As an art student in college, I remember the first time I painted a disrobed model. I had chosen to place my easel in the front of the class and practically fainted when our model stripped down just a few feet away. I had never been in a predicament like that and I think I held my breath the whole time, trying to appear cool and collected while I proceeded to paint my canvas. When the shock of sitting by a naked stranger finally wore off and the artist within me took over, I was able to marvel at my wonderful new experience. To study the bare human form with an artist's eye is to examine an exquisite geographical interaction of colors pulsating in nature. The hues of rose, peach, mint, lavender, the blues, siennas and yellows playing off the skin tones are all breath-taking.

In modern society, there are some who would still judge a woman's physique by a certain ideal "look" but I have always felt that the disrobed female form is sublimely beautiful in all its shapes and sizes. Nature and the all-mighty creator have carved a certain kind of unique beauty in the female curves of the body.

The most symbolic feature of a woman's body throughout time has been the female breast - the nurturing, life-giving, cushioning symbol that speaks of motherhood, endowment and the bounties of life. Look at how the female breast has been ever-present and revered in art throughout time. In fact, there is probably no other intimate physical feature that has received more attention throughout the ages in art than the female breast.

Perhaps that is why when I hear the term "breast cancer" there always rings discordant in my mind. It sounds like a misnomer or a complete mismatch of words...one life giving and one life-taking. When I see the demure pink tie symbol that has come to symbolize breast cancer awareness, I think "breast cancer," but I am one step removed. The whole dark issue is tied up with a nice feminine pink ribbon and the harsh realities do not sink in. October is National Breast Cancer Awareness Month. In that month-long campaign, as well as throughout the year, we need to think one step further than the pink ribbon to how breast cancer can affect each of our lives. Whether it is you, a family member, a friend, relative or co-worker, in modern society today we are all touched to some extent by this illness.
The American Cancer Society (ACS) gives these statistics. In 1999 there will be approximately 175,000 new cases of breast cancer diagnosed in the U.S. About 43,700 women will die of the disease. Breast cancer is most often diagnosed in women over the age of 50 - approximately 77% of the total cases. It is true then that a woman's risk of breast cancer increases as she ages. In younger women, ages 40-49 about 18% of all breast cancer cases are diagnosed and in ages 30-39, only 4%.

Statistics

The American Cancer Society sites that worry about breast cancer among younger women is sometimes disproportionately high when compared to the even greater numbers of heart disease and lung cancer related deaths they face due to smoking. Still, breast cancer in younger women when found is often in advanced stages, or is more aggressive. It is believed that higher estrogen levels in younger women may cause this.

Risk Factors

Although causes of breast cancer are not entirely known, there are a number of risk factors that fall into play:
(1) Having a close blood relative with breast cancer increases the risk, especially if the relative was diagnosed with breast cancer at a younger age;
(2) Risk is doubled if the blood relative with breast cancer is a first degree relative (mother, sister, daughter). Among women with two affected first degree relatives, the risk increases 5-fold;
(3) Among a small proportion of women, inherited genetic defects significantly increase the risk of breast cancer. Mutations in the BRCA 1 or BRCA 2 genes (two that have recently been identified) inhibit the manufacture of proteins that help prevent cancerous cell growth. Up to 60% of women with this trait will develop breast cancer by 70 years of age. Inherited genetic mutations, however, only account for 5-10% of all newly diagnosed breast cancer cases;
(4) Women who have had previous breast biopsies which indicate "proliferative breast disease without atypia" may have a slightly higher risk of breast cancer;
(5) Women who have not had children or had their first child after age 30 may be at higher risk;
(6) Women who started menstruating before age 12 or who went through menopause after age 50 have a higher risk of breast cancer;
(7) Current use of oral contraceptives may increase risk;
(8) Consumption of alcohol increases risk for breast cancer, even if only one drink is consumed daily;
(9) Having had treatments for illnesses (for example, Hodgkin's disease or non-Hodgkin's lymphoma) which involved radiation to the chest area may increase the risk for breast cancer.
(10) Current or recent long term use (10 years or more) of estrogen replacement therapy (ERT) for relief of menopause symptoms may slightly increase the risk of breast cancer. Within five years of stopping ERT, a woman's risk of developing breast cancer returns to that of the general population. For some women however, ERT is an advantageous therapy as it also lowers the risk of heart disease and osteoporosis. Women should discuss the pros and cons of ERT with their doctors.
(11) Regular physical exercise has recently been demonstrated to decrease a woman's risk of breast cancer.
Other potential risk factors include a high fat diet, smoking, and exposure to environmental toxins.

