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U N I T 1 1
Genitourinary and Reproductive Function
The prognosis for women with breast cancer is
related more to the extent of nodal involvement than
to the extent of breast involvement. Greater nodal
involvement requires more aggressive postsurgical
treatment, and many cancer specialists believe that a
diagnosis of breast cancer is not complete until dis-
section and testing of the axillary lymph nodes have
been accomplished. A newer technique for evaluat-
ing lymph node involvement is a sentinel lymph node
biopsy. A radioactive substance or dye is injected into
the region of the tumor. In theory, the dye is carried
to the first (sentinel) node to receive lymph from the
tumor. This would therefore be the node most likely
to contain cancer cells if the cancer has spread. If the
sentinel node biopsy is positive, more nodes are tested.
If it is negative, further lymph node evaluation may not
be needed.
Systemic therapy refers to the administration of
chemotherapy, biologic therapy, or hormonal therapy.
Neoadjuvant therapy is given before surgery to shrink
the tumor and make surgical removal more effective.
Adjuvant therapy is given after surgery to women with
and without detectable metastatic disease. The goal of
this therapy depends on nodal involvement, menopausal
status, and hormone receptor status. Systemic adjuvant
therapy has been widely studied and has demonstrated
benefits in reducing rates of recurrence and death from
breast cancer.
61
Biologic therapy, using the drug trastu-
zumab (Herceptin), is used to stop the growth of breast
tumors that express the HER2/neu receptor on their cell
surface. The HER2/neu receptor binds an epidermal
growth factor that contributes to cancer cell growth.
63
Trastuzumab is a recombinant DNA-derived mono-
clonal antibody that binds to the HER2/neu receptor,
thereby inhibiting proliferation of tumor cells that over-
express the receptor gene.
63
Hormone therapy is used to block the effects of estro-
gen on the growth of breast cancer cells. Tamoxifen is a
nonsteroidal antiestrogen that binds to estrogen recep-
tors and blocks the effects of estrogens on the growth
of malignant cells in the breast. Studies have shown
decreased cancer recurrence, decreased mortality rates,
and increased 5-year survival rates in women with estro-
gen receptor–positive tissue samples who have been
treated with the drug. Aromatase inhibitors block the
enzyme that converts androstenedione and testosterone
to estrogen in the peripheral tissues. This reduces the
circulating estrogen levels in postmenopausal women
and is becoming the most effective adjuvant therapy
for women with early-stage breast cancer.
64
Autologous
bone marrow transplantation and peripheral stem cell
transplantation are experimental therapies that may be
used for treatment of advanced disease or in women at
increased risk for recurrence.
Paget Disease
Paget disease accounts for 1% of all breast cancers.
57,58
The disease presents as an eczematoid lesion of the
nipple and areola. Paget disease usually is associated
with an infiltrating, intraductal carcinoma. When the
SUMMARY CONCEPTS
■■
The breast contains alveolar glands and ducts
that are lined with epithelial tissue that may give
rise to benign and malignant lesions.
■■
Benign conditions include inflammatory
disorders (mastitis, mammary duct dysplasia,
and fat necrosis) and benign epithelial lesions
(nonproliferative lesions, proliferative lesions
without atypia, and proliferative lesions
with atypia). Some benign conditions, such
as proliferative lesions, may predispose
to malignant disease, and others, such as
fibrocystic changes and fat necrosis, may present
with a mass and signs that resemble malignant
disease.
■■
Breast cancer is a significant cause of death
for women. Some inherited breast cancers are
associated with mutations in breast cancer
genes BRCA1 and BRCA2. The combination of
clinical breast exam and mammography afford
women the best opportunity for detection
of breast cancer which allows for earlier
treatment and improved outcomes. The choice
of treatment, which includes surgical resection,
radiation, and chemotherapy, depends on the
stage of the disease.
lesion is limited to the nipple only, the rate of axillary
metastasis is approximately 5%. Complete examina-
tion is required and includes a mammogram and biopsy.
Treatment depends on the extent of spread.
R E V I EW E X E R C I S E S
1.
Most oral contraceptive agents use low doses of
estrogen and progestin to prevent conception.
A.
Use Figures 40-5 and 40-6 to explain how these
oral agents prevent ovulation and pregnancy.
2.
A 32-year-old woman has been told that the report
of her annual Pap test revealed the presence of mild
cervical dysplasia.
A.
What questions should this woman ask to
become informed about the significance of these
findings?
B.
Cervical cancer is often referred to as a sexually
transmitted disease. Explain.
C.
What type of follow-up care would be
indicated?
