Why Do People Get Breast Cancer? How Is It Treated? Can TCM Cure Breast Cancer?

Overview of breast cancer

An increasing number of patients are troubled by breast cancer, which ranks as the number one tumor among women worldwide. Every year about 1.2 million women develop breast cancer and 500,000 women die of it. North America and Europe are high-incidence regions, and China is a low-incidence region, but the incidence is rising year by year. Shanghai, Beijing, Tianjin and the developed coastal areas are high-incidence areas within China.

The average annual incidence of breast cancer worldwide is 30.30 per 100,000. Nearly 60% of new breast cases occur in developed countries, where breast cancer accounts for about 25% of all female malignant tumors, with an incidence of 79.09 per 100,000. Overall, female breast cancer incidence is highest in Western developed countries, next in Eastern and Southern European countries, and lowest in Asia, Africa and Latin America. However, the incidence of breast cancer is rising globally, attracting the attention of many countries.

China belongs to the regions of low incidence and low mortality of breast cancer, but with economic development and changes in lifestyle, its breast cancer incidence is also rising rapidly. In some large and medium-sized cities, breast cancer has already become the first or second most common malignant tumor among women. Nationwide statistics on breast cancer incidence in China are still lacking. According to epidemiological surveys in Tianjin in recent years, the incidence of female breast cancer in Tianjin was 18.20 per 100,000 in 1981–1982 and rose as high as 24.94 per 100,000 in 1988–1992, an increase of 37%. In Shanghai the female breast cancer incidence was 18.8 per 100,000 in 1981–1982, rose to 28.5 per 100,000 in 1990—a sharp increase of 51.6%—and by 1999 had risen to 52.98 per 100,000, ranking first among female malignant tumors.

Mortality from breast cancer is also showing a clear year-by-year upward trend. Recent statistics show that in Tianjin the breast cancer fatality rate in the 1980s was between 6.0 and 7.2 per 100,000; in Beijing it was 6.40 per 100,000 in 1991; and in Shanghai the female breast cancer fatality rate was 11.2 per 100,000 in 1990. All ranked fourth among deaths from female malignant tumors.

Female breast cancer in China also shows characteristics of regional high incidence and clustering in certain populations: coastal areas higher than inland, economically developed areas higher than less developed ones, cities higher than rural areas, and women employed in government institutions and well-educated women higher than women in general.

Breast cancer occurs mainly in women; male breast cancer accounts for about 1% of all breast cancer patients. It is rare before age 20, and the incidence rises rapidly after age 30. Age at menarche and age at menopause are related to the onset: early menarche and late menopause are both high-risk factors. The later the age at first full-term pregnancy, the greater the risk. Total duration of breastfeeding is inversely related to breast cancer risk. A first-degree relative with breast cancer, a high-fat diet, obesity, environmental pollution, work stress, a long history of benign breast disease, ionizing radiation, poor lifestyle habits, viral infection, and excessive intake of exogenous estrogen can all increase the risk of breast cancer.

Emotional factors and endocrine disorders are closely linked to the onset of breast cancer. Long-term tension and repression cause disturbances of the immune and neuroendocrine systems, increasing the risk of breast cancer. TCM has always held that women with troubled family relationships are more prone to breast cancer than women with harmonious families. A specific foreign study showed that nuns who never had sexual relations had a rate of breast cancer several times higher than that of women in general.

Pathology, course and progression of breast cancer

Histologically, breast cancer can be classified as: 1. invasive breast carcinoma; 2. precancerous lesions; 3. benign epithelial lesions; 4. myoepithelial lesions; 5. mesenchymal tumors; 6. fibroepithelial tumors; 7. nipple tumors; 8. malignant lymphoma and metastatic tumors; 9. male breast tumors.

Precancerous lesions of the breast include: 1. lobular neoplasia, i.e. lobular carcinoma in situ; 2. intraductal proliferative lesions: ductal epithelial hyperplasia, atypical ductal hyperplasia, ductal carcinoma in situ (DCIS); 3. microinvasive carcinoma; 4. intraductal papillary tumors: intraductal papilloma, intraductal papillary carcinoma, intracystic papillary carcinoma, etc.

Breast cancer has a long occult period, averaging 12 years, during which it is not easy to detect. The natural survival time after diagnosis is generally 26.5 to 39.5 months. The average doubling time of breast cancer is 90 days.

Metastatic pathways of breast cancer

Local extension of breast cancer spreads along ducts or fascial spaces, involving the skin and producing a series of manifestations; deeply it may invade the pectoral fascia or pectoral muscle, even the intercostal muscles, ribs and chest wall. Lymphatic spread occurs via axillary lymph node metastasis and subclavian lymph node metastasis; deep cervical lymph nodes and supraclavicular lymph nodes may be involved, or hematogenous metastasis may finally occur via the lymph nodes. In addition, breast cancer of any part, especially the medial and central regions, can metastasize to the internal mammary lymph node chain, which ultimately also drains into the bloodstream. Both the internal mammary nodes and axillary nodes are first-echelon lymph nodes for breast cancer metastasis. Tumor cells may also spread via retrograde pathways to the contralateral axillary or inguinal lymph nodes. Hematogenous dissemination occurs when cells directly or via lymphatics invade blood vessels and cause distant metastasis. The most common distant site is the lung, followed by bone, liver, soft tissue, brain and adrenal glands. About 5% to 15% of breast cancer patients already have distant metastasis at clinical confirmation.

