یکشنبه, 20 دی 1394 ساعت 21:33

عوامل خطر در سرطان پستان

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کلینیک امید تهران: عوامل متعددي در بروز سرطان پستان دخيل هستند كه مهمترين آنها عبارتند از :

1ـ جنس : از آنجا كه سرطان پستان به عنوان يك بيماري جنس مونث شناخته شده، لذا جنس اغلب به عنوان يك عامل خطر در نظر گرفته نمي‌شود.اما بطور كلي تنها 1% سرطان‌هاي پستان در جنس مذكر اتفاق مي‌افتد.

2ـ سن: افزايش سن از عوامل خطر بسيار مهم در سرطان پستان مي‌باشد. سرطان پستان در زنان زير 30 سال شايع نيست. اما متاسفانه ميانگين سن بروز سرطان پستان در زنان ايراني بين 15-10 سال كمتر از كشورهاي غربي است و بيشتر ين موارد سرطان پستان در بين سنين 49-40 سال گزارش مي شود.

3ـ سابقه فاميلي: سابقة فاميلي مثبت سرطان پستان، از عوامل خطر شناختة شدة مهم بروز بيماري مي‌باشد و هرگونه سابقة فاميلي سرطان پستان ميزان كلي خطر نسبي را افزايش مي‌دهد كه اين افزايش خطر را مي‌توان با نقش ارث و شرايط ژنتيكي يكسان، سبك زندگي مشابه، عادت‌هاي بدني مشابه و سن اولين قاعدگي توصيه كرد. تنها 5-10% بيماران مبتلا به سرطان پستان، سابقة فاميلي مثبت دارند و افزايش خطر ابتلا به سرطان پستان در فردي كه مادر يا خواهر مبتلا دارد، 5/1 تا 3% ذكر شده است.

4ـ عوامل ژنتيكي: تشخيص دو ژن سركوب كنندة تومور، BRCA1 و BRCA2، تأثير ژنتيك در سرطان پستان را ثابت كرده است. جهش در اين ژن‌ها باعث افزايش خطر قابل توجهي در بروز سرطان مي‌شود به طوري كه جهش هر كدام از ژن‌هاي BRCA1 و يا BRCA2 ، خطر بروز سرطان پستان را در تمام طول عمر يك زن، حدود 85-50% افزايش مي‌دهد. اين دو ژن به صورت اتوزومال غالب به ارث مي‌رسند و مسئول اكثر موارد سرطان پستان ارثي مي‌باشند. در موارد بروز سرطان پستان در سنين پايين (كمتر از 45 تا 55 سال) يا وجود سوابق متعدد فاميلي سرطان پستان يا سابقه فاميلي ساير سرطان‌ها (بخصوص تخمدان) جهش اين دو ژن بايد مدنظر باشد.

5ـ عوامل هورموني: وسعت بروز سرطان پستان در جنس مونث، رابطه آن با هورمونهاي جنسي مونث را بيان مي‌كند. چندين عامل خطرزا در بروز سرطان پستان دخيلند كه همه در ارتباط با استروژن‌هاي درون‌زا يا مصرف هورمون مي‌باشند كه عبارتند از:

ـ سن زودرس اولين قاعدگي : شروع اولين قاعدگي در سنين پائين، خطر سرطان پستان را مي‌افزايد. به نظر مي‌رسد به ازاء هر سال تأخير در سن اولين قاعدگي، خطر سرطان پستان 20% كاهش مي‌يابد كه ممكن است سطح هورمون در بدن در سنين باروري، در زنان با سن زودرس قاعدگي نسبت به زنان با سن ديررس قاعدگي، بالاتر باشد.

ـ شروع ديررس يائسگي: تاثير افزايش سن در افزايش ريسك سرطان پستان، تنها تا قبل از سنين يائسگي، شدت دارد و پس از شروع يائسگي ميزان خطر آن يك ششم قبل مي‌شود كه بيانگر تاثير فعال بودن تخمدان در بروز سرطان پستان مي‌باشد. احتمال بروز سرطان پستان در زنان با شروع سن يائسگي بعد از 55 سال، 2 برابر زناني است كه قبل از 45 سالگي، يائسه مي‌شوند.

ايجاد يائسگي مصنوعي (با عمل جراحي حذف تخمدانها) مي‌تواند احتمال بروز سرطان پستان را كاهش دهد و اين اثر حفاظتي در تمام طول زندگي باقي مي‌ماند.

