the milk from the lobules out to the nipple. Each breast has between five and ten duct systems. There are roughly one million lobules in each breast. The remainder of the breast is connective tissue and fat. (Susan G. Komen Breast Cancer Foundation) The breasts have a vast lymphatic system.

The lymph system in the breasts begins in the spaces between the lobules, called a plexus. It is also located on the duct walls. The lymph fluid leaving the breasts are collected into two branches that then pass in the pectoral group and then into the axillary lymphatic glands. Drainage from the medial part of the breast pierces through the chest wall and into the sternal glands. Another passageway for lymph fluid emerges from the superior aspect of the breast, runs through the pectoralis major muscle and ends in the subclavian lymphatic glands. (Anatomy of the Human Body, Gray, H.

) The skin over and tissues inside the mammary glands are innervated by the upper thoracic nerves. Namely the anterior divisions of the 2 nd through 6 th thoracic nerves. These are also called the thoracic intercostal nerves. The anterior branches of the lateral cutaneous branch of the intercostal nerves run forward along the sides and frontal area of the chest. These branches supply the tissue of the breasts. (Anatomy of the Human Body, Gray, H.

) The vascular supply to the breast is from the mammary branches of the anterior ram us of the intercostal arteries. The intercostal arteries are nine branching pairs from the posterior aspect of the aorta. Each of these intercostal arteries is accompanied by vein as well as a nerve. Other branches of the anterior ram us of the intercostal arteries include lateral cutaneous, muscular, and collateral intercostal branches. In particular, the mammary branches are given off by the blood vessels in the 3 rd through 5 th intercostal spaces. These will increase considerably in size during pregnancy and especially during lactation.

(Anatomy of the Human Body, Gray, H. ) Risk Factors Certain risk factors are associated with a person's likelihood of developing breast cancer. These risk factors can be divided into two separate categories: Factors that can be controlled/Lowers overall risk Factors that cannot be controlled Controllable Factors Factors that can be controlled fall largely under the umbrella of lifestyle choices. Unfortunately, there is no 100% surefire way for a woman to completely eliminate her chance of developing breast cancer. There are some known ways for a woman to empower herself in regard to her health and to reduce her risk. One of the primary ways a woman can lower her risk of developing breast cancer is through her diet.

A diet that is high in fruits and vegetables, especially those with high antioxidant carotenoids, may reduce the risk of breast cancer. Current research is being explored regarding the relationship between the risk of breast cancer and the level of insulin in a woman's system. The pancreas releases insulin to help cells shuttle in sugar from the bloodstream after a meal containing carbohydrates. A few studies have revealed that increased levels of insulin in the bloodstream can increase the risk of breast cancer.

More research needs to be completed in order to determine definitive associations between high insulin levels and breast cancer risks. A general rule of thumb is that a diet rich in whole grains, whole fruits, fresh vegetables, and legumes will reduce the overall risk of developing breast cancer. Current recommendations include a minimum of five fruits and vegetables per day. Other vitamins and minerals that are believed to reduce risks include getting enough fo late, calcium, and vitamin D everyday.

(Nikoletti, et al 2003) Other controllable factors include weight management and physical activity. One study found that before a woman reaches menopause, it is beneficial (decreases risk of breast cancer) to be slightly overweight. But after menopause, being overweight will increase her risk of breast cancer by 20 to 60%. It is believed that an increase in physical activity will lower a person's risk of developing cancer. This may be due to the body's increase in immune function, allowing it to destroy cancerous cells, or at least slow down their growth rate. (Dimensions of Human Sexuality, Shriver, S.

2002) A few other controllable factors for lowering the risk of breast cancer development include drugs and childbirth / breastfeeding . There are a couple widely used drugs that are believed to lower the risk of breast cancer: Tamoxifen and Raloxifene. Tamoxifen has been used for a longer period of time. The National Cancer Institute did a study of over 13, 000 women who had a high risk of developing breast cancer. They found that tamoxifen lowered their risk of developing breast cancer by almost 50%.

However the known side effects to the drug therapy included the risk of developing cataracts, uterine cancer, DVT's in the large veins and lungs, and stroke. More studies need to be done before it is completely known how much benefit vs. the negative side effects these drugs offer. (Susan G. Komen Breast Cancer Foundation) Women who postpone having children until after 30 are at a two times higher risk for breast cancer than those who begin having children at an earlier age. The more children she has, the lower her risk of cancer.

