Cancer is a disease characterized by its great diversity. It is a disease that can form from any part of the body and later metastasize. This allows it to clinically imitate other diseases, earning it the title a “great masquerader” or “great imitator”. Additionally, the capacity to derive from almost any structure and later to metastasis is also one of the causes of the high mortality levels associated with the disease. Along with cardiovascular and respiratory causes, cancer is one of the leading causes of mortality worldwide.
However, there are some common signs and symptoms of malignancy such as weight loss, fever, and numerous risk factors. The clinical manifestations resulting from malignancies from a common region also share a similar presentation. For example, regardless of the diversity of subtypes in breast cancer, they share some common clinical manifestations.
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Signs and Symptoms of Breast Cancer
Breast cancer is one of the most common types of cancer and an early diagnosis is crucial for improving the patient’s outcome. In the last few years, this has been possible due to both, screening policies and symptomatic identification of breast cancer. Therefore, it is important for everyone to know the signs and symptoms of breast cancer either as a patient at risk or as a general physician that can refer a patient to a breast specialist. Knowledge of the clinical manifestations will allow adequate treatment that can save lives.
Breast cancer signs and symptoms manifest as general manifestations of malignancy or as specific findings of the malignant tumors. It is important to observe that the manifestation all have a basis either the result of systemic alterations or the alteration of breast tissues.
General Signs of Cancer
One group of signs and symptoms of breast cancer are the systemic or general signs of cancer. The presence or absence of these signs varies a lot. Also, they will vary according to the size of the cancerous mass and the molecular behavior of the cancerous cells.
1. Weight Loss
One of the most common general signs of cancers is undesired or unexplained weight loss. Cancer patients can experience losses of up to 10 pounds in some cases. Weight loss is sometimes explained as the result of increased metabolism and cellular activity of the cancerous cells. Additionally, the increase in caloric consumption can also cause fatigue in patients. Fatigue is described as extreme tiredness that does not improve with rest. The extent and magnitude of these two signs are largely dependent on the size of the cancerous mass. A larger mass will represent more energy consumption, therefore, greater weight loss and worsening of a patient’s fatigue.
Another general sign or symptom is a fever. Either perceived as the patient as a symptom or when measured clinically as a sign, almost all cancer patients will experience fever during the progression of their disease. However, these signs tend to manifest once the cancer mass has begun to metastasize around the body. Only in cancer such as leukemia and lymphomas, the fever will appear as early signs of cancer.
It must be noted that these general signs are not specific to breast cancer. Almost all if not all, type of cancer will show some of these signs. Additionally, each of these signs can be the result of other diseases affecting the patient, such as infections or severe conditions which can even cause all general signs. It is the responsibility of the patient to seek medical assistance if he or she has these signs. Once in the medical consult, a physician should be able to determine the nature of the disease which is causing the clinical manifestations. One of the things that will allow for the differentiation of the underlying cause is the local breast cancer signs and symptoms.
Local Signs and Symptoms of Breast Cancer
The local signs and symptoms of breast cancer are restricted to the breast area and are largely dependent on the anatomical and histological structure of the breast. First of all, it is essential to understand what is the breast area. The breast area is defined by four borders for each breast. On a cranial-caudal aspect, the breast stretches from the upper limit border defined as the collar bone or the 2nd rib to the lower border defined by the 4th rib. Corresponding from the medial to lateral limits, the breast stretches medially from the sternum to laterally to the anterior axillary line.
Within this area is found the breast with all of its structural components. The breast is composed of 15-18 lobes which connect through the main duct which opens into the nipple. The lobes are composed of numerous lobules that have ducts that connect to the main ducts of each lobe. Additionally, vascular, fatty and nervous tissue is found within the breast. Breast cancer originates from the diverse structures described which allow breast cancers to be classified into histological classifications. Furthermore, the signs and symptoms of breast cancer will result from the alterations in these structures. Among the local signs and symptoms of breast cancer are visual findings in the breast, the presence of lumps, axillary lumps, alterations of the nipple, and breast pain.
In general, the study signs and symptoms of breast cancer need certain considerations before studying them. Another aspect to consider in the signs and symptoms of breast cancer is the symmetry of the findings. Symmetrical findings in the breast tend to be the result of a benign process. For example, if a patient presents a secretion of unknown composition, the symmetry of this process can help determine the nature of the underlying condition. Another aspect is the temporal progression of the findings. A patient with a lump that recently appeared is more like to have a malignant process. On the other hand, if the patient has had the lump for a long period of time it’s not likely to be malignant. Finally, being aware of the general state of the patient is relevant as well. Changes in the menstrual period and the puerperium are often physiological and not the signs of malignancy.