ـ فقدان حاملگي يا حاملگي در سنين بالا : احتمال بروز سرطان پستان در زنان نازا يا زايمان نكرده، 30-70% بيش از زناني است كه زايمان كرده‌اند. هرچه سن اولين حاملگي كامل، پائين‌تر باشد، خطر سرطان پستان كمتر خواهد بود. احتمال ابتلا به سرطان پستان در زناني كه قبل از 18 سالگي يك دوره بارداري كامل داشته‌اند يك سوم آنهايي است كه سن اولين حاملگي آنها بيش از 35 سال بوده است. خانم‌هايي كه سن اولين حاملگي آنها بيش از 30 سال مي‌باشد حتي نسبت به كساني كه اصلاً فرزند ندارند نيز در معرض خطر بالاتري قرار دارند.

ـ شيردهي: در گذشته شيردهي به مدت طولاني (<36 ماه در تمام طول زندگي) از عوامل كاهش  خطر سرطان پستان محسوب مي‌شد ولي اكنون اين نظريه مورد قبول نيست. اما برخي مطالعات همه‌گير شناسي هنوز نشان مي‌دهد كه مدت طولاني شيردهي در زنان قبل از سن يائسگي تا حدي خطر ابتلا به سرطان پستان را كاهش مي‌دهد.

ـ مصرف قرص‌هاي ضد بارداري: در مورد مصرف قرص‌هاي ضد بارداري خوراكي مطالعات مختلفي شده است. برخي مطالعات نشان داده‌اند كه مصرف قرص‌هاي ضدبارداري خوراكي افزايش قابل توجهي در سرطان پستان ندارند ولي در زنان كمتر از 35 سال به طور خفيفي خطر سرطان پستان را مي‌افزايند.  

ـ هورمون درماني: جايگزيني هورمون‌هاي برون‌زا پس از يائسگي (HRT) با افزايش خطر ابتلا به سرطان پستان همراه است. مطالعات اخير نشان داده‌اند كه هورمون درماني با تركيب استروژن و پروژسترون بيش از هورمون درماني با استروژن به تنهايي، خطر سرطان پستان را افزايش مي‌دهد. گزارشات از دانشگاه آكسفورد نيز هورمون درماني جهت يائسگي را از علل افزايش مختصر بروز سرطان پستان دانسته‌اند. مصرف استروژن به عنوان جايگزين هورموني در قبل و بعد يائسگي بخصوص در افراد با سابقة بيماري‌هاي خوش خيم پستان، خطر ابتلا به سرطان پستان را مي‌افزايد.

ـ سقط : نقش سقط در بروز سرطان پستان هنوز به درستي معلوم نيست. اما برخي مطالعات، سابقة وجود سقط را از عوامل خطر براي ابتلا به سرطان پستان مي‌دانند.

6ـ رژيم غذايي و سبك زندگي: رژيم‌هاي غذايي حاوي چربي بخصوص چربي حيوانات پستاندار، از عوامل دخيل در بروز سرطان پستان است. شيوع سرطان پستان در زنان ژاپني عليرغم مصرف زياد چربي پائين است. اين افراد از چربي‌هايي كه در بدن آبزيان است و حاوي اسيدهاي چرب امگا 3 مي‌باشد، مصرف مي‌كنند. البته مطالعات هنوز تفاوت معني‌داري بين نوع چربي‌هاي مصرفي با ميزان افزايش خطر سرطان پستان نيافته‌اند. به نظر مي‌رسد رژيم‌هاي حاوي ميوه و سبزي زياد شانس ابتلا به سرطان پستان را مي‌كاهند.

مصرف الكل از دیگر علل افزايش خطر ابتلا به سرطان پستان است كه اين افزايش وابسته به دوز مصرفي مي‌باشد. اثر جذب الكل كه همراه با افزايش سطوح استروژن است باعث خطر بروز سرطان پستان مي‌باشد كه طبق مطالعات اخير به نظر مي‌رسد مصرف بالاي اسيد فوليك در تخفيف اين خطر موثر است.

