Breast Cancer

Dr. JAYAPRAKASH MADHAVAN, Senior Oncologist in Kerala, and Head of KIMS Pinnacle Oncology, Thiruvananthapuram, gives an expert analysis to help empower you to combat breast cancer.

One of the biggest challenges that modern medicine faces today is understanding and dealing with the disease called cancer. The word “cancer” simply means uncontrolled growth of a few cells, which may invade into surrounding tissue and may even spread to other parts of one’s body. Breast cancer is the second leading cause of cancer deaths today, after lung cancer and is the most common cancer among women, excluding non-melanoma skin cancers.          

     Every woman is at a definitive risk of breast cancer, which is second only to cervical cancer among women in India. On rare occasions, men also present with breast cancer. The rise of breast cancer among women is being documented mainly in the metros, but it can be safely said that many cases in rural areas go unnoticed. It is reported that one in 22 women in India is likely to suffer from breast cancer during her lifetime. In Kerala, this is the most common cancer diagnosed among women. Statistics has it that approximately 4500-5000 women in Kerala develop breast cancer annually.       

     When diagnosed early, breast cancer can be treated using surgery, radiation therapy and systemic therapies (chemotherapy, hormones or both). If diagnosed in the early stages, this cancer is pretty much curable. Unfortunately, the majority of patients in India come in for treatment when the disease has already reached advanced stages. In such scenarios the onco-surgeon and oncologist have fewer options of treatment to offer to the patient and breast removal is a norm either with or without chemotherapy, followed by radiotherapy many times.  Since the incidence of breast cancer is increasing in India, it has become very important to prevent and detect it early in order to reduce breast cancer related fatalities.

Risk factors

Most breast cancers are sporadic, caused by multiple factors. Only about 5-10% are due to familial cancers. The hereditary breast cancer is traced to inherited mutation in the BRCA1 and BRCA2 genes. The main identifiable risk factors for breast cancer are family history of breast cancer, increasing age, early menstruation with late menopause, and women who have had no children or have had their first child after 30 years. There are also other factors like long-term use of post menopausal replacement therapy and early exposure of chest or breast to radiation.

Symptoms and early detection

                The most important feature of breast cancer is a lump that develops in the breast or surrounding area. The mass that develops is often painless. Since most breast cancers are painless, and not all lumps are cancers, it is advisable to follow the following steps to facilitate early detection. Women aged 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. Women in their 20’s and 30’s should have a clinical breast examination (CBE) as part of a periodic health examination by a health professional, at least every 3 years. After age 40, women should have a breast exam by a doctor or a trained nurse every year. 

Breast self exam (BSE) is another option for women starting in their 20’s. Women should be informed about the benefits and limitations of BSE. Any changes in the breast tissues to the doctor right away. Current recommendations emphasize that women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.       

     Many a time breast cancer may present or be associated with skin changes called peau d’orange appearance (the skin will have a pitted surface, like the peel of an orange), dimpling of skin, nipple retraction, or crusting of the nipple. Associated nipple discharge may also be present. These are due to the strictures and contractions formed by the growing cancer beneath.

Diagnosis

      Diagnosis of breast cancer is done from history, physical examination and mammography. Diagnosis is confirmed by cytological or histopathological examination of a biopsy sample. Fine needle aspiration cytology (FNAC), core needle biopsy, incisional or excisional biopsies are done to obtain the tissue sample for examination. Pathological examination helps to grade the tumor, and assess the completeness of the surgery. Special immunohistochemistry examinations and molecular markers (like ER – Estrogen Receptor, PR– progesterone receptor or Her2Neu – Human Epidermal Growth Factor Receptor 2) help to assess the receptor status to predict the behavior of the tumor and select the appropriate treatment for a particular tumor. Medical science is moving to the era of personalized treatment.

Staging

     After confirming the diagnosis of breast cancer, staging investigations are done to assess whether the tumor has spread to other areas. Cancer can spread to lung, liver, bone and brain. So imaging studies like CT scan, MRI scan, bone scan and PET scan are done to rule out this possibility.   Once all the investigations are obtained, the patients are advised to decide the optimal management. Breast cancer patients require surgery, radiation, chemotherapy, hormones and biological agents for treatment.

