Cancer is many different diseases characterized by the uncontrolled growth of cells in the body. Cells and tissues are considered to be cancerous, when for reasons not clearly understood, they grow more rapidly than normal and assume abnormal shapes and size and discontinue functioning in a normal manner. Cancer cells do not cease replicating when they touch other cells and when they invade other tissues. Moreover, they do not cling strongly to other cells, and individual cells or clumps of cells float off in the lymphatic system or bloodstream to form a metastasis. Cancer cells are also capable of slow continual division.

  Among women, breast cancer is considered one of the major causes of deaths throughout the world. It is the leading cause of cancer deaths in women from the age of 15 to 74 and in women aged 25 and older is second only to colorectal cancer (Lemberg,1993).

  In the Philippines, data from the 1991 Department of Health (DOH) – Rizal Cancer Registry (Philippine Cancer Society, 1997) indicated that the top three mortality sites among Filipino females were the breasts, lungs and cervix uteri. Furthermore, Laudico et al (1993) and Lim et al (1990) ( as cited in Jumalon, 1997) reported that in our country, the most common type of cancer that strikes Filipino women is breast cancer. In fact, "breast cancer is RP women’s number 1 killer " (PDI, 1992). Compared to other nations in Asia, breast cancer incidence in our country is the highest. From 1983 to 1987, there were 4649 cases and in 1990, this figure rose to 6325. By 1993, 8321 breast cancer cases were reported by the Philippine Cancer Society (PSC).

  Many women die of breast cancer despite the fact that among all cancer types, it is the easiest to treat. Cancer statistics indicates that women whose breast cancers are detected in the early stages, before nodal metastasis and when the tumor is small, survive much longer and have greater opportunity for cure than those women whose breast cancers are discovered at later stages, when nodal or distant metastases and larger tumors are present (Lemberg,1993). Breast cancer detected in the early stages usually requires less-extensive treatment, and conservative therapy is more likely to be attempted and to be effective. Although studies have shown that a 1/3 reduction in mortality can be attributed mainly to mammography, not everyone can avail of it due to its cost. Thus, the importance of breast self-examination (BSE) is emphasized by the DOH in its campaigns against breast cancer. A BSE can detect at least 90 percent of tumors.

  The 1997 Review of Philippine Cancer Facts and Figures reported that a Metro Manila KAP survey by Ngelangel et al in 1989 revealed that only 50 percent of women knew about breast exam and only 54 percent had ever done a breast self-examination. The same team conducted a study in 1993 on the determinants of late stage diagnosis of breast cancer among Filipino patients. The study indicated that economic factors, non-awareness of the gravity of breast cancer upon first presentation and fear of being diagnosed with cancer might be the reasons for late diagnosis.

  Much has been written about the biological aspect of breast cancer. Foreign materials, especially, have been exhaustive in the discussions of the risk factors, diagnosis, treatment and prevention, among others, of breast cancer. However, there is an evident dearth of literature on the social and psychological costs of having this disease. Materials that delve on the needs, i.e. ,aside from the alleviation of physical pain, thoughts and feelings and coping mechanisms of women after having been diagnosed as breast cancer victims are wanting. There is also a need to look into the importance and effectiveness of support groups of cancer patients. In our country, for four years now, the Kapisanan ng May K sa Pilipinas has been functioning as the umbrella society for all cancer support groups. This organization is comprised of patients, their friends, relatives and health – caregivers. But as the Philippine Breast Cancer Network (PBCN) laments, there is a need to have support groups that will address each cancer type, with the rationale that more sensitivity and understanding of the needs of the patient is afforded when the direction is leading towards a single focus.

  This review shall provide information about breast cancer. Thoroughly discussed in separate sections are the following: (a) breast cancer as a disease; (b) risk factors of breast cancer; (c) diagnosis and treatment; (d) preventive measures against breast cancer; (e) factors associated with patient and provider delay in seeking help for breast cancer; (f) life after diagnosis of victims and (g) research gaps. A synthesis caps this review.

