Breast cancer

What is breast cancer?

Important information about breast cancer

• Breast cancer is one of the most common cancers in women with most cases occur in women over 50. In developed countries around one in eight women develop breast cancer at some stage in their life.
• Breast cancer develops from the cancerous cell which develops in the lining of a milk duct or milk gland lobule in one of the breasts.
• If you notice any lump or change to your normal breast then you should see a doctor promptly.
• If breast cancer is diagnosed at an early stage there are good chances of cure.

Types of breast cancer

Broadly breast cancer is divided into :

• Non-invasive and carcinoma in situ. 1) Some people are diagnosed when the cancerous cells are still totally within a duct/lobule. These are called carcinoma in situ as no cancer cells have grown out of the original site. 2) Ductal carcinoma in situ / DCIS is the most common type of non-invasive type of breast cancer.
• Invasive Cancer: 1) Most breast cancers are diagnosed when a tumor has grown from within a duct or lobule into the surrounding breast tissue. These are called invasive breast cancers. 2) Invasive breast cancers are also divided into those where cancer cells have invaded into local blood or lymphatic vessels and those that have not.

Breast cancer stages

• This does not describe a type of cancer but describes how much cancer has grown and whether it has spread.
• Generally the earlier the stage the greater the chances of cure.

Breast cancer Causes

• A cancerous tumor starts from one abdominal cell and multiples “out of control”.
• The exact reason why a cell becomes cancerous is unclear.

Risk factors

Although breast cancer can develop for no apparent reason, there are certain “risk factors” which increase the chances that breast cancer will develop.

Ageing : The risk of developing breast cancer roughly doubles for every 10 years of age.

Where you live : The rate of breast cancer varies between countries, possibly due to environmental factors.

Family history : This means if you have close relatives who have or have had breast cancer.

Being childless or if you had your first child after the age of thirty.

Early stage of starting periods.

Having a menopause over the age of 55.

Taking HRT (Hormone Replacement Therapy) for several years leads to a slightly increased risk.

Have dense breasts.

A past history of some benign breast diseases.

Lifestyle factors : little exercise, obesity after the menopause, excess alcohol.

Family history & genetic testing

• About 102 in 20 cases of breast cancer are caused by a ‘faulty gene’ which can be inherited.
• Breast cancer which is linked to a faulty gene most commonly affects women in their 30’s and 40’s.
• The genes BRCA1 and BRCA2 are the common faulty genes.
• If you have any of the following in your family, you might want to see your doctor.
• Three close blood relatives who developed breast or ovarian cancer at any stage.
• Two close relatives who developed breast or ovarian cancer under the age of 60.
• A close relative, under 40, who developed breast cancer.
• A case of breast cancer in a male relative.
• A relative with cancer in both breasts.

Breast cancer symptoms

The usual first symptoms is a pinless lump in the breast.

Note :

• Most breast lumps are non cancerous.
• Most breast lumps are fluid-filled cysts or fibroadenomas, which are benign.
• Hhowever, you should always see a doctor if a lump develops as the breast lump may be cancerous.

Other symptoms

Other symptoms which may be noticed in the affected breast include :

• Changes in the size or shape of a breast.
• Dimpimg or thickening of the skin on a part of a breast.
• The nipple becomes inverted or retracted.
• Rarely, a discharge from a nipple occurs (Which may be bloodstained).
• A rare type of breast cancer causes a rash around the nipple which can look similar to a small patch of eczema.
• Rarely, pain the breast.

The first place that breast cancer usually spreads to is the lymph nodes (glands) in the armpit. If this occurs you may develop a swelling or lump in an armpit. If the cancer spreads to other parts of the body then various symptoms can develop.

Diagnosis of breast cancer

Initial assessment 

• If you develop a lump or symptoms which may be breast cancer, a doctor will usually examine your breasts and armpits to look for any lumps or other changes.
• You will normally be referred to a specialist.
• Sometimes a biopsy of a obvoius lump is arranged, but other tests may be done first such as :
• Digital Mammogram : This is a special x-ray of the breast tissue which can detect changes in the density of breast tissue which may indicate tumors.
• Ultrasound scan of the breast.
• MRI scan of the breast : This is more commonly performed on younger women, especially those with a strong family history of breast cancer.

Biopsy to confirm the diagnosis

• A biopsy is a small sample of tissue that is removed from a part of the body.
• The sample is examined under the microscope to look for abnormal cells.
• A specialist may take a biopsy with a needle which is inserted into the lump and some cells are withdrawn (FNAC-Fine Needle Aspiration Cytology).
• Sometimes the doctor may be guided as to where to insert the needle with the help of a mammogram or ultrasound scan.
• Sometimes a small operation is needed to obtain a biopsy sample.
• The biopsy sample can confirm or rule out breast cancer. Also the cells from a tumor can be assessed and tested to determine their grade and receptor status.

