Breast cancer is a type of cancer that starts within the tissues of the breast. It is the common type of cancer affecting many American women who are second to lung cancer that is the cause of cancer death. Breast cancer cam is diagnosed in the median age between the ages of 60 and 65 years. The incidence rate of breast cancer is also high in middle age woman. Statistics reveal that 1 in 8 women are susceptible to developing breast cancer in their lifetime.

How to Reduce Breast Cancer

Types of Breast Cancer

Below are the main types of cancer

Ductal Carcinoma:

It starts in the ductal tubes that regulate milk from the breast tissues to the nipples. This is the most common type of breast cancer.

Lobular carcinoma:

It starts in the milk-producing parts of the breast called lobules. This type of cancer is least reported.

Invasive carcinoma:

• Most of the breast cancers are of adenocarcinomas which are classified on the basis of the microscopic appearance of ducts and lobules.
• Invasive ductal carcinoma frequently affects bone, liver, lung or brain, whereas infiltrating lobular carcinoma tends to affect GI tract, reproductive organs, leptomeninges, peritoneal surfaces and other unusual sites.

Non-invasive carcinoma:

DCIS is commonly diagnosed than lobular carcinoma in the situation (LCIS).

Who Are More Susceptible

Breast cancer not only affects female but it also affects males. This type of cancer in males is of the rare type. It is the largest cause of death in American women after lung cancer.

Causes and Risk Factors

They are a variety of things which cause breast cancer

Endocrine factors:

• Marriages at the late age after 30s and first childbirth after 30 as well as nulliparity increases the risk of developing breast cancer.
• Prolonged usage of HRT (Hormone replacement therapy) and longer use of progestins are the contributable factors of breast cancer.
• Environmental and lifestyle changes also contribute to developing breast cancer in women.

Genomic factors:

BRCA1, include BRCA2, in chromosome 13 as well as 17. Other genes identified are associated with hereditary breast cancer includes TP53, CHK2, ATM and PTEN.

Signs and symptoms

General symptoms

They will be no symptoms visible in the asymptomatic patients until the screening of mammary gland is done.

Local signs and symptoms

There is the presence of a painless palpable lump in the breast is the most common symptom.
Nipple discharge retraction or dimpling oedema of the skin with redness or warmth is a less common symptom.
Palpable lymph nodes are local regional symptom also present.

Systemic metastases signs and symptoms

This symptom depends on the site of metastases, it includes bone pain, breathing difficulty, pain in the abdomen or enlargement of it, mental disturbance, jaundice.

How Breast cancer can be diagnosed

It can be diagnosed through following laboratory and diagnostic tests

Lab tests include :

Tumour markers are used to test cancer antigens or carcinoembryonic antigen.

Liver function tests or alkaline phosphatase are used in the evaluation of metastatic disease.

Diagnostic tests include :

Mammogram (it can be done with or without MR scan of the breast)

Biopsy for pathological review and determination of tumour receptors which include estrogen/progesterone status and HER2 status.

Chest x-ray, chest CT scan, abdominal CT scan or

Ultrasound or MRI scan.

Invasive carcinoma:

• Most of the breast cancers are of adenocarcinomas which are classified on the basis of the microscopic appearance of ducts and lobules.
• Invasive ductal carcinoma frequently affects bone, liver, lung or brain, whereas infiltrating lobular carcinoma tends to affect GI tract, reproductive organs, leptomeninges, peritoneal surfaces and other unusual sites.
• Non-invasive carcinoma: DCIS is commonly diagnosed than lobular carcinoma in the situation (LCIS).

Treatment

Stage 1 and stage 2

Breast-conserving therapy involves removal of part of the breast, evaluation of the axillary lymph node, radiation therapy of the breast lump.

Treatment

Systemic adjuvant therapy includes the administration of systemic therapy followed by definitive local therapy (radiation, surgery, or a combination of these). These therapies are followed if there is no evidence of metastatic disease.

Adjuvant Chemotherapy

This therapy can be used alone or in a combination with adjuvant therapy in breast cancer. The medications which are used are fluorouracil, paclitaxel, doxorubicin, epirubicin, cyclophosphamide, paclitaxel, vincristine and vinorelbine.

Stage 3 (Locally advanced breast cancer)

• This type of cancer refers to breast carcinomas with significant primary tumour and nodal disease, but in which distant metastases cannot be documented.
• The NCCN guidelines addressing the management of locally advanced disease recommend starting chemotherapy with either anthracycline or taxane containing drugs.
• Many patients have successful BCT response to chemotherapy is seen. Adjuvant therapy is prescribed to advanced cancer patients to minimize local recurrences, regardless of the type of surgery used for the individual patient.

Stage 4 (Metastatic breast cancer)

Treatment of this stage includes cytotoxic, biological or endocrine therapy often results in regression of disease as well as improves the quality of life of the patients. If the patient responds to the therapy, the duration of survival is also increased. The most important factor which determines response to endocrine therapy is the presence of estrogen and progesterone in the primary tumour tissue. 50-60% patients with ER-positive tumours and 70-80% of patients with ER and PR-positive response to the hormonal therapy successfully whereas ER-negative tumours respond less than 10% to the therapy.

Pharmacogenetic approach

Skincare

• Follow proper hygiene and keep skin clean and dry.
• Keep skin moisture to prevent chapping of the skin.
• Follow proper hygiene of the nails by not cutting the cuticles.
• Do not expose skin to the harmful radiation of the sun, if moving outwears sunscreen.
• Do not perform activities like washing dishes, gardening, using detergents, or working with any other tools without wearing gloves.
• If any minor injury occurs on the skin, clean it with soap and apply antibiotics ointment to avoid the spread of infection.