 Cancer of the breast is a major health problem of women. According to current cancer statistics, an estimated one woman out of eleven or twelve will develop breast cancer in her lifetime (Lemberg,1993).

 A malignant tumor in the mammary glands of either a male or female characterizes cancer of the breast. However, the occurrence of tumors among the male population is rare. More than 90 percent of malignant tumors start their growth in the mammary ducts. Lesions located far out on the periphery of the breast often spread to the lymph nodes and enter the bloodstream, while those in the central portion spread to the chest. Two major types of tumor can be categorized according to appearance. The first is single, hard, poorly movable lump. This type of tumor radiates out into the fat tissue and may involve the nipple. The second type of tumor is soft and may contain cysts and may show signs of bleeding; and it tends to bulge more than the first type.

  Most breast cancers are characterized by a type of tumor called adecarcinoma. This type of tumor is hard and immobile and measures 2 to 3 cm in diameter when detected. It causes dimpling of the skin or retraction of the nipple.

  Whatever lump is detected in the breast, medical experts say that an immediate and thorough investigation is imperative.

 Age. The peak incidence of breast cancer is generally between 40 to 60, with individual risk beginning to rise at age 25 and continuing to do so as age progresses (Jumalon, 1997).

  The number of newly diagnosed cases of breast cancer has risen during the past few years for women in their 20s and 30s. Prognosis is generally poorer for younger women.

 Previous Cancer in One Breast. The risk for development of carcinoma in the contralateral breast has been estimated to be 5 to 10 times greater than that of the general population, depending on whether the age of primary diagnosis was postmenopausal or premenopausal, respectively (Lemberg, 1993).

  Family History. The increased risk to the individual woman can be very minimal if the primary female relative was a mother or sister diagnosed with postmenopausal, unilateral breast cancer, or very high if the primary relative’s cancer was premenopausal and bilateral (Jacobson et al, 1989). There are no reliable data on risks for women with more distant affected relatives.

 Age at first pregnancy. Women who are over 30 when they have their first child run a slightly greater risk of developing breast cancer than women who had children before age 25.

  Menstruation. Onset of menstrual period (menarche) at a young age, that is before 12, and their discontinuation (menopause) at an older age has been associated with a slightly increased risk of breast cancer (Jacobson, 1989; Lemberg, 1993).

  Body Size. A research team headed by Swanson (1996) came up with the findings that height and one measure of frame size were associated with risk. Height was directly related to breast cancer risk. Women taller than 167 cm had a 46% greater risk compared with women less than 159 cm tall. While a high sitting to standing height ratio was associated with early onset of menarche, breast cancer risk was reduced somewhat among long- waist women. Elbow width was not a breast cancer risk factor. However, large frame size, as assessed by wrist width was protective.

  These assertions are grounded on the theses that height may be related to mammary gland mass and by inference, to the number of ductal stem cells at risk of transformation. Furthermore, adult stature may reflect early environmental influences such as energy intake during childhood and adolescence. Sitting height may be particularly sensitive to early diet and relative sitting height has been proposed as an indirect index of preadolescent nutrition. Briefly, long waisted women tend to experience early menarche and early maturation may reflect increased nutrition during childhood.

  In the same study, weight and adiposity, but not body fat distribution, were found to be related to breast cancer risk. Current body weight was inversely associated with breast cancer risk. Risk was reduced 28% among women who weighed more than 77 kg compared with women who weighed less than 58.6 kg.

 Multiple Births and Maternal Risk of Breast Cancer. Having a multiple last birth was found to be protective against breast cancer. The overall finding of a reduced risk of breast cancer among women who have had a multiple birth is consistent with the hypothesis that the presence of 2 or more fetuses may have a physiologic effect on the mother that protects her against subsequent breast cancer (Jacobson et al, 1989). The double dose of fetal alpha - fetoprotein received by the mother during a twin pregnancy acts a biochemical mediator of the reduction in lifetime risk of breast cancer. Alpha - fetoprotein has recently been reported to possess an important anti-hormonal activity.