Classification and staging of breast cancer

The pathological morphology of breast cancer is complex, and there are many classification systems intended to reflect its pathological features and biological behavior more comprehensively and accurately. The 1978 National Symposium on Early Diagnosis of Breast Cancer divided breast cancer into three categories: non-invasive carcinoma, non-special-type invasive carcinoma, and special-type invasive carcinoma. The 1983 meeting of the National Breast Cancer Pathology Cooperative Group revised this into the current classification of four major categories: non-invasive carcinoma, early invasive carcinoma, invasive special-type carcinoma, and invasive non-special carcinoma.

In 1988, the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer jointly established the TNM classification and staging, classifying breast cancer according to the TNM system. When multiple tumors are present in one breast, the T category is based on the largest; bilateral breast cancers should be classified separately. TNM is assessed according to physical examination and imaging.

Currently, breast cancer generally uses the TNM staging proposed by the UICC (2002, 6th edition).

T Primary tumor

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ: intraductal carcinoma, or lobular carcinoma in situ, or Paget's disease of the nipple with no tumor mass

T1 Tumor 2 cm or less in greatest dimension

T1mic Tumor 0.1 cm or less

T1a Tumor more than 0.1 cm but not more than 0.5 cm

T1b Tumor more than 0.5 cm but not more than 1 cm

T1c Tumor more than 1 cm but not more than 2 cm

T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension

T3 Tumor more than 5 cm in greatest dimension

T4 Tumor of any size with direct extension to chest wall or skin

T4a Extension to chest wall

T4b Edema (including peau d'orange) or ulceration of the breast skin, or satellite skin nodules confined to the same breast

T4c Both T4a and T4b

T4d Inflammatory breast cancer

N Regional lymph nodes

Nx Regional lymph nodes cannot be assessed or have been removed

N0 No regional lymph node metastasis

N1

N1a Metastasis in 1–3 movable ipsilateral axillary lymph nodes

N1b Internal mammary node micrometastasis detected by sentinel node dissection but not clinically apparent

N1c Metastasis in 1–3 axillary nodes plus internal mammary node micrometastasis detected by sentinel node dissection but not clinically apparent

N2

N2a Metastasis in 4–9 ipsilateral axillary lymph nodes

N2b Clinically apparent ipsilateral internal mammary node metastasis without axillary node metastasis

N3

N3a Metastasis in 10 or more ipsilateral axillary lymph nodes, or subclavian node metastasis

N3b Clinically apparent internal mammary node metastasis with more than one ipsilateral axillary node, or more than 3 axillary nodes plus internal mammary node micrometastasis detected by sentinel node dissection but not clinically apparent

N3c Ipsilateral supraclavicular lymph node metastasis

M Distant metastasis

M0 No distant organ metastasis

M1 Distant organ metastasis present

Clinical staging criteria for breast cancer

Stage 0: Tis N0 M0

Stage I: T1 N0 M0

Stage IIA: T0N1M0, T1N1M0, T2N0M0

Stage IIB: T2N1M0, T3N0M0

Stage IIIA: T0N2M0, T1N2M0, T2N2M0, T3N1M0, T3N2M0

Stage IIIC: Any T, N3 M0

Stage IV: Any T, any N, with M1 — all such cases are stage IV breast cancer

Clinical manifestations of breast cancer

1. Breast mass

A breast mass is the most common symptom of breast cancer. It is usually painless, sometimes accompanied by skin adhesion, skin edema, peau d'orange, or skin ulceration. Some patients have nipple discharge, which is common in tumors arising in a large duct or in intraductal carcinoma. When the lesion involves the nipple or subareolar region, it may cause the nipple to be deviated toward the tumor, becoming flattened, retracted, inverted or eroded.

2. Nipple discharge

A minority of breast cancers present as nipple discharge, mostly bloody, with or without an associated breast mass.

3. Lymph node enlargement

Breast cancer may metastasize to the axillary nodes, presenting as single or multiple enlarged axillary nodes. Enlargement of supraclavicular and cervical nodes is a late-stage sign.

4. Occult breast cancer

A small number of cases present first with enlargement of an axillary node, with no primary breast lesion found.

5. Inflammatory breast cancer

It grows rapidly, presenting as widespread redness of the breast with local skin edema; the local skin temperature may be mildly elevated. This condition is easily misdiagnosed as mastitis. The distinguishing points are that mastitis is more painful, with a more marked rise in local skin temperature, and is often accompanied by systemic symptoms such as fever.

6. Correct examination method for breast cancer

The patient sits or lies supine. Place the palm flat on the breast and gently palpate in sequence from the upper-outer, lower-outer, lower-inner, upper-inner quadrants to the axillary tail and the nipple-areolar region, repeating several times. Note whether there is a mass and its size, consistency, border, mobility, and whether the skin is involved; record these in detail. The best time for breast examination is about one week after menstruation.