Not every woman with any of these potential risk factors will develop breast cancer. Conversely, breast cancer does occur in some women who have none of these characteristics. Because the causes of breast cancer are still not clearly understood, the American Cancer Society suggests that women follow a personal program of screening appropriate to their own age and their doctor's recommendations. Screening is particularly important, as the best odds of survival are present in cases that are diagnosed early. If caught before spreading to the lymph nodes, the five-year survival rate for women with breast cancer is 97%. With earlier detection and improvements in therapy, there has been a general improvement in survival from all types of cancer. For breast cancer, however, there has always been an emphasis on individual responsibility to perform monthly breast self examination (BSE) and to get mammograms.

Recommendations for Women

Recommendations for a vigilant watch by women of their own breast health is as follows:
(1) A monthly Breast Self Exam (BSE) on the same date of the month for women age 20 and older. An ideal time to do this for menstruating women is one week after their period. For non-menstruating women, the first day of the month is good.
Women are sometimes uncomfortable touching their own bodies, however Breast Self Exam is an important tool. Done once a month (it only takes about ten minutes) a woman can learn a tactile and visual "map" of her own breasts, the area between the breasts and the armpits. With this knowledge she will be able to report any changes to her doctor.
(2) Women ages 20-39 should have a clinical breast exam by a health professional every 3 years. After age 40, once a year is recommended.
(3) Women are also suggested to get an annual screening mammogram beginning at the age of 40, (younger if a woman is considered by her health care provider to be at particularly high risk).
A mammogram is an X-ray of the breast. This is the best screening tool available to date for breast cancer, able to detect tumors at a smaller stage than can be felt by BSE. Still mammograms are not foolproof. They detect true breast cancer at a rate of 76% to 94% of the time. Accuracy is lower in younger women, because breast tissue is more dense at younger ages.

Although Breast Self Exams combined with regular mammograms can be effective in detecting breast cancer, fewer than half of women age 40 and older follow these guidelines. A national survey in 1998 indicated that women still underestimate their personal risk of breast cancer and often claim ignorance of the risk factors. Clearly, there is still a need for greater awareness.

Currently there is no sure way to prevent breast cancer. Women are advised to reduce risk factors when they can and to follow screening recommendations. In recent years, women at high risk for developing breast cancer do have some options available to them that may improve their odds. One of these is genetic testing for BRCA 1 and BRCA 2 mutations for women with a history of breast cancer in close relatives. Genetic testing, however, is costly and insurance companies may not provide benefits to women who test positive. Although still another potentially preventative option for women at high risk is use of the drug Tamoxifen. Some women who consider themselves to be at very high risk for breast cancer have opted for preventative (prophylactic) mastectomy (surgical removal of the breast). One recent study has even suggested that in some high risk women with the mutated BRCA 1 gene, removal of their ovaries as well may reduce the incidence of breast cancer. These are drastic options, however, which are not universally agreed upon among the medical community.

What If The Diagnosis is Breast Cancer?

Statistics are hard to remember and don't make us think of the individual. What if it is you or someone you know or love who has a suspicious lump? If a suspicious area is found on any of the preliminary screening tests, further tests will be ordered by the doctor. These tests may include:
(1) a complete history and physical;
(2) diagnostic mammography to focus in on the suspicious area;
(3) breast ultrasound;
(4) ductogram (specific X-ray of the nipple area);
(5) nipple discharge exam;
(6) biopsy;
(7) fine needle aspiration biopsy (FNAB);
(8) core needle biopsy;
(9) surgical biopsy.

The breast contains glands for milk production, called "lobules" and tubes which connect them to the nipple "ducts." Breasts also have fatty, connective and lymph tissue. Generally, the most common type of breast cancer affects the ducts, "ductal cancer." Cancer originating in the lobes is called "lobular cancer." A rarer form of cancer is "inflammatory breast cancer" where there is a raised skin temperature, redness and swelling of the breast.

If cancer is found the clinician will seek to determine the stage of the cancer. There are different systems of doing this however the TNM system of the American Joint Committee on Cancer (AJCC) is utilized most often. It evaluates the
(1)"T" - the size of the tumor;
(2) "N" whether it has spread to the lymph nodes; and
(3) "M" - whether the cancer has metastasized or spread to other parts of the body.
With this information, the cancer is categorized in a stage 0 to IV. The lower the number, the less severe the cancer, with a corresponding higher survival rate. There are other systems of categorizing the severity of the cancer. Patients may hear terms as "local," "regional," or "distant" to describe the scope of their cancer. This author encourages patients to inquire of their physicians the meanings of specific terms used to gain better understanding of their illness and any treatments.

