Why do some people get breast cancer and others do not?
The increase in the incidence of breast cancer in India is due to life style changes such as early menarche, late menopause and either no children or few children and no breast feeding. Inactivity, a sedentary life, obesity and alcohol intake further increase the incidence of breast cancer. Recent data suggest that taking HRT for control of menopause symptoms is another risk factor for breast cancer. Taking low dose hormone birth control pills, however, is not associated with increased risk. Getting older and being a female are the biggest risk factors.
80% of women in our own series of 300 operated breast cancer patients at Delhi Apollo Hospital actually had none of the risk factors enumerated earlier. So, the truth is that we really do not know exactly what causes breast cancer.
The Genetic element in Breast Cancer
BRCA 1 & BRCA 2 are two genes that are linked to breast cancer. Damage to these genes can put women at a very high risk for breast cancer. The presence of these two genes can be determined with a blood test. Wide spread use of these tests to identify women who are at a high risk is under debate as the benefits and risk of knowing of the presence of these genes is not clear. Being positive for these genes does not mean that one will get the disease and being negative does not mean that one will not get the disease. Only 5% to 10% of women with breast cancer have this gene mutation. 90% to 95% of women who do get the disease do not carry this gene.
What are the types of Breast Cancer?
Breast cancer can arise either from the lining of the milk carrying ducts, called ductal cancer, or from milk producing lobules, called lobular carcinoma.
In its earliest form, the cells lining the duct or lobule become abnormal and stay within its wall. This is called in situ (or in place). In situ cancers do not spread to the rest of the body. Once the cells cross the lining of the duct or lobule they are called invasive or infiltrating. In situ cancers almost always are diagnosed on screening mammography.
Infiltrating or invasive cancers, where malignant cells cross the lining of the duct or lobule, can invade or infiltrate adjacent tissues and can spread to neighboring lymph nodes and to the rest of the body by blood vessels. If the cancer cells enter the blood stream, these can then spread to the liver, lung, bones and brain. These then form new tumors called metastases. These distant metastases are most worrisome as the only treatment for these is systemic medicines called chemotherapy, hormonal therapy and immunotherapy.
How can we recognize the early warning signs of Breast Cancer?
• A painless lump (mass) in the breast or axilla.
• Recent thickening of any part of the breast or axilla.
• Bloody discharge or clear discharge from the nipple.
• Scaliness or eczema of the nipple or areola.
• In-drawing of the nipple or skin of the breast.
How do we confirm the presence of Breast Cancer ?
The best way to diagnose breast cancer is to do a biopsy where either a piece from the abnormal mass/thickening is taken and examined under the microscope (core biopsy) or a few cells are withdrawn from the mass and examined (fine needle aspiration cytology – FNAC). FNAC is done with a very thin needle; it takes 2-3 minutes and does not hurt. A core biopsy is done with a larger needle. This is done under local anesthesia and takes 10-15 minutes. It can be done while palpating the tumor with the hand or under ultrasound guidance. Sometimes the tumor is only seen on mammograms or MRIs, then mammographically guided or MRI guided stereotactic instruments are used.
Once a diagnosis of breast cancer is made, other tests are needed to determine whether or not the cancer has spread to other parts of the body. These may involve a Chest X-ray and Ultra sound of the abdomen or a CT scan or MRI of the chest and abdomen. Bones are other sites where the cancer can spread. The most effective way to find any metastasis is to do a bone scan. This test can be omitted if the tumor is small and has not spread to the lymph nodes. One of the newest and most sensitive techniques to find functioning cancer spread is a PET CT scan This reflects both functioning and tissue structure and is more reliable than the conventional CT scans.
What are the treatment options ?
Each cancer is different; each woman is unique and breast sizes vary. Treatment options depend on all the above factors. To choose the right treatment it is essential to know the stage of the disease, type of cancer (DCIS or invasive) and the size of the breast. Breast cancer is divided into four stages: Stage I and II are called early stage, low risk cancers while stage III is advanced high risk cancer. Stage IV is the last stage where there is obvious spread of cancer to the rest of the body and curative treatment is not possible.
For successful treatment of cancer, initial treatment is complete surgical removal of the tumor. Radiation therapy, chemotherapy and hormonal therapy cannot replace complete surgical removal but play an important role in the complete treatment process.
There are two surgical options
WLE (Wide Local Excision or lumpectomy)
Wide local excision removes just the tumor with a safety margin of healthy breast tissue around it and thus conserves the breast. This is called WLF (wide local excision) or wide lumpectomy. This is followed by radiation therapy, i.e., treatment of the remaining breast with high energy x-rays to destroy any cancer cells that may have been left behind. The choice of saving the breast depends on the size of tumor, size of the breast, and personal preference.
Surgical removal of the breast with the cancerous growth is the other treatment option. The modified radical mastectomy removes the entire breast, skin over the tumor and nipple and areola.Reconstruction of the breast by a variety of reconstruction methods can be done at the same sitting. With a mastectomy, a large number or a few lymph nodes under the armpit are also removed and examined histopathologically. The presence of cancer cells in the lymph nodes determines the need for future adjuvant treatments, such as chemotherapy or hormonal therapy. If the tumor is in situ, lymph node removal can be avoided.
After a mastectomy, the breast can be reconstructed using the patient's own tissues or by an implant. Though reconstructive surgery cannot give a new normally functioning breast, it can create a form which will have the shape and texture of the normal breast.
Today reconstruction has become popular mainly because disease is diagnosed in earlier stages of the disease, have longer survival periods and newer methods of plastic surgery reconstruction have evolved. Overlooking a recurrence in a reconstructed breast is a myth. Reconstruction can be done immediately after the mastectomy or at a later date. Reconstruction can be done with synthetic implants or the patient's own tissue taken from another part of the body.
Radiation therapy is a form of treatment that uses high energy x-rays. Radiation destroys the ability of cells to grow and multiply. Both normal and cancerous cells are affected. Normal cells can resume their growth activity but multiplying cancerous cells are destroyed permanently. Radiation therapy is a local regional treatment unlike chemotherapy that treats the entire body. Radiation can be delivered from an outside source or tiny radioactive needles or seeds can be placed inside the breast called brachy therapy.
Surgery and radiation treatment affect and treat the local and regional areas of the breast. Breast cancer, during its development and progression, develops abnormally increased vascularity, which facilitates the spread of cancer cells to the rest of the body. In the initial stages these cancer cells that have broken away are so small that no technology can see them. This spread to rest of the body can only be attacked by chemotherapy (drugs that kill cancer cells), hormonal therapy (drugs that prevent cells from growing), immunotherapy (drugs that fights off cancer) or a combination of these.
Chemotherapy can be given before surgery or afterwards. Chemotherapy given before surgery is called neoadjuvant and is given to reduce the size of the cancerous tumor so that a lumpectomy is possible (if the tumor was large and not suitable for lumpectomy). Chemotherapy cannot totally eliminate all the cancerous cells and hence other treatments, like hormonal and immunotherapy, are needed if the tumor is amenable to such treatment options.
Female hormones are natural chemicals produced by the body to regulate breast growth and milk production, etc. Some of the breast cancers need the female hormones, oestrogen and progesterone, to grow. Anti oestrogens are chemicals that block the action of these hormones and thus stop the growth of the cancer cells. There are three kinds of hormonal drugs. Tamoxifen blocks the effect of oestrogen on the cancer cell, while aromatase inhibitors keep the body from producing these hormones. The third compound, called Faslodex, works by eliminating the hormone receptors on the surface of the cells making the cells insensitive to growth enhancing effects of oestrogen and progesterone