INTRODUCTION

Breast cancer is a malignancy in breast tissue originating from its ductal epithelial or
lobules. Breast cancer is one of the most prevalent cancer in Indonesia. According to Pathological
Based Registration in Indonesia, breast cancer is in the top position with relative frequency about
18,6%. This disease can also be suffered by men with a frequency of around 1%.

RISK FACTOR
Factors having correlation with increased incidence of breast cancer are:
 Female
 Age >50 years old
 Familial history and genetic (genetic mutation at BRCA1, BRCA2, ATM or p53)
 Previoud breast disease history (DCIS at the same breast, LCIS, high density in
mammography)
 Early menarche (<12 years old) or late menarche (>55 years old)
 Reproduction history (nulliparous and lactation history)
 Hormone
 Obesity
 Chest radiation history
 Environmental factors

PREVENTION AND SCREENING

Primary prevention) is an effort to avoid breast cancer. Primary prevention in the form of
reducing or eliminating risk factors that are thought to be very closely associated with an increased
incidence of breast cancer.
Secondary prevention is breast cancer screening. Breast cancer screening is an examination
to find abnormalities that lead to breast cancer in asymptomatic people. The purpose of screening
is to diagnose breast cancer in early stage so that the treatment results are effective; thus reducing
the likelihood of recurrence, reducing mortality and improving quality of life. Some screening
methods include :
a. Periksa payudara sendiri (SADARI)
SADARI is done individually for female, starting from 20 years old. SADARI is
done every month, 7-10 days after the first day of last menstruation. Steps for SADARI:
1. It starts by looking to both breasts in front of the mirror with the position of the
arms hanging down and then the hands on the waist. See and compare the two
breasts in their shape, size and skin color. Check for the possible abnormalities,
including:
a. Dimpling, skin swelling.
b. Position and shape of the nipple (whether it retracted or swells)
c. Skin redness, wrinkles or ulcers and swelling.
2. Stay in front of the mirror then lift both arms and see abnormalities as in step
1.
3. Check for signs of discharge from the nipple.
4. Next with a lying position, touch both breasts, left breast with right hand and
vice versa, use the inside (volar / palm) of the finger to 2-4. Feel the whole
breast in a circular way from the outside in or can also be vertical from top to
bottom.
5. The next step is to feel the breast in a wet and slippery condition because of the
soap in the bathroom; touch it in a standing position and do it like step 4.
b. Periksa payudara klinis (SADANIS)
This clinical examinations are carried out by trained health workers, starting from
the Level of Primary Health Services. Clinical examination of the breast is carried out at
least once every 3 years or if there is an abnormality in the process
c. Screening mammography
Screening mammography plays an important role, especially in tumors that are very
small or non-papable. Sensitivity varies between 70-80% with a specificity between 80-
90%. Usually mammography is done to women aged above 35 years but because
Indonesian people’s breast aren denser so best results for mammography should be done
after 40 years old. Mammography examination should be done on 7th-10th day of
menstruation because it will reduce discomfort when compression. Mammography for
malignant lesions is divided into primary and secondary signs. The primary sign of
 heightened form of density on the tumor, the tumor boundary irregular because of the
infiltration process to the surrounding tissue or unclear boundaries (comet sign),
translucent features around the tumor, stelata description, the presence of
microcalcifications according to Egan criteria, and size clinical tumor is larger than
radiologist. For secondary signs include skin retraction or skin thickening, increased
vascularization, changes putting position, axillary lymph nodes (+), the state of the tumor
area and irregular fibroglandular tissue, sub-areolar tissue density in the form of a thread.
d. Ultrasonography
Whole breast ultrasound may allow the clinician to screen for breast cancers not
detected by traditional mammography, especially in dense breasts where mammographic
sensitivity is lower(Shah R, 2014). Some studies studies have shown that the incremental
detection of breast cancer by ultrasound following screening mammogram offers only
marginal added benefit just 7,4%.
e. Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging(MRI) has become an important modality in the
detection, assessment, staging, and management of breast cancer in selected patients but
mammography remains the gold standard. Screening MRI is more sensitive but less
specific for the detection of cancer in high risk women. The sensitivity of MRI is 0.77-0.79
compared to mammographic sensitivity of 0.33-0.39. Specificity of MRI is 0.86-0.89
compared to mammographic specificity of 0.95. MRI and mammography demonstrated a
combined sensitivity and specificity of 0.94 and 0.77.
f. Anatomic Pathology Examination
Anatomical Pathology Examination in breast cancer includes cytological
examination, which is assessment of abnormalities breast cell morphology,
histopathological examination is a morphological assessment of tumor tissue. Biopsy done
by frozen cutting and paraffin blocks, molecular examination in the form of
immunohistochemistry, in situ hybridization and gene arrays. Histopathological
examination of paraffin block is the gold standard for determining benign or malignant of
a tumor tissue and can be continued for molecular examination that is
immunohistochemical examination.
 For cytology examination, sampling performed by fine needle biopsy, smear biopsy
and fluid analysis. While for histopathological examination can be done by ttru-cut biopsy
or core biopsy, open biopsy or incision and surgical removal breast (mastectomy).