  Passive and Active Exposure to Tobacco Smoke. Results of a Geneva study by Morabia et al (1996) of women with breast cancer suggest that both passive and active smoking increase breast cancer risk. The mammary gland is not directly exposed to tobacco smoke but active smoking is associated with cancers of non-respiratory organs. Some polycyclic aromatic hydrocarbons are absorbed by active and passive smokers and concentrated for prolonged periods of time in the mammary ducts as other carcinogens are.

 Alcohol. Dreher (1988) reported that a recent study of the Harvard School of Public Health revealed that women who consumed 0-2 drinks a week had no increased risk of breast cancer. But women who had 3 to 9 drinks a week drove up risk by 30 percent and for those who took 9 or more drinks per week increased risk by 60 percent. Moreover, younger women appear to be most affected. This is based on the premise that alcohol acts as a solvent aiding in the transport of carcinogens across cell membranes.

  High Fat Diets. High fat diets increases the risk of colon, breast and prostate cancer. Dreher (1988), who conducted a laboratory study on mice found out that fatty diets enhance cancerous growth, whether the tumors were chemically caused, occur spontaneously, or are transplanted from other mice. Breast cancer growth was enhanced in these mice when high - fat diet was fed to them after - not before -chemical carcinogens were given. Fat, therefore, is a cancer - promoter, not a cancer - initiator.

  Fat can also facilitate the growth of breast cancer in another way, via its effect on the female hormone. A high estrogen and prolactin level can over stimulate and trigger cancer. Apparently, a high fat diet causes women to produce more estrogen. Women who are overweight and ingest a lot of fat have reduced level of a protein substance responsible for binding estrogen. Without enough of this protein, greater amounts of "unbound" estrogen can circulate and do their breast damage to breast tissue.

 . Mammography and needle aspiration or biopsy are primary diagnostic procedures. A negative mammogram should not deter the biopsy of a suspected lesion.

  Needle aspiration biopsy is used if the lump is suspected to be a mere cyst. Tissue biopsy is undertaken if a malignant tumor is suspected. A pathologist examines both needle aspirate and tissue biopsy. If breast cancer is diagnosed, its spread to other parts of the body is checked through blood tests, x-rays and scanning.

 Treatment is dependent upon the type of breast cancer, its stage, the woman’s age as well as her menopausal status and general health (NCI,1990). Surgery is the primary treatment of breast cancer. Until recent years, the classical radical mastectomy was the treatment of choice for earlier stages of breast cancer. Modified radical mastectomy is now performed, and this is the generally recommended surgical treatment (Lemberg, 1993) . In this surgical procedure, the breast and the axillary lymph nodes are removed but the pectoralis major muscle is preserved. The benefits are reduced difficulties with arm mobility, improved cosmetic effect and improved chances for successful breast reconstruction.

  Surgical diagnosis and treatment can be done in a one-step (surgical biopsy and therapy with one surgical induction) or two-step procedure, which is increasingly accepted. With the two-step procedure, the brief interval between surgical procedures enables the woman to have increased decision-making ability regarding her treatment.

 Radiation therapy is also another type of treatment. Here, high-powered rays are applied to destroy cancer cells and stop them from growing. Like surgery, this treatment is localized; it affects only the cells in the treated area.

 Another accepted treatment of breast cancer is chemotherapy. Chemotherapy uses drugs to eliminate cancer cells. Because of the potency of the drugs used, it is given in cycles, that is, a treatment period followed by a rest period, then another treatment, and so on. This type of treatment is considered systemic therapy.

  In the case of mastectomy, breast reconstruction has been more available for women. Newly developed surgical techniques now make breast reconstruction available to women. In this process, the surgery entails either a flap reconstruction using the patient’s own transplanted tissue and skin or more commonly, a prosthesis is implanted under the muscolufascial layer of the chest wall. Generally, reconstructive surgery is done based on the patient’s desire.

 Untreated, a malignant breast tumor advances in stage, diminishing a woman’s chances of survival. Crucial, therefore, are the early detection and presentation of breast cancer signs and symptoms.

  Signs and Symptoms. The initial complaint of 90 percent of women with breast cancer is lump. On palpation, the lump is usually solitary, unilateral, solid ,hard, irregular, poorly delineated, nonmobile, painless and nontender.

  Nipple discharge, although not frequent, is the second most common initial symptom of breast cancer. Other nipple symptoms include retraction or elevation. Paget’s disease, a category of breast cancer is characterized by eczematoid-like rash of the nipple. Itching or burning of the nipple can be symptomatic of the Paget’s disease.

  Pain occurs among 11 percent of women with breast cancer.

 Skin symptoms such as dimpling, edema, fixation of the breast to the chest wall and later ulceration are usually due to malignancy.

 Signs and symptoms of breast cancer in men include a painless lump under the areola, with or without nipple discharge, retraction or ulceration.

  Detection of Breast Cancer. Success in detecting breast disease is directly related to the thoroughness of the breast examination. Detection can be done through breast self-examination (BSE), clinical breast examination (CBE), and mammography.

 Although the value of BSE in early cancer detection is controversial, studies support that women who properly perform BSE detect their breast cancers at significantly earlier stages. At least 90 percent of tumors are detected by women or their partners, either on purposeful examinations or accidentally (Lemberg, 1993). Those discovered on purposeful examination are earlier-stage tumors than those discovered accidentally.

  BSE involves two steps. First, it is done by observing and second, by touching the breasts. The observation is done for the purpose of detecting changes in appearance, abnormal nipple discharges or bleeding. Touching the breasts are done to determine the presence of lumps or unusual thickening of the breast tissue (Jumalon, 1996).

  CBE is usually done by a health professional. Most often, it is part of the routine in general physical examination. Similar signs and symptoms are checked by the health professional.

  Mammography is an X-ray procedure for detecting breast cancer at an early stage. This is the only procedure that can detect tumors which are less than about one half inch. Studies worldwide show that routine mammography screening reduces mortality among women over 50 years by 30 to 50 percent (Lemberg, 1993).

 Consequential beliefs. Influential but incorrect beliefs increase the likelihood that women delay in seeking professional help. A review of several studies cited by Facione(1993) explain that some women do not realize the significance of the symptom they experience because of the belief that the lump would just go away on its own. Some women also dismiss observed lumps as normal because they have preconceived notion that they are not vulnerable to breast cancer (Calnan,1985).

  Symptom Attribution. Experiencing symptoms other than a lump is associated with significantly greater patient and provider delay (Facione,1993). Pain, bleeding or discharge, dimpling or tissue thickening, inverted nipple were associated with greater delay in patients seeking for medical help as well as medical provider acting immediately. The most common reasons for delay in diagnosis of breast cancer by physicians were physical findings that failed to impress them and low suspicion that the lesion represented a cancer especially when younger women presented self-discovered breast lumps.

  Affective Responses. The timing of help-seeking is also affected significantly by emotional reactions related to the discovery of symptoms. Fear of mastectomy is the leading reason. Other fears were associated with dying and breast loss.

  Social influences. The delay in help - seeking is also seen as a consequence of perceived social role demands. Devotion of time and attention to the needs of other people who are considered by the woman as her significant others, taking time to make domestic arrangements prior to the biopsy, demands associated with summer and school holidays, work-related demands, caring for other ill family members and temporary presence of relatives in the home were some of the social factors that contribute to patient delay in seeking professional help.

  Habits and Prior Learning. Women and provider alike were observed to falsely attribute breast lumps to the benign fibrocystic process. Biopsy was reported as being delayed until additional symptoms provoked reassessment.

 The few researches that describe the self-care practices women try in attempting to cure their breast cancer symptoms cite the following self-care actions taken by women prior to help-seeking : applying antibiotic ointments to cure ulcerations on the nipple, changing bras to correct pain under the breast, washing the nipple to clear secretions, rubbing hard areas to soften the tissue, applying heat to reddened, painful skin areas, removing bra padding and pulling on the nipple to correct nipple inversion ( Facione,1993).

  Calnan(1985) further lend credence to the idea that a lot of women have misconceptions about breast cancer. The general perception of the women respondents was that nothing could be done anyway or they did not know of anything that could be done to reduce their chances of getting breast cancer. One theory was that cancer is already in the body and it just needs to be triggered off.

 Facilitating Environmental Conditions. Economic constraints were reported as affecting women’s help-seeking for breast cancer symptoms. Delays in help-seeking with women belonging to low socioeconomic status were observed in some studies. Thus, the political and economic realities of the status of women throughout the world should alert investigators to the need to explore economic constraints to help-seeking experienced by symptomatic women.

  Literature related to the lives of women after having been diagnosed as breast cancer victims is still in its infancy especially in the Philippines. There certainly are numerous studies that discuss the importance of support groups for the patients but studies dealing with how breast cancer patients feel, adapt and adjust to necessary changes in one’s lifestyle and the importance of the role of the significant others are wanting.

 Needs. The few studies that talk on this topic are one in saying that relief of emotional distress is one of the most important need of cancer patients (MB,1995; Delvaux,1988; Mock,1993). Perhaps, the most evident proof that this need ought to be satisfied is the increasing frequency of breast reconstructive surgery for the purpose of reducing the impact of mastectomy on body image. According to Mock (1993), body image is a mental picture of the "physical self" and includes attitudes and perceptions regarding one’s physical appearance, state of health, skills and sexuality. It is an integral component of self – concept. The female breast is looked upon as a symbol of womanliness, sexual attractiveness and nurturance and consequently then, its loss is regarded a great blow to the woman’s self-concept. Mock’s study found out that there are significant differences in body image according to type of surgical treatment experienced. Women treated with conservative surgery reported greater satisfaction with their bodies than women either with mastectomy or immediate reconstruction. Knobf (1990) presents a negation to this study. She wrote that,

  "at one time, it was thought that breast-preserving surgery would offer women a psychological benefit as well as a cosmetic surgery advantage. Yet , 13 published studies found that the psychological adjustment of women who had mastectomies to be similar to that of women who had conservative surgery".

  Clearly, there are a lot more needs of breast cancer patients that require further inquiry.

  Coping Mechanism. Few medical diagnosis elicit as much fear and feelings of hopelessness as that of cancer. Sutherland’s study (1992) reported that while the survival rates for many types of cancer are improving, the patient and the family may undergo tremendous stress in coping with the medical, physical, psychological, economic and social consequences of the disease. The study further asserted that improved social support is beneficial for patients, particularly if patients receive support from fellow cancer patients for they need to communicate with others who could understand what they were feeling from first hand experience. Unfortunately, the availability of social support is threatened by fear and stigma associated with the disease. In several cases, the demands that go with the disease threaten or overwhelm family and friends. In other instances, despite the availability and willingness to help of a support network, cancer patients themselves may have apprehensions about overburdening those close to them with their emotional and physical needs. The relevance of social support is also discussed in Thompson’s study (1989). The findings show that the effects of social support on coping are not clear. Furthermore, Thompson’s review of several researches indicate that although some studies show that patients with social support find adjusting to their circumstances easier, a number of studies have suggested just the opposite. They suggest that support provided by the significant others may result to "overprotection", which creates additional adjustment problems such as helplessness on the part of the patient. However, the prevailing view is that support from others eases the trauma of stressful life events and aids in successful adjustment. In addition, positive social support has been found to help victims maintain self-esteem and speed recovery from post-traumatic stress. Although the exact mechanisms through which social support works are not known, presumably, support serves a number of functions, including providing material aid, physical assistance and a chance for the expression of feelings.

 Most theoretical discussions of the effects of social support focus on these positive stress-reducing properties; however, there is increasing recognition that all social support is not necessarily beneficial and that some social relationship may serve as a source of further stress for victims.

  The importance of alleviating stress cannot be understated. Stress, mediated by the central nervous system may cause differential progress through cancer stages of tumor induction, growth and metastatic spread (Gross, 1989). A local research by Palma (1997) evaluated the effectiveness of the holistic health management as an approach in alleviating the level of stress of cancer patients. This approach is geared towards getting in touch with emotions, cognitive restructuring of faulty beliefs of controlling the uncontrollable areas of one’s life and learning to establish trust and harmony with God. Findings however showed that though there was reduction in the level of stress felt by cancer patients after the holistic health management, the difference between the level of stress before and after the treatment was not significant.

  This lends credence to the thesis that there is a great need for further studies on how stress among patients especially their families is lessened.

 Research Gaps. The medical field has certainly progressed in improving the chances of survival of breast cancer patients. Yet , a lot of women still die of breast cancer (Lemberg,1993). This presupposes that breast cancer should not solely be investigated by the biomedical field. Gross (1989) supports this contention. Accordingly, several researchers have maintained that the growth of cancer has not been curbed by the intensive biomedical research in oncology which has started since WW II. Such dissatisfaction with the traditional biomedical approach has encouraged oncology research that has followed a more inclusive model of health and illness, to utilize the biopsychosocial model. Unlike the biomedical model which insists that disease is completely caused by divergence from the norm of measurable biological (somatic) variables, Engel’s biopsychosocial model gives weight to the social, psychological and behavioral dimensions of illness as well as the biological. In this model, disease is analyzed at several different levels at once. A consensus has emerged that several clusters of psychological factors warrant further investigation, namely a particular personality style, emotional non-expression and feelings of depression or helplessness and hopelessness (Gross,1989). Until very recently, these factors had stood in an uneasy relationship, with little agreement as to how they were related.

 Dreher (1988) further said that the 1960’s saw the resurgence of interest in the psychosocial aspect of this disease but there is still much to be scrutinized in this concern. For one, psychological researchers have been busy investigating the connections between emotional status and susceptibility to cancer. Since the middle of this century, increasing number of researchers have suggested that emotional expression may also be involved in cancer onset and progression. They have developed a body of highly suggestive data, illuminating a pattern of shared characteristics among those who develop cancer. But many of the biological scientists found psychological issues too vague ad the instruments to measure mind states too imprecise. Thus, at present, the relationship between cancer and the mind stirs strong waves of controversy. Ultimately, it is the patient who suffers in this "war". The patient finds himself or herself torn between his /her belief in the traditional medical approaches of surgery, chemotherapy and radiation and the possibility of additional therapies that often deal with mental states and emotions.

  Other aspects of breast cancer that need to be further explored include how the victims cope with their changed lifestyle. Coping in this sense is used to mean how the women really perceive their situation, how she deals with others especially her family, her expectations from the significant others and her needs apart from the alleviation of pain.

 The literature review presented foreign and local studies delving with the important aspects of breast cancer. Although much has been done to probe on this disease, to date, no explanation has been established yet to pinpoint the cause of breast cancer. Studies however have revealed risk factors. Furthermore, early detection of breast cancer through regular breast self-examination (BSE), clinical breast examination (CBE) and mammography are important for a good prognosis. Despite the effort to promote BSE, studies reveal that this is not done regularly and that, there is patient delay in reporting. Several social factors account for this.

 There are scant of materials on how breast cancer patients deal with their life- threatening illness in terms of changing their lifestyle, importance of support groups and remedies other than what their doctors prescribed to them. This was noted by PBCN and became the driving force behind the establishment of such organization. Studies documenting the effect of support groups on breast cancer patients are important for they highlight the importance of institutionalizing such organizations.