Breast Cancer Treatment

A woman finding out she has breast cancer frequently cannot absorb all the information it takes to make a decision. The American Cancer Society suggests that a breast cancer patient should seek as much information as possible and take time to evaluate her options before going into treatment. Factors to consider are the patient's age, general health and the stage of the cancer. Treatments have various side effects to consider as well. Frequently treatments are combined for the best result. The most commonly utilized treatments include surgery, radiation therapy, hormone therapy, and chemotherapy.

Surgery can range from a lumpectomy (removal of the cancerous tissue only followed by a course of radiation therapy), to a radical mastectomy (where the entire breast, lymph nodes and chest wall muscles under the breast are removed). Most women undergoing surgery have a modified radical mastectomy in which the breast and the lymph nodes under the arm are removed.

Other treatments which are used may have potent side effects, although every woman responds differently to any given treatment. Radiation therapy is used to target the area where the cancer cells were originally located. Breast cancer patients undergoing radiation therapy by getting small targeted doses of radiation in a course of treatment, often something like 5 days a week for 5 to 7 weeks. Common side effects of this treatment include swelling, a sunburn-type reaction in the area being treated, heaviness and fatigue. Treatment of the lymph nodes may cause "lymphedema" which is swelling of the arm due to fluid retention. This can occur near the time of treatment or years later.

Chemotherapy utilizes drugs, or a combination of drugs specifically geared to the patient's breast cancer. The drugs my be ingested orally or be injected into a muscle or vein. Chemotherapy is done in cycles-a course of treatment followed by a course of rest, and so on. Side effects vary. The most common are nausea, vomiting, hair loss, mouth sores, diarrhea and blood count changes. There are effective remedies today for many of the side effects.

Hormone therapy (sometimes called "anti-hormone therapy") are drugs or surgery which seek to prevent the cancer cells from getting the hormones they need to grow.

Tamoxifen (Nolvadex) is a drug taken in pill form. It has been used to treat early and advanced stage breast cancer. Its track record is about 20 years. What Tamoxifen does is have an anti-estrogen effect on breast cancer cells. The hormone estrogen fuels the growth of breast cancer. It has been known to slow or stop breast cancer cells already in the body. In follow-up treatment it has been known to prevent the original cancer from returning and prevent the development of new cancers in the opposite breast. Tamoxifen is usually taken for a period of 2 to 5 years. Women at high risk for breast cancer sometimes take Tamoxifen to decrease their risk of getting breast cancer. Tamoxifen can also have other beneficial effects as it may act like estrogen in other body systems much like menopausal estrogen replacement therapy, lowering blood cholesterol and slowing bone loss. Tamoxifen cannot be taken by all women. Some women do experience side effects.

Complicated Life Issues for Breast Cancer Patients

The diagnosis of breast cancer or any cancer can open up a Pandora's box of complicated life issues for a patient. Including medical treatment decisions, other areas in life affected by cancer include medical insurance, employment, finances, legal issues, personal relationships and psychological considerations. As one survivor notes, you can never have enough help when cancer is concerned. It truly becomes a challenge to the cancer patient and all those close to the patient.

Physical Changes and Self-Esteem

In breast cancer treatment it is important for a woman to maintain a sense of privacy, dignity and self-esteem. There are many avenues to help a woman feel better about her appearance and the physical changes she is experiencing during and after treatment. Some practitioners believe that bolstering spirits at this critical time about issues of self-esteem and appearance are a tremendous help in the patient's ability to cope with their illness.

"Show Me: Photo Collection of Breast Cancer Survivors' Lumpectomies, Mastectomies, Breast Reconstructions and Thoughts on Body Image" is a recent publication by members of a breast cancer support group at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. The goal of the publication is to describe the personal experiences of 23 breast cancer survivors to wome undergoing breast cancer treatment. Dialogue and photographs of the survivors' bodies post-treatment are provided. The support for the publication has been tremendous as it has addressed a need in breast cancer patients making life-altering decisions for information regarding how certain procedures will change the body. The message is that there is life after breast cancer and that there is valuable information someone who has undergone the procedure can provide to a "newcomer."

Many women undergoing mastectomy procedures choose to have breast reconstruction. Some women are able to have the reconstruction at the same time as the mastectomy and some doctors prefer to wait 6 months or a year before reconstruction is done. Breast prostheses are used after surgery by some breast cancer patients. Products on the market today for breast cancer prosthetics, undergarments and clothing have grown, making more choices available. The American Cancer Society has a "Reach to Recovery" program where a trained volunteer, who is a breast cancer survivor, will visit a woman in the hospital undergoing breast cancer treatment. The volunteer provides support, answers questions, provides information and demonstrates exercises to speed up recovery. In addition, the volunteer may provide a gift kit with a temporary prosthesis. The resource list at the end of this article will provide information regarding products for the breast cancer patient.

CONTINUED IN ABILITY MAGAZINE...... subscribe