Diagnosis of breast cancer

The breast is located on the body surface; a detailed history and clinical physical examination can lead to a correct diagnosis of most masses, and further auxiliary examinations can confirm it. In early patients the mass is tiny or ill-defined and hard to palpate on physical examination, so multiple examinations are needed.

1. X-ray examination

Mammography is a common examination method for breast cancer, divided into dry-plate and molybdenum-target X-ray mammography; each has advantages and disadvantages, and low-dose molybdenum-target mammography is now mostly used. Mammography is not recommended for women under 35. Breast diseases may appear on X-ray as direct or indirect signs. Direct signs include mass or nodule shadows; calcification is of great significance in diagnosing breast cancer. Indirect signs often include ductal shadow hyperplasia and skin thickening.

2. Ultrasonography

It is non-invasive and can be used repeatedly. It is valuable for patients with dense breast tissue and can distinguish whether a mass is cystic or solid.

3. Magnetic resonance imaging

MRI is highly sensitive for breast cancer and is often used in cases that cannot be confirmed by conventional methods. It is important in preoperative evaluation for breast-conserving surgery in early breast cancer.

4. Cytological and histological examination

Exfoliative cytology: cytological smears of nipple discharge; when nipple erosion is suspected to be Paget's disease, scrapings or imprint cytology of the eroded area may be done. Fine-needle aspiration cytology: simple and convenient, now widely used, with a false-positive rate of 1%. Needle aspiration cytology does not affect prognosis, so there is no need to fear it based on hearsay. Biopsy: divided into excisional and incisional biopsy; unless the tumor is very large, excisional biopsy is generally performed.

5. Laboratory tests

Tumor markers for breast cancer can only serve as references in diagnosis, but may be more meaningful in detecting postoperative recurrence and metastasis. Commonly used ones include CA15-3, CEA and ferritin.

6. Differential diagnosis: breast cancer should be differentiated from mammary hyperplasia, fibroadenoma, giant fibroadenoma, phyllodes cystosarcoma, and mammary fat necrosis.

TCM's understanding of breast cancer. Can TCM cure it? What is the point of choosing TCM for breast cancer?

Traditional Chinese medicine recognized breast cancer long ago. Among the four incurable diseases of surgery in ancient TCM texts was ruyan ("rock breast," i.e. breast cancer—so named because advanced breast cancer develops into a rock-like immovable mass). TCM classics from ancient to modern times all record ruyan as a disease with a grave prognosis, and most TCM works note that ruyan cannot be cured, only that life may be prolonged. Famous TCM surgical classics such as Waike ZhengZong (Orthodox Manual of External Medicine), Waike Zhengzhi Quansheng Ji (Quansheng Compendium on External Conditions), and Yangyi Xinde Ji (Reflections of a Ulcer Physician) contain many external methods and internal formulas for treating breast cancer, but successful cases of curing ruyan are rarely recorded.

Contemporary TCM case records contain sporadic accounts of breast cancer cured by pure TCM, but the number is extremely small and the proportion of all breast cancer patients is far too low. Therefore, choosing pure TCM treatment for breast cancer is a very risky undertaking. Combined comprehensive treatment using modern medicine together with TCM can greatly improve the cure rate. Once breast cancer is discovered, the patient should not delay: if there are surgical indications, surgery should be performed as early as possible, followed by integrated Chinese-Western internal medical treatment.

TCM treatment has a certain role in preventing recurrence after breast surgery, assisting Western surgery, and enhancing the efficacy of Western surgery, radiotherapy and chemotherapy. For some breast cancer patients who are already at a very late stage and for whom Western medicine has no good options, TCM can improve quality of life and prolong survival. There are also a few patients who, after pure TCM treatment, survive long-term until they die a natural death.

TCM treatment of breast cancer should begin as early as possible, rather than being adopted only when the condition has become uncontrollable. TCM can help patients reduce the side effects of radiotherapy and chemotherapy, help them complete chemotherapy courses smoothly, and markedly improve their postoperative constitution.

Overview of modern medical treatment for breast cancer

Modern medical treatment of breast cancer includes surgery, radiotherapy, chemotherapy, endocrine therapy, molecular targeted therapy, and integrated Chinese-Western medicine. Individualized comprehensive treatment is the trend. Before treatment the disease should be accurately assessed: when the lesion is confined locally or to regional lymph nodes, local treatment is primary, supplemented by pre- and postoperative systemic therapy; when the disease is more extensive or distant metastasis has occurred, systemic treatment is primary and local treatment secondary.

According to hormone receptor status, breast cancer is divided into three types: endocrine-responsive, endocrine-response-uncertain, and endocrine-non-responsive: 1. Endocrine-responsive: cells express hormone receptors; this type can improve disease-free and overall survival through hormone therapy. 2. Endocrine-response-uncertain: hormone receptors are expressed but in small or relatively insufficient amounts, indicating response to endocrine therapy but requiring the addition of chemotherapy. 3. Endocrine-non-responsive: cells have no measurable hormone receptor expression.