Breast Cancer
What is the breast? Where is it located?
The breast is a superficial organ attached to the muscle on the rib cage. It is present in both males and females and is however more well developed in females. In women, it is made up of milk-producing glands and ducts that carry milk to the nipple. The glands and ducts are supported by fat and fibrous tissue which gives the shape of the breast.
What is breast cancer?
Normally, the healthy cells in our body grow old and replace themselves with new cells in an orderly manner. When there are abnormal changes in this process, the cells go haywire and there is no control over the growth of new cells. This purposeless proliferation of cells takes over the body’s function and is called cancer. When this happens in the breast it’s called breast cancer.
Why have I developed breast cancer?
A majority of women who develop breast cancer have no known risk factor. There are some risk factors that make women more prone to developing breast cancer and this is associated with prolonged exposure to the hormone oestrogen. However, one must keep in mind that just because one or two of these factors may be present, it does not necessarily mean that this is the cause of the cancer
- Early menarche
- Late menopause
- No pregnancies
- Late first childbirth
- Lack of breastfeeding
- Use of OCP (oral contraceptive pills) or HRT (hormone replacement therapy) for prolonged periods
- Obesity
Nearly five percent of breast cancers are genetic and have a strong family history of cancers. Certain genetic mutations like BRCA, P53, can increase the risk of getting cancer.
What are the symptoms of breast cancer?
The presence of breast cancer can be varied. The following symptoms should raise awareness and one must see a doctor for the same:
- New – onset change in the size of one breast
- Lump in the breast
- Skin thickening or ulceration
- Redness in the breast
- Nipple discharge
- Nipple inversion
- Puckering or dimpling, particularly while raising the arms above the head
- Lump in underarm area
- Any new or unusual change in the breast
In western countries, owing to the higher incidence of breast cancer, screening strategies are employed. By this, all patients above the age of 40-50 years are advised to have a mammogram either yearly or once in two years. In India, while a formal screening program does not exist, it is advisable for adults above the age of 40 years, especially those with a family history of breast cancer, to get themselves tested with a baseline mammogram and then a decision of how frequently it needs to be done can be discussed on a case-by-case basis with your doctor.
What investigations will I be subjected to?
The best investigations to help diagnose breast cancer is a mammogram combined with an ultrasound. A mammogram is an X – ray of the breast and the breast is flattened in different positions between two plates for compression. An ultrasound of the breast is many times done in addition to the mammogram and is a painless procedure and does not have any radiation. Jelly is placed on the breast and a probe is used to visualize all areas of the breast systematically. If there is an abnormality or lesion detected in one of these reports, then it is recommended to undergo a core needle biopsy. This help give confirmation as to whether the lump is cancerous or not. It is a minor procedure that takes less than 5-10 minutes and is done under local anaesthesia. A small needle is used to get tissue from the lump that can be sent to the pathologist for testing. The report usually takes a couple of days and hormone receptor testing (including ER/PR/Her 2) can be done on this sample to give us more information regarding the tumor. A staging scan like a CT scan or Ultrasound / X-ray and possibly a PET CT may be asked to check for the spread of cancer to other parts of the body. If an operation is being planned, some more tests may be necessary to decide the fitness of the patient for general anaesthesia.
Are there different types of breast cancer?
Yes, there are different types of breast cancer depending on the type of cell/tissue from which the cancer is arising. Ductal carcinoma is the most common; other varieties include lobular, medullary, papillary, etc. The treatment is usually similar for all the different types of cancer.Â
What is more important is the hormone receptor status of cancer.Â
It can either be hormone-positive or hormone-negative and treatment protocols vary based on this.
At what stage is the cancer?