Breastfeeding also plays a role in breast cancer risk factors. Breastfeeding can lower a woman's risk by 6% if she does so for at least one year, and by 11% if she does so for two years. (Susan G. Komen Breast Cancer Foundation) Some women who have extremely high risk factors and a family history of breast cancer may choose preventative surgery to virtually eliminate the chance they will develop the disease.

A Bilateral Prophylactic Mastectomy would remove both of the woman's breasts, but it cannot remove all of the women's breast tissue, some will remain. Therefore, this procedure is not 100% effective. One of the reasons a woman may choose this procedure is possessing the BRCA 1 or BRCA 2 gene mutation. This mutation will increase her risk of developing breast cancer.

The genetic testing is done by a blood test. The test is usually only performed on those women who already have a higher risk of developing breast cancer. (Susan G. Komen Breast Cancer Foundation) Uncontrollable Factors When determining a woman's chance of developing breast cancer there are known factors that come into play. We have already discussed some of the factors that can be controlled or managed.

But many of the risk factors involved in breast cancer are simply not within her control. Factors such as age, familial history, first menses and age at menopause, height, breast density, and prior bouts with cancer all greatly contribute to her risk analysis. Age has long been known as a primary risk factor. Basically, the older the female, the more likely her chances are of developing breast cancer. Before age forty, the incidence of breast cancer is relatively lower than after age forty.

Women seventy years and older have the highest rates of breast cancer. Approximately 77% of women who develop breast cancer every year are past age fifty. (Dimensions of Human Sexuality, Shriver, S. 2002) Family history also plays a role in determining the risk of breast cancer.

A woman has at least a four times greater risk of breast cancer if she has had one family member with the disease. The age of the family member when diagnosed with breast cancer also plays a role. The younger the family member is when diagnosed, the more it increases the woman's risk of breast cancer. (Dimensions of Human Sexuality, Shriver, S. 2002) Due to hormonal factors, the age a woman begins menstruation and the age that she begins menopause also plays a part in the risk of breast cancer. Generally, the younger she is at first menses and the older she is at menopause will adversely affect her risk factors.

Her risk is slightly increased if menses begins before age 12. However, menopause after fifty-five will double her risk of developing breast cancer. The hormonal role is due to exposure to estrogen. The more overall exposure to estrogen, it is believed the more likely it is to adversely effect breast tissue. (Roger, 2003) Even height has been found to play a part in breast cancer risk factoring. The taller the woman is, the higher her chance of breast cancer.

Woman under 5'3' have a lower risk of breast cancer. The connection here again is hormonal. Rapid growth at younger ages can create a chance for breast cells to be adversely effected. (Mahon, 2003) An increased breast density will increase the risk for breast cancer.

Increased breast density means that there is a higher ratio of breast tissue to fat in the breast. The way to determine the density of breast tissue is by mammography. (Mahon, 2003) Obviously having a prior experience with breast cancer will automatically greatly increase the likelihood of the disease returning. Second primary breast cancer is the new cancer that develops. This means that it is not connected to the first cancer, but an entirely new cancer. A prior experience with another form of cancer early in life will also increase the chance of developing breast cancer.

(Mahon, 2003) Hormonal Relationships and Breast Cancer Many women going through menopause have used hormone replacement therapy to reduce their symptoms such as hot flashes. The two primary forms of hormone therapy are estrogen and a combination of estrogen and progestin. The combination of estrogen and progestin is the more commonly used therapy. However, this form of therapy can greatly increase a woman's risk of developing breast cancer. Each year that a woman is on the combined hormone therapy plan, their risk of breast cancer increases 8% each year.

What is worse is that the risk is cumulative. A woman on this therapy for five years has an accumulated increase of 40% in her risk of developing breast cancer. (Miller, 2004) Hormone replacement therapy can also have a negative impact on other areas of woman's health. Strokes, heart disease and blood clots are also associated with hormone therapy. There is also some evidence that taking the combination of hormones can increase the chance of developing dementia.

