Breast Cancer

Introduction 

Breast is the most feminine organ of the body. Breast consists of 15-20 sections called lobes. They are further divided into smaller lobules, which have groups of tiny glands that make milk. After the birth of a child, milk is secreted from the lobules and delivered to the nipples through tiny ducts. The space between the lobules and ducts consists of fat and fibrous tissues. The breast also consists of fat and fibrous tissues. The breast also consists of Lymph ducts, which acts as drainage systems for the wastes created by the breast cells and tissues. They connect to small round tissues called Lymph nodes, which are mainly in the axilla, over the collarbones and in the chest region behind the chest rib.

Breast Cancer

 Breast cancer is one of the most common cancer among Nepali women. Breast cancer mainly denotes cancer arising from the milk ducts that supply milk from the lobules up to the nipple and they are called Ductal Carcinomas. Cancer may also arise from the lobules and other part of the breast. Cancer arising from the lobules are called lobular Carcinoma. The size, stage, rate of growth and other characteristics of tumor determine the kind of treatment the person will receive. Breast cancer is mainly found in women but men also can have breast cancer. As there is less awareness about breast cancer in male there is delay in diagnosis and have poorer outcomes.

What to do when you find a lump in the breast? 

Eighty percent of the lump in the breast is not caused by cancer. They mainly comprises of fibrous tissues, or cysts. But whenever there is a lump in the breast, you should see a doctor for definite diagnosis. It is always helpful to know what your breast normally feels like. That is why monthly breast self-examination is very important. If any changes in the breast is felt, no matter how small or insignificant, it is always good to consult a breast specialist or nearby Breast Clinic.

Risk Factors for Breast Cancer 

1. Age: The chances of getting breast cancer increases as the age increases. Breast cancer is more common in the 5th and 6th decade of life.
 2. Family Health History: The risk of breast increases if you have a first degree relative with Breast cancer, eg. Mother, father, sister or daughter. The risk is even higher if their cancer was diagnosed before the age of 50

3.Genetic changes:If there are certain changes in gene, such as BRCA1 or BRCA2, there is substantial increase in the risk of Breast Cancer.

These specific gene changes can run in the family.If there are more than one person with breast cancer in the family or if breast cancer occurs in person

less than 40 years of age there genetic test can be done to see if there are these risk factors.

4.Reproductive and menstrual history:

- The chance of breast cancer increases if the woman has her first child at an older age, usually above 30 years of age.

- Women who donot breast feed.

- Women who donot have children.

- Women who had their menstrual period before age of 12 or who had menopause after 50 years of age.

- Women who take menopausal hormone therapy for many years have an increased risk of breast cancer.

5. Obesity after menopause: The chance of getting breast cancer are higher in women who are overweight after menopause.

6.Physical Activity: Women who are physically inactive through out their life have an increased risk for breast cancer.

7.Alcohol consumption and smoking : Studies suggest that women who consume alcohol and having smoking habit have an increased risk of breast cancer.

Early Signs and Symptoms of Breast Cancer

Early Breast cancers are without any symptoms, but as the tumor grows it shows following common changes:

- lump or thickening in the breast or underarms

- Change in shape and size of breast

- Dimpling in the skin of breast

- Inward pulling of the nipple

- Discharge from nipple , especially bloody

- change in color or texture of the skin of breast , eg: scaly , swollen, or looks like skin of an orange

Always a doctor or a breast specialist should be consulted without any delay if any of the above symptoms are present.Most of these symptoms are not necessarily

due to cancer but consultation should be done to rule out cancer.

How can we detect and diagnose breast cancer?

Breast specialist or breast clinics do not only diagnose cancer in the breast but can also check for cancer before you

have any symptoms.

Breast Cancer screening:

- Breast self examination:Monthly self examination of breast

- Clinical examination of breast:Done by doctor yearly for women more than 40 years and 2-3 yearly for women between 20-39

years of age.

- Mammogram: Mammogram is an X-Ray of the breast.It can be felt in clinical examination , or before they have any symptoms.

-Women above 40 years should have mammogram done yearly or 2 yearly.

- Women with risk factors for breast cancer should have mammogram earlier in the advice of their doctor.

if a lump is detected then to confirm whether the lump is cancerous or not, a series of test can be advised bt your doctor.The triple test is the recommended breast lesions.

It comprises the following components:

- Clinical breast examination and medical history

- Imaging- mammography and/or ultrasound

- Non-excision biopsy - FNA cytology and/or core biopsy.

1. FNAC of lump/ Cytology of discharge:It is a simple test where a needle is inserted into the lump to aspirate a small amount of cells or discharge is taken under slides, to be examined under microscope. it is easy to perform and inexpensive

2.Core/ Trucut Biopsy: This is also a simple process where a thicker trucut needle is inserted into the lump to take out a chunk of tissue.This biopsy not only helps in establishing the diagnosis but also helps in establishing the hormone receptor status which basis for selection of drugs for further treatment.

3. Hormone receptor test: Some breast cancers need hormone to progress, so they may have receptors for the hormones called estrogen, progesterone, or both. if these hormones are present then hormonal therapy is recommended as an additional treatment option.

4. Her2 /Neu Test : Her2/Neu proteins are found  in some of the breast cancer. if the tumor tissue has too much of her2/neu protein then target therapy drugs can be recommended for them.

5. Other tests: Doctors may advise for other tests like chest x-rays , ultrasound examination of Abdomen, MRI of breast or CT scan of chest and abdomen to further diagnose breast cancer or to examine if cancer has spread to other organs like lungs, liver , bone etc

Staging

When the cancer diagnosis has been established, doctors need to learn the extent of the disease to properly treat the cancer. Staging is based on size of the cancer, if it has spread to the underarm or if it has spread to other organs. So after diagnosis a full examination and tests are done. Usually Staging of breast cancer comprises of Stage I to IV.

Stage one denoting tumor confined to breast, Stage II denoting tumor in Breast and underarm, where as Stage III denote large tumor in breast and more spread to underarm. Stage IV denotes tumor spread to adjacent or far organs.

Treatment in Breast Cancer

The treatment of breast follows individual protocols. The options are Surgery, Chemotherapy, Radiation Therapy,Hormone therapy and Targeted Therapy and Targeted Therapy. Surgery and Radiation Therapy destroys tumor in the breast and underarms, where as Chemotherapy, Hormone Therapy, and Targeted Therapy are systemic therapy where they enters blood stream and dsstroys tumor cells throughout the body. You may receive one or combination of multiple therapy options. In early breast cancer Surgery followed by chemotherapy may be a treatment of choice where as in Late stage chemotherapy or chemotherapy followed by surgery may be of choice. The treatment that is best for one woman may not be best for another. Surgery has become more focused as breast can be preserved with Oncoplastic Techniques, where as if all breast is to be excised; breast can be reconstructed too. Chemotherapy is also personalized as it is catered individually according to patient and tumor sensitivity.

What is best treatment for you can only be decided according to your examination and evaluation. This decision is usually taken by a group of doctors comprising of surgical Oncologist, Medical Oncologist, Radiation Oncologist, Radiologist, Pathologist, etc.