Accurate staging of the cancer is based on histopathology and will be possible only after surgery. Breast cancer can be broadly classified into Stage 0 cancer or carcinoma in situ is the earliest form of cancer where the cancer is limited to the milk ducts or lobules and has not spread out of the duct. Early cancer – Cancers limited to the breast (less than 5 cm) and ipsilateral (same side) axilla with no skin involvement. Locally advanced – when the tumours are larger than 5cm / number of lymph nodes involved by cancer are high / skin involvement. Metastatic – where cancer has spread far from the breast, e.g. to the liver, lungs, bones, etc.
Now that I have been diagnosed to have breast cancer, how will I be treated?
Different types of treatment are available for patients with breast cancer. There are usually six components to the treatment and based on the stage and characteristics of the diseases, options from these six are chosen. Surgery is usually required for all patients(unless cancer has spread to other parts of the body) and the other parts of the treatment are chosen based on the type of cancer that one has.
- Surgery
- Chemotherapy
- Targeted therapy
- Radiotherapy
- Hormone therapy
- Bisphosphonate therapy
Some patients may be given chemotherapy or targeted after surgery to kill any cancer cells that are left. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells either by killing the cells or stopping them from dividing. Targeted therapy uses drugs or substances to identify and attack specific cancer cells without harming normal cells. Radiation therapy is a ‘light or X-ray therapy’ given to the breast and surrounding areas to prevent the disease from coming back locally. Hormone therapy is given as a tablet for 5-10 years and is given for cancer that is hormone-positive (ER/PR positive). Bisphosphonate therapy is an injection of zoledronic acid which is given to post-menopausal women (usually every six months for three years) for bone health, and it also has a positive outcome for breast cancer.
What kind of surgery is done for breast cancer?
Surgery for breast cancer can be divided into two parts – surgery for the breast and surgery for the axilla (axillary lymph glands)
Surgery for the breast:
Breast preserving operation– Tumour size, breast size, presence of more than one tumour in the breast and stage of the disease, all help to determine if the breast can be preserved during surgery. If you are a candidate for a breast preserving option and are offered this, you should know that the survival (longevity of life) is not affected by preserving the breast and that it is a safe surgery. One must note that if you choose to have a breast preserving surgery, it must be followed up with radiation.
Mastectomy (removal of the whole breast) – When it is not possible to save the breast, or the patient chooses to have her breast removed, then a mastectomy is done. The skin is put together after the surgery and there is no raw area. At the end of the surgery, there is a flat straight surgical scar.
Oncoplasty – Sometimes when a large area of the tissue has to be removed during a breast conservation surgery, the gap to fill is large and just closing it as it may give an ugly result. Therefore, tissue and fat from the neighbouring areas like the back or side fat or breast tissue itself is remoulded to fill in the gap and give a better outside.
Reconstruction– There are options to create a new breast with one’s own tissue (commonly the tummy fat) or with an implant (made of silicon) to make a new breast after a mastectomy. This can either be done at the time of the first surgery itself or as a second surgery anytime in the future.
Surgery for the axilla is always part of the treatment for any breast cancer. If done with the mastectomy, there is no separate scar; but if done with breast conservation there may be a separate scar in the area of the armpit.
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Sentinel lymph node biopsy– This is a procedure where the first set of lymph nodes draining the breast in the axilla are marked out by special techniques and they are removed and sent for testing. If cancer has spread to these lymph nodes, then an axillary clearance is usually done and if the nodes do not have cancer, then there is no further surgery done in the axilla. All this usually happens when one is under anaesthesia itself (frozen section for the lymph nodes) and does not need to be done as a separate procedure.
Axillary clearance– This is a surgery to remove all the lymph nodes in the armpit and is also done in the same anaesthesia as the breast surgery. If we know prior to surgery that the lymph node is involved or if there was a positive node on sentinel lymph node biopsy, then this procedure is performed. At the end of a mastectomy and/or an axillary clearance, a drain is placed, and these come out below the wound and are left in place for 7-10 days. They are meant to drain the fluid from the wound, and this may be a little blood-tinged. Once the amount coming out reduces, the drain is removed.