(Susan G. Komen Breast Cancer Foundation) Another hormone that is taken routinely by millions of women is birth control pills. However, the risk of developing breast cancer is only minimally raised with the use of oral contraception. Newer forms of the birth control pills have a much lower overall dose of hormones than earlier versions. Even though the risk is small, it is still important for women, especially those with already increased risks, to understand the drugs they are taking and what the possible side effects are in taking them.

(Susan G. Komen Breast Cancer Foundation) Early Detection/Screening Due to the recent increase in breast cancer awareness, the mortality rate has been decreased. There are three primary detection / screening options available to women. These are: Breast Self Examination, Clinical Breast Examination, and Mammography. (Mahon, 2003) Breast Self Examinations should be performed monthly.

While there is inconclusive evidence on how effective these exams actually are, it is still recommended. Women who regularly examine their breasts will be more likely to notice any slight changes. The breast self exam is a way women can detect the presence of tumors, notice any thickening of the breast tissue, discharge from the nipple, and any unusual changes in the skin. Breast tissue is somewhat bumpy in texture and it may benefit the woman to be shown how to conduct the self exam by a health care professional that is familiar with the procedure to ensure she is performing the procedure correctly.

If there is an area that is particularly firmer than the other tissue of the breast she should consult a health care provider. However, it should be stressed to the patient by t he health care provider that there may be other causes for the abnormality. Fibro adenomas and cysts can also feel like lumps in the breast. Self breast exams should be done monthly when a woman reaches her early twenties.

(Mahon, 2003) Clinical breast exams are performed by health care professionals. This exam is usually done in conjunction with the regular yearly check-up for women. The clinician will be checking for the same findings as in the breast self exam: lumps, thickening of tissue, nipple discharge, and skin changes. The clinical breast exam should be performed at least every 3 years, beginning when a woman reaches her early twenties, then once every year after age forty. (Yarbrough, 2004) Mammography is the third early detection / screening option available to women. Mammography is a form of x-ray used to create an image of the breast.

The images are called mammograms. Mammograms can detect the tumors that go undetected during the manual breast exam. Mammography is considered to be the screening tool most effective in detecting breast cancer early. Mammography is generally performed at hospitals or at a radiology center. The procedure usually takes less than a half an hour. It consists of compressing the breast between two plates while the x-ray image is made.

While this is a less than pleasant experience, it is not extremely painful as some may believe. After the image has been created, a radiologist will read the x-ray and interpret the results. Many areas offer free or low cost mammograms. Insurance companies will also cover the costs of a mammogram. It is recommended that women over age 40 undergo a mammogram once a year. (Yarbrough, 2004) (Susan G.

Komen Breast Cancer Foundation) Treatment Options For Breast Cancer There are several treatment options for breast cancer. Unfortunately, none of them offer a 100% success rate. While one treatment may work well for one individual, it may be completely ineffective for another. The primary two options will be discussed in this paper. These options include: Radiation therapy - Limited Field and Whole Breast Irradiation Surgical treatment - Lumpectomy (Breast Conserving Therapy) and Mastectomy Radiation Therapy Approximately one half of all women diagnosed with breast cancer in the early stage will undergo breast surgery followed by some form of radiation therapy. Advances in radiation therapy have made it possible to reduce the problems that have been associated with it in the past, such as fatigue, discomfort, and skin alterations.

(Gordilis-Perez, et al, 2003) Conflicting studies were found as to whether whole breast vs. limited field irradiation is the more effective choice. One study presented by Dr. Gary Freedman of the Fox Chase Cancer Center, claimed that whole breast irradiation following a lumpectomy had better results than limited field. The study went further to state that irradiating the whole breast can ensure that microscopic pieces of the tumor cells are more completely destroyed. (Women's Health Weekly, 2003) However another study in the Journal of the National Cancer Institute claimed that limited field radiation is just as effective as the whole breast treatment option.

This study states that 199 women with similar cancer presentations were matched up. The first group had limited field radiation therapy, while the other had whole breast radiation therapy. After 5 years, there were no differences between outcomes in the recurrence rate between the two groups. The conclusion drawn was that women should not have to undergo the increased side effects and damage from whole breast treatments when limited field radiation was just as effective. (Cancer Weekly, 2003) There have been some recent advances in radiation oncology in treating breast cancer. These advances are having the treatment performed while the patient is in the prone position, Intensity-Modulated Radiation Therapy, and Brachytherapy.

