Breast Cancer – Take Care, Be Aware

Dr Jem Kalathil,
Lead Senior Consultant, Surgical Oncology,
Aster Medcity,
Kochi

The statistics are scary. Breast cancer has today become the leading cause of cancer related deaths in Indian women and accounts for 27% of all cancers in women. Overall, 1 in 28 women is likely to develop breast cancer during her lifetime. The incidence is more in urban areas as compared to rural areas but lack of awareness and absence of regular screenings in the rural areas may contribute to this difference. The incidence rates in India begin to rise in the early thirties and peak at ages 50-64 years.

It is a cause for concern that as per the latest data available, while 1,44,937 new cases were registered in 2012, there were over 70,000 deaths from breast cancer, implying that for every 2 women newly diagnosed with breast cancer, one women died of it. When compared to 2,32,714 new cases and 43,909 deaths from breast cancer in the US, it is clear that more patients in India only turn up for diagnosis and treatment when the cancer is in advanced stages.

It is time to take care and be aware!

The three main risk factors for developing breast cancer are:

1. Gender: Females have a greater chance of developing breast cancer. Breast cancer also affects men, but it is rare.
2. Age: More than 80% of breast cancers occur in women over the age of 50 years. Most men who get breast cancer are over 60 years of age.
3. Family History: Around 5% of people diagnosed with breast cancer have been found to have a faulty BRCA1 or BRCA2 gene.

Other risk factors that contribute to the risk of developing breast cancer are:

1. High fat diet: A high fat diet increases the risk because fat triggers estrogen production that can fuel tumor growth.
2. Smoking: Smoking is a risk factor for many types of cancer. Recent research has shown that smoking is a contributing risk factor for developing breast cancer.
3. Alcohol: Excess consumption of alcohol may contribute to the risk of developing breast cancer. Alcohol also increases estrogen in the blood.
4. Birth control pills: There is an increased risk of breast cancer for women who have been using birth control pills for more than 5 years. The risk is relatively small due to the low quantity of hormones used in the pills today.
5. HRT or Hormone Replacement Therapy: Women with known risks should select alternative methods for symptoms related to menopause.

Visiting a doctor every month for a breast cancer check up in neither practical nor is it required. Any woman can do Breast self examination once a month looking out for any changes in breast tissue, such as changes in size, feeling a lump, dimpling or puckering of the breast, inversion of the nipple, redness or scaliness of the breast skin or nipple/areola area or any discharge of secretions from the nipple.

The self examination should be done 8-10 days after the start of the menstrual period as this is the time when the breasts are least tender and lumpy. If in menopause, then the same day of the month should be selected for self-examination. While it is not unusual to have lumps in the breast, one needs to look out for any change from the previous month’s exam. If there is a persistent lump or other changes, it is important to see a doctor for further investigations. All lumps need not be breast cancer. In fact only a small percentage of breast lumps turn out to be cancerous.

A clinical breast examination should ideally be done annually by a physician or surgeon who is trained to recognise the different signs and indications of possible breast cancer. While the specialist will look for the same signs that a woman may be looking for during her monthly self examination, an experienced doctor can recognise something suspicious that a woman may miss or may not recognise as a warning sign. In such cases, the doctor may ask for further investigations.

Investigations that help in the diagnosis of breast cancer are:

1. Mammogram: A mammogram is an x-ray that allows the doctor to examine the breast tissue for any suspicious areas. In a diagnostic mammogram, more x-rays are taken that help to provide views of the breast tissue from different angle. Mammography is the standard method for diagnosing early-stage breast cancer.Mammogram is advocated as a screening tool only after the age of 40 years.

2. Ultrasound: An ultrasound also may be used to look for suspicious areas.Ultrasound is the choice of breast screening in ladies those who are less than 35 years

3. MRI (Magnetic Resonance Imaging) of the breast: Although breast MRI is not regularly used for breast cancer screening, it may help detect breast cancer in its earliest stage for some women who are at high risk for developing the disease, especially in those with a genetically proven familial Breast cancer

4. Biopsy: Tissue or sometimes fluid is removed from the suspicious area and cells are examined under a microscope as well as subjected to further tests to check for the presence of cancer.

5. Lab Tests: Additional laboratory tests may be ordered to check the prognosis.

In addition to helping in the diagnosis of breast cancer, the investigations and tests help the doctor determine which stage the cancer is in. Knowing the stage of breast cancer helps the doctor to decide on the course of treatment. The stage of breast cancer depends on:
1. The size of the tumor
2. The number of lymph nodes affected
3. Whether or not the breast cancer has spread to other organs in the body like bones, liver, lung or brain.

The stages range from Stage 0 to Stage 4. Stage 0 and Stage 1 are only found during very early detection and the cancer cells are confined to a very limited area. In Stage 2, the cancer is still in the early stages and contained to the breast area, but there is some evidence that the cancer has begun to grow or spread. In Stage 3, cancer has invaded surrounding tissues near the breast and is considered to be locally advanced cancer. Stage 4 is when the cancer has spread beyond the breast to other parts of the body.

Once the doctor has determined the state, the course of treatment will be decided upon. The treatment may include one or more of the following in combination:

1. Surgery: The definitive form of treatment for breast cancer is surgery. This involves removal of the tumor along with the tissue on the margins of the tumor. Depending on the spread, surgery may involve a lumpectomy, Breast Conservation surgery (Removal of only the lump with margins) or mastectomy and reconstruction. Axillary nodes also will be addressed in form of axillary dissection or Sentinel lymph node biopsy (Picking up only the suspicious nodes)
2. Chemotherapy: A combination of drugs that destroy the cancer cells or slow down their growth.
3. Radiation Therapy: High energy rays are used to kill the cancer cells. It also affects the nearby skin or cells in the part exposed to the radiation.
4. Hormone therapy: Hormone therapy drugs may be used if the cancer cells have hormone receptors to destroy the cancer cells by cutting off their supply of hormones.
5. Targeted therapy: This is a newer type of cancer treatment that uses drugs or other substances to more precisely identify and attack cancer cells, usually while doing little damage to normal cells. These are of two types – monoclonal antibodies or small molecules.

Although cancer cannot be prevented, the risk of breast cancer can be reduced through good habits. These include:

1. Maintaining a healthy weight,
2. Staying physically active,
3. Eating fruits and vegetables, and
4. Avoiding smoking and alcohol.

Finally early detection is what leads to the greatest chance of successful treatment. When breast cancer is detected early and is in the localised state, the five year survival rate is almost 100%. So take care, be aware.