Assessing the extent and spread (Staging)

• If you are confirmed to have breast cancer, further tests may be needed to assess if it has spread.
• For example, blood tests, an ultrasound scan of the liver, chest , X-ray, a bone scan or other types of scan. This assessment is called ‘staging of the cancer’.

The aim of staging is to find out :

• How large the tumor has grown, if the cancer has spread to local lymph node in the armpit or other areas of the body.
• The grade of the cells and the receptor status of the cancer help doctors to advise on the best treatment options.

Treatment of breast cancer

Treatment options which may be considered include surgery, chemotherapy, radiotherapy and hormone treatment. The treatment selected depends upon :

The cancer itself: 

• Its size and stage (Whether it has spread)
• The grade of the cancer cells
• Whether it is hormone responsive or expresses HER2 receptors.

The women with the cancer

• Her age
• Whether or not she has
  achieved menopause
• Her general health and personal preferences for treatment

Breast Surgery

The type of breast cancer surgery which may be considered are :

• Breast conserving or organ preservation surgery: This is the current option and often suggested if the tumor is not too big.
• A “Lumpectomy” (or wide local excision) is one type of operation where just the tumor and some surrounding breast tissue is removed.
• It is usual to have radiotherapy following this operation
• This aims to kill any cancer cells which have been left in the breast tissue.

Removal of the affected breast (mastectomy)

• This may be necessary if there is tumor of a tumor in the middle of the breast.
• If is often possible to have breast reconstruction surgery to create a new breast following a mastectomy.
• This can often be done at the same time as the mastectomy, although it can also be done later.
• Whatever operation is done, it is usual to remove one or more the lymph nodes int he armpit. These lymph nodes are where breast cancer usually spreads to.
• The lymph nodes which are removed are examined under the microscope to see if they contain any cancer cells.
• This helps to accurately stage the disease and helps to guide the specialist as to what treatment to advise post surgery.
• Alternatively, a sentinel lymph node biopsy may be performed which is a way of assessing if the main lymph nodes draining the breast contain cancer, if they are clear then the remaining lymph nodes in the armpit will not be removed.

Rediotherapy

• Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissues.
• This kills cancer cells or stops cancer cells from multiplying. For breast cancer, radiotherapy is mainly used in the addition to surgery.
• New techniques for radiotherapy are currently in use which reduce the toxicity and duration of treatment.

Chemotherapy

• Chemotherapy is a treatment of cancer by using anti-cancer drugs which kills cancer cells, or stop them from multiplying.
• When chemotherapy is used after surgery it is know as ‘adjuvant chemotherapy’.
• Chemotherapy is sometimes given before surgery to shrink a tumor so that surgery may have a better chance of success and also a smaller operation may be performed. This is known as ‘neoadjuvant chemotherapy’.
• New gene tests are being developed to help doctors decide which women will benefit the most from chemotherapy.
• Chemotherapy may also be used for some women to treat breast cancer which has spread to other areas of the body.

Hormone therapy

• Some types of breast cancer are affected by the female hormone estrogen (and sometimes progesterone).
• These hormones stimulate the cancer cells to divide and multiply
• Treatments which reduce the level of these hormones or prevent them from working are commonly used in people with breast cancer.
• This hormone treatment works best in women with ‘hormone responsive’ breast cancer.
• Hormone treatment include

Estrogen blockers 

• Tamoxifen has been available for many years and is still widely used.
• It works by blocking the estrogen from working on cells. It is usually taken for five years.

Aromotase inhibitors

• These are drugs which work by blocking the production of estrogen in body tissues.
• They are used in women who have gone through menopause.

GnRH (Gonadotropin releasing hormone) analogues

• These drugs work by greatly reducing the amount of estrogen that you make in the ovaries.
• They are usually given by injection and may be used for women who have not yet reached menopause.

Breast cancer in India

• According to Globocan 2012, India along with UnitedStates and China collectively accounts for almost onethird of the global breast cancer burden. (Study Source)
• India is facing challenging situation due to 11.54% increases in incidence and 13.82% increase in mortality due to breastcancer during 2008–2012.
• Breast cancer is now the most common cancer in most cities in India and 2nd most common in rural places. (Source)
• Breast cancer accounts for 25-32% of all cancers in big cities.
• Breast cancer has ranked number one cancer among Indian females with age adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women.
• The age adjusted incidence rate of carcinoma of thebreast was found as high as 41 per 100,000 women for Delhi, followed by Chennai (37.9), Bangalore (34.4)and Thiruvananthapuram District (33.7).
• Besides this young age has been found as a major risk factor for breast cancer in Indian women. Breast cancer projection for India during time periods 2020 suggests the number to go as high as 1797900.