Having the patient in the prone position, with the breast lowered down on an adjustable breast board can reduce the dose of radiation received. Intensity-Modulated Radiation therapy, a computed tomography scanner creates a three dimensional figure of the breast. Then a computerized optimizing algorithm creates dose constraints. This is for the breast as well as the structures below the breast. This way there is a more accurate dose applied precisely to the area of the breast that requires treatment. The third advance is called Brachytherapy.

Because over 70% of cancer that returns comes back at the initial site, radiation to the area is designed to destroy any remaining cancer cells. Brachytherapy places a radioactive source within or right next to the tumor or close to the tumor. This method allows a high radiation dose to be placed right next to the target area, while sparing the surrounding area, while doing so in a much shorter time period than the normal radiation therapy. More research and development is needed before this process can be more widely used in breast cancer treatment. (Gordilis-Perez, et al, 2003) Surgical Treatment The two forms of surgical treatment in regards to breast cancer are lumpectomy and mastectomy. Lumpectomy is referred to as a breast conserving therapy.

It is a removal of the affected tissue while sparring the surrounding tissues. This procedure is generally followed by radiation therapy. The mastectomy calls for the complete removal of the entire breast and it's surrounding tissues to ensure that all cancer cells have been removed. The decision as to which procedure is to be undertaken is up to the patient. The patient should be well informed of the pro's and con's of each option so that she may make the best possible choice for herself. (Saka, et al, 1998) Alternative Care There were no studies on alternative therapies for the treatment of breast cancer.

This does not mean however, that alternative treatment options do not exist for the patient. There may be options available, including chiropractic, but there are no studies to work from at present. Future studies might include how chiropractic, massage therapy, herbal therapies, and others may affect breast cancer. A study that could be very interesting would be on how chiropractic could be used to help prevent breast cancer by maintaining proper neurological functioning, especially in the mid thoracic region that innervates the breasts. Psychological Impact of Breast Cancer Breast cancer presents a complicated problem for women. Not only must they face the fact that they have cancer, and perhaps even lose their life to it, or at the very least undergo complicated and dramatic therapies, they also must face the psychological aspects of the disease.

The society in which we live places a great deal of importance on appearances. (Gibson, et al 2003) Women experience a sense of loss if they must undergo a treatment that affects the breast dramatically. Up to 60% of women diagnosed with breast cancer will also experience depression. Many women may feel that they are no longer complete, or whole, or still feel like a woman. Since a woman's self image can be so strongly tied to her physical appearance and how she believes others will see her, the prospect of losing a breast to cancer may be especially difficult for many women. This fear and depression can adversely affect her treatment outcomes.

Younger women appear to be more adversely affected psychologically than older women. (Cohen, et al, 2000) Conclusion Over 200, 000 women are diagnosed with breast cancer each year. Approximately 40, 000 of these women will lose their life to it. There are many factors that lead to the risk factors of breast cancer. Many of these factors are controllable, such as diet and activity levels.

However, many factors are uncontrollable, such as hereditary and genetic factors. Hormones play a role in breast cancer development. Hormone replacement therapies may increase the chance of developing breast cancer, even birth control pills may increase this risk. There are three screening procedures that are primarily used to detect breast cancer. These are the breast self exam, the clinical exam, and mammography. Once a woman has been diagnosed with breast cancer, treatment is often limited to radiation therapy and either breast conserving surgery, or complete surgical removal of the breast.

While alternative care may be an option, no studies have been published on their effects. Research into chiropractic care is greatly needed. With a primary focus of the chiropractic research into the preventative aspects of chiropractic care in regards to breast cancer development. Women who come into a chiropractor's office should be educated not only as to the benefits of chiropractic, but also in other areas important to her overall good health. One of these areas is breast cancer awareness.

She should be given a risk assessment questionnaire, information on how to perform a breast self exam, and where to go locally for a mammogram. The chiropractor could also tell the patient where to go for more information. If the chiropractor has been thoroughly trained on how to perform a clinical breast exam and feels comfortable in doing so (and their state and malpractice insurance allows) they may perform this procedure in their office. However, it is strongly advised to have a female assistant present during the procedure, so as not to have any appearance of inappropriateness.

The most important thing is to get the patient educated as best we possibly can in regards to their overall health, including breast cancer.