Treatment

For treatment purposes breast cancer patients can be divided into three major groups  

     1- Early operable breast cancer 

     2- Locally advanced breast cancer

     3- Metastatic breast cancer

Surgery: Earlier the better

                Early breast cancer is operable and usually limited to breast alone or and to axillary lymph nodes. Treatment of early breast cancer has two components. The first step is local treatment surgery alone or surgery and radiation. The second step is systemic treatment - chemotherapy, hormones and biological agents. This systemic treatment is called adjuvant treatment.                        

Local treatment varies from removal of the breast and axillary lymph nodes (Modified Radical Mastectomy) to lumpectomy and radiation. (breast conservation treatment). In breast conservation treatment, the tumor with a thin rim of normal breast tissue all around the tumor is removed (lumpectomy). After lumpectomy, the breast is irradiated. Both mastectomy and breast conservation treatments have shown equal success in locally controlling and curing the tumor. In western countries 90% of patients present with early stage disease and the majority opt for breast conservation treatment. Even after a mastectomy, some high risk patients require post operative radiation to the chest wall and the armpit. Breast reconstruction surgeries can be done after the mastectomy.

Recurrence-Another threat 

     Adjuvant systemic treatment (supporting treatment) is given to early breast cancer patients because many such patients come back with the cancer recurring at distant sites. At present we do not have mechanisms to predict which patient is going to relapse and which patient is going to be cured by local treatment. Therefore, all are given adjuvant systemic treatment to prevent future recurrence of the disease. The choice of the drugs for adjuvant treatment is determined by factors like stage and grade of the tumor, age, menopausal status, and molecular markers

     Adjuvant treatment is given for a definite period of time. Almost all early breast cancer patients receive chemotherapy. Some of them require hormones and or biological agents like Trastuzumab in addition to chemotherapy. These adjuvant treatments are very effective in significantly reducing the number of breast cancer related deaths.

Locally advanced breast cancer

     More than fifty percent of women approach the doctor when the disease is at an advanced stage.  This group requires anterior chemotherapy to reduce the tumor  in order to facilitate complete surgery. After mastectomy they need local radiation to the chest wall and local lymphatic drainage area, along with systemic treatment.

Metastatic breast cancer

     When breast cancer spreads outside the breast and regional lymph nodes to distant areas, it is called Metastatic breast cancer. The objective of treatment at this stage, is control of disease and prolongation of life. Only subsets of patients achieve long term relief and cure. At present metastatic breast cancer is treated with systemic treatments. The main groups of drugs are chemotherapy, hormones and biological targeted drugs. These drugs are used in combinations or sequentially to control the disease and improve the quality of life. Occasionally patients need radiation treatment to bone and brain metastasis.

Prevention and early detection

     The incidence of breast cancer is increasing in India. It has been observed that lifestyle changes contribute much to this. Low fat intake and regular exercise can reduce the incidence of breast cancer. Drugs like raloxifene are effective in preventing breast cancer in the high risk group of women.

     Early detection is very important, because early stage breast cancer has a high cure rate. The currently available methods of early detection are self examination, Physician breast examination and Mammographic Breast Examination. Mammographic examination uses soft X-rays to image the breast. With this test we can detect tiny, even non palpable breast cancer. Mammography is used for women above 40 years. In high risk women below the age of 40, MRI examination of the breast is useful to detect early cancers. The American Cancer Society recommends annual mammographic examination for all women above 40 years of age.

     Early detection and adjuvant treatment of breast cancer have contributed immensely to reducing breast cancer related deaths. Early detection will help the majority of our women with breast cancer to undergo breast conservation treatment also, which in turn can help them lead a normal life.

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Women at high risk include those who:

•Have a known BRCA1 or BRCA2 gene mutation  •Have a first-degree relative (parent, brother, sister, or child) but have not had genetic testing themselves  •Have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history

•Had radiation therapy to the chest between the ages of 10 and 30 years

•Have Li-Fraumeni syndrome, Cowden syndrome, or hereditary diffuse gastric cancer, or have first-degree relatives with one of these syndromes

Women at moderately increased risk include those who:

• Have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below) 

• Have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH) 

• Have extremely dense breasts or unevenly dense breasts when viewed by mammograms

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