Signs and symptoms of breast cancer also need to be evaluated through an adequate physical exam. The physical exam of the breast can be done by both the physician and the patient. Evidently, the patient must keep assisting the regular checkups, but patient self-examination can be crucial to identifying breast cancer at early stages. Following the regular steps of a physical exam, it begins with a visual inspection followed by the palpation of the breast. As previously mentioned, it is important to consider both the symmetry and temporal basis of the findings. Additionally, examination in a different position is essential, which includes a sitting and a standing evaluation. The standing evaluation has two additional different positions, one with the patient’s hand over their head and the other with the patient’s hands on their hips. The first standing position allows the breast tissue to “relax” permitting the evaluation of superficial aspects of the breast. In contrast, the second standing position squeezes the pectoral muscles allows the study of deep aspects of the breast.
Following the regular physical examination, the visual signs and symptoms of breast cancer are the first to be evaluated.
1. Asymmetry of the breast size
Asymmetry of the breast size is one of the first visual signs to be evaluated. Even though regularly one breast is slightly smaller than the other when the difference in size becomes too significant, this can be one of the first signs of breast cancer. This is easily explained by the growing mass on the larger breast.
2. Changes in Breast’s skin texture
Another visual sign of breast cancer is variations in the patient´s breast skin. In one particular type of cancer, Paget´s disease of the breast can be identified through this sign. The changes in the skin found in Paget disease include redness along with flaking or thickened skin around the nipple. Paget’s disease of the breast can also produce other signs and symptoms which will be discussed further ahead. These signs include visual identification of lumps along with variations in the patient´s nipple.
Lumps are one of the most frequent and widely known signs of breast cancer. Once again, both the patient and the physician can play a part in identifying the precise of this clinical finding. For this reason, educating the public about breast examinations has been one of the key parts of the pink ribbon campaign. Lumps can be observed in some cases but are often found upon the palpation of the breast. The palpation must include initially the evaluation of the complete breast area as defined by the boundaries of the breast. Later axillary and other lymph nodes should be palpated aswell.
Breast lumps need to be described in great detail. Lumps that are symmetrical and have been present for a long period of time can generally be considered benign. Asymmetrical and new lumps can be associated with a malignant process. However, additional characteristics of the lump need to be considered to identify it as a sign of breast cancer. Lumps need to be evaluated regarding their size and firmness. Lumps can also be described as regular and with defined borders or as irregular. The latter is typically associated with breast cancer.
4. Lymph node changes
After evaluating the breast, areas outside the breast area also need to be palpated. One of the components of the breast are the lymphatic vessels, which can sometimes act as highways for cancer metastasis. Therefore, lymph nodes can be the site of cancerous metastasis. In particular for breast cancer, the cervical, supraclavicular, infraclavicular and the axillary nodes need to be evaluated. The most common site of breast cancer spread are the axillary nodes. Lymph nodes, to which cancer cells have migrated to, will often be swollen or hard.
5. Nipple retraction or inversion
Within the breast, the nipples can present diverse signs and symptoms of breast cancer. The lobules and lobes of in the breast all lead to the nipple. Because of this, signs and symptoms in the nipple can provide lots of information. Among these findings in the nipple are retractions, inversions, discharges and those associated with Paget´s disease of the breast.
Visual inspection of the nipple in the standing position (with hand over their head) allows greater ease in the evaluation of nipple inversion or retractions. The presence of these findings can suggest an underlying malignant process however it is essential to keep in mind the symmetrical and temporal characteristics of the appearance of this sign.
6. Nipple Discharge
Another important sign which can be found in the nipple is the discharge. Even though the breast’s purpose is to provide milk through its secretion from the nipple, other substances can leak out of the nipple. As with all previous findings, symmetry is an essential aspect to consider when evaluating nipple discharge. However, consistency also needs to be evaluated. White symmetrical secretions can either result from the physiological process after childbirth or as the result of some neurohormonal dysfunction. If a female develops mastitis (which frequently occurs during the breastfeeding period), a unilateral greenish secretion can be secreted through the nipple. However, if instead, a patient produces a spontaneous unilateral red secretion (due to the presence of blood in the discharge), this might indicate a malignant process. Finally, in Paget´s disease of the breast nipples might be flattened, crusty or itchy.
It has been said that knowledge is power, something which can be seen with breast cancer. Yearly during October, great efforts are made to teach patients about the signs and symptoms of breast cancer. Part of comprehending the significance of these clinical manifestations is the understanding of the underlying anatomical and histological basis of the breast exam. The responsibility of this task does not only rely upon the physician as patients are expected to perform self-evaluation of the breast. The combination of efforts by the physician and patient can provide great benefits to society and the patient´s quality of life. Patients who are educated about the disease and its clinical manifestations will be able to identify the presence of underlying malignant processes. These patients will seek medical assistance and be further evaluated by other screening methods currently available. As a result, the physician will be able to provide proper management with better probabilities of success.
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