Lifestyle Changes

• Follow the proper diet and maintain the duration and intensity of the exercise.
• Take rest while performing an exercise which allows the limb to recover.
• Maintain a healthy weight.
• Garments
• Wear non-constricting garments and it should be well-fitted.
• For air, travelling wear well-supported garments

Additional safety measures

• Avoid standing for a long duration of time
• Avoid sitting crossed legs and sitting for a prolonged time.
• Wear clean and hygienic footwear and hosiery.
• Support at-risk limb with well-fitted garment while performing strenuous activity.

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Cardiac arrhythmias occur because of abnormalities of impulse formation or propagation. Abnormal impulse formation

Abnormal Automaticity

Automaticity is another term for pacemaker activity, a characteristic possessed by all cells of the specialised cardiac conduction system during health and, potentially, by other cardiac myocytes during certain disease states. The rate of firing of a pacemaker cell is largely determined by the duration of the phase 4 diastolic interval This in turn is determined by (i) the maximum diastolic potential following depolarization of the preceding action potential, (ii) the slope of diastolic depolarisation due to pacemaker currents and (iii) the threshold potential for generation of a new action potential. In the healthy state, there is a hierarchy of firing rates within the specialised conduction system with the highest rate in the sinus node followed by the AV node and then the His–Purkinje system.

Arrhythmias

Abnormal Impulse Propagation

Re-entry

Many clinically important arrhythmias are due to reentry, in which an activation wavefront rotates continuously around a circuit. Re-entry depends upon a trigger in the form of a premature beat, and a substrate, that is, the reentry circuit itself.

Signs And Symptoms of Arrhythmias

Patients with a cardiac arrhythmia may present with a number of symptoms:

The most common symptom is palpitation, an awareness of an abnormal heartbeat, although some patients with clearly documented arrhythmia have no palpitation. Arrhythmias start suddenly and, therefore, if the patient clearly describes palpitation of sudden onset (‘like flicking a switch’), this is a useful pointer to an arrhythmia rather than heightened awareness of sinus tachycardia, which has a less sudden onset.

The heart is designed to work most efficiently in sinus rhythm. Any arrhythmia compromises cardiac function. Classical symptoms that arise due to reduced cardiac output include reduced exercise capacity, breathlessness and fatigue.

Angina may accompany tachycardia, even in the absence of coronary artery disease. Tachycardia increases the metabolic rate of cardiac muscle and hence its demand for blood flow. Myocardial perfusion occurs predominantly during diastole and during tachycardia proportionately less time is spent in diastole and so myocardial demand for blood can exceed supply, resulting in angina.

A sudden drop in cardiac output may accompany either bradycardia or tachycardia, causing episodes of dizziness (presyncope), loss of consciousness (syncope) or, in extreme cases, sudden death from cardiac arrest.

Atrial tachyarrhythmias such as atrial flutter and atrial fibrillation may be complicated by the development of intracardiac thrombus, usually within the left atrial appendage. This thrombus may embolize to any part of the body but the most common clinical presentation is with a transient ischaemic attack or stroke. Arrhythmias may aggravate heart failure in two ways: (i) the haemodynamic effect of the arrhythmia may precipitate heart failure or aggravate existing heart failure and (ii) prolonged tachycardia of any type may lead to tachycardia-induced cardiomyopathy

Diagnosis of Arrhythmias

It includes a 12-lead ECG and an echocardiogram to detect structural heart disease. Other investigations for structural and ischaemic heart disease may be indicated at this stage with the aim of detecting any underlying structural heart disease. If the history does not include sinister features such as syncope or a family history of sudden unexpected death at a young age, and the resting 12-lead ECG and echocardiogram are normal, then the patient can be reassured that they are extremely unlikely to have a serious heart rhythm disturbance. The extent of further investigation will be dictated by how troublesome the symptoms are.

Treatment for Arrhythmias

Management

Cardiac arrhythmias associated with unstable angina, heart failure or hypotension requires emergency treatment. In most cases, the treatment of choice is d.c. cardioversion.

Concerns about thromboembolism as the heart returns to sinus rhythm are valid but should not delay emergency treatment. Immediate d.c. cardioversion is appropriate when the onset of arrhythmias is clearly identified as within 48 h of presentation or when the patient is already taking warfarin and has had a therapeutic INR for at least 4 weeks.

If facilities permit, a transesophageal echocardiogram may be performed in patients not already on warfarin in order to exclude intracardiac thrombus. Heparin should then be given immediately and continued until the INR is within the therapeutic range.

Anticoagulant therapy should be continued for at least 3 months following cardioversion. Long-term stroke prophylaxis is guided thereafter by the CHADS2 score.

If d.c. cardioversion is deemed inappropriate, rapid ventricular rate control may be achieved with intravenous ß-blockers, verapamil or digoxin.

Drug Therapy for Arrhythmias

Antiarrhythmic drug therapy is used to control the frequency and severity of arrhythmias, with the aim of maintaining sinus rhythm where possible. Although antiarrhythmic drug treatment has been the mainstay of arrhythmia treatment, many of these drugs have limited efficacy and important toxicity. Many arrhythmias are now curable by catheter ablation. Implantable devices such as permanent pacemakers and ICDs have assumed an increasingly important role in the treatment of arrhythmias and, in many cases, antiarrhythmic drugs have an adjunctive role.

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