خطر ابتلا به سرطان پستان با وزن نسبي بدن ارتباط مستقيم دارد و احتمال بروز بيماري در افراد چاق، 5/1 تا 2 برابر افراد عادي است. چاقي مي‌تواند باعث افزايش سطوح استروژن خون شود. در بررسي‌هاي اخير اين نتيجه بدست آمده است كه چاقي بعد از يائسگي خطرابتلا به سرطان را بسيار مي‌افزايد.

 ورزش روزانه، به ويژه در سنين پائين، خطر ابتلا به سرطان پستان را در تمام طول زندگي چه قبل و چه بعد از يائسگي كاهش مي‌دهد كه علت آن كاهش سطوح استروژن در گردش خون بدنبال ورزش مي‌باشد.

7ـ نژاد : بر طبق مطالعاتي كه انجام شده است، در زنان كمتر از 40 سال، نژاد سياه و در زنان بيشتر از 45 سال، نژاد سفيد، گروه پرخطر جهت ابتلا به سرطان پستان هستند. كمترين ميزان سرطان پستان در آسيا و بيشترين ميزان در اروپاي شمالي است. شانس سرطان پستان در زنان يهودي خصوصاً در صورت وجود سابقة فاميلي مثبت، 4 برابر ساير افراد است. ميزان بروز سرطان ستان در زنان ايراني حدودا يك پنجم ميزان بروز آن در كشورهاي غربي است. (2/22 در 100 هزار)

8ـ عوامل آسيب شناسي :سابقة شخصي سرطان پستان و سابقة شخصي سرطان مجرايي درجا (DCIS)، عوامل خطر جدي براي ايجاد سرطان پستان جديد مي‌باشند.

در زناني كه سابقة سرطان اولية پستان داشته‌اند، احتمال ابتلاي پستان مقابل 3 تا 4 برابر بيشتر مي‌شود كه در صورت وجود سابقة فاميلي مثبت اين احتمال بيشتر خواهد شد.

در خانم‌هايي كه سابقة كارسينوم رحم يا تخمدان داشته‌اند، احتمال بروز سرطان اولية پستان حدود 3/1 تا 4/1 بار بيشتر مي‌شود.

ضايعات خوش‌خيم پستان، دو نوع تكثيريابنده و غير تكثيريابنده هستند. انواع غيرتكثير يابنده در بروز سرطان پستان دخالتي ندارند ولي انواع تكثير يابنده باعث افزايش خطر نسبي ابتلا به سرطان پستان در حد 5-5/1 درصد مي‌شوند.

9ـ وضعيت اقتصادي و اجتماعي : خطر ابتلا به سرطان پستان، در افراد با وضعيت اقتصادي و اجتماعي بهتر و در افراد تحصيل كرده، بيشتر مي‌باشد. كه اين امر ناشي از وضعيت زندگي متفاوت، مثل رژيم غذايي، سن اولين حاملگي، مصرف هورمون، مصرف الكل و ... مي‌باشد.

10ـ سيگار : در يك بررسي در سال 2000 در كانادا، نشان داده شد كه سيگار كشيدن و يا در معرض دود سيگار قرار گرفتن، باعث افزايش خطر ابتلا به سرطان پستان مي‌باشد. بخصوص در زنان سنين قبل از يائسگي، سال‌هاي كشيدن سيگار و مقدار آن و تعداد سالهاي ترك سيگار، در بروز سرطان دخيلند.

11ـ پرتوتابي: شيوع سرطان پستان در افراد در معرض بمباران‌هاي اتمي هيروشيما و در خانم‌هايي كه به دليل ماستيت، پس از زايمان، تحت درمان با دوز بالاي اشعه قرار گرفته‌اند و نيز در خانم‌هايي كه براي درمان سل ريه يا لنفوم هوجكين، تحت پرتوتابي تشخيصي يا درماني مكرر قرار گرفته‌اند، بيشتر بوده است.  خطر ابتلا به سرطان پستان در افرادي كه به دفعات مكرر تحت تاثير اشعه با دوز كم قرار گرفته‌اند، برابر با كساني است كه يك بار تحت تاثير همان ميزان اشعه با دوز زياد قرار گرفته‌اند.

12ـ تماس با ميدان‌هاي الكترومغناطيسي و مواد حشره‌كش ارگانوكلرايد، نيز از عوامل احتمالي دخيل در بروز سرطان پستان گزارش شده است اما هنوز ارتباطي قطعي آنها ثابت نشده است.

 

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