Retraction of the overlying skin, at points if not over a considerable area, giving it a peculiar “saddle-skin” or “pig-skin” appearance. This indication of itself is always suspicious and one which should be noted if present.
In addition to the local evidences in the breast the involvement of the nodes in the axilla and of the lymph vessels leading up toward it. These should be carefully studied, the patient’s arm being held loosely away from the body, and somewhat to the front, in order to relax the pectoral muscle. In fleshy subjects it may not be possible to discover them even if present. The supraclavicular region should also be examined, and enlargements may be felt here or along the cervical chain.
In addition to the above features others which are more indicative, because they point to advanced disease, are the appearance in the skin or just beneath it of shot-like nodules, more or less red, or of any mass which causes the skin to protrude and to have an unnatural appearance, usually one of lividity or threatening ulceration. Pain is an uncertain and variable feature, upon which little stress should be laid. The laity have incorrect notions about the constancy and significance of pain, and many a woman has deluded herself into the notion that she had no cancer because her tumor was not painful. Pain is sometimes pronounced and severe, even radiating down the arm; at other times it is absent until almost the terminal stage.
Any tumor in the breast which presents any one of the above characteristics is to be regarded as at least suspicious, while the occurrence of two or more of the above features should stamp it as malignant, and consequently condemn it. This is equally true of the cancers which rarely appear in the male breast.
Cancer is supposed to be a disease of middle and usually of advanced life. This, again, is an error. To be sure, carcinoma is rare below the age of thirty, and yet one sees it not infrequently in women much younger than that. One of the saddest cases I have ever known was one of carcinoma of both breasts in a young mother of twenty-two, advanced to hopeless condition because her physician had held that it could not be cancer at her age, and because she had coincided with his belief, since she had not suffered pain.
The course of a cancer in the breast depends on several factors. There is a rapidly growing type which tends to kill within a few months, this occurring usually in younger patients. On the other hand there is a slowly growing type which may last over a period of years. This is the so-called atrophic cancer, and its slow growth is due to the perfection of the protection afforded around the cancerous masses by the density of the stroma. Occurring in a fatty breast it leads to a diminution of its total mass, even though the cancerous features themselves be advancing, and this makes it sometimes hard to convince patients that a breast which is actually diminishing in size is becoming more and more seriously involved. Cancer tends ever to advance, and sometimes, as it were, by leaps, the method of invasion being usually one of steady progress and infection of the adjoining tissues; while metastases are to be expected as the case goes on, and occur sometimes in unexpected forms. Thus in cancer of the breast there is a well-known metastatic invasion of the bones, even of the extremities, with the consequent liability to so-called spontaneous fracture. In cases of the latter the former condition should always be suspected. There is a possibility always of invasion of the sternum and the ribs by continuity. It has been shown that invasion of the pectoral muscle, and even of the firm pectoral fascia, was a common result, and this demonstration has led to the adoption of the more recent radical methods of removing both of these structures along with the involved breast. In rare instances both sarcoma and carcinoma assume the miliary type, and evince it by a miliary invasion of the skin of the thorax which becomes gradually infiltrated, softened, and perhaps finally ulcerated, the involved skin thus having the aspect of a corset of diseased tissue, and being spoken of as “jacket cancer” or “cancer en cuirasse.” Such a condition may before the patient’s death involve the entire circumference of the thorax. Any of these miliary expressions of malignancy stamp a case with a hopeless aspect. General miliary carcinosis is also known to occur.
Nearly all cancers grow faster in the young. Other things being equal, there is a somewhat better prognosis for the condition in elderly people, and this applies equally to prospect of recurrence after removal.
In regard to the curability of cancer the reader is again referred to an earlier chapter on the general subject, but doubtless there is a time when if the growth were recognized and thoroughly removed it would not recur and the patient might be cured. This time is, unfortunately, too often past when the case comes under the observation of one competent to deal with it. This is due partly to fear and ignorance on the part of the patient, and unfortunately too often to failure on the part of some practitioner to appreciate the significance of the early manifestations, i. e., to a failure in early diagnosis.
Cancer also occasionally occurs in the male breast, and I have record of a number of fatal instances of this kind. It is, however, quite rare. It is usually of the scirrhus type, but may be the result of epithelioma commencing about the nipple and spreading. It cannot assume marked size without becoming thoroughly distinctive, and probably ulcerating, and there should be no difficulty in diagnosis. It demands the same radical operation as cancer in the female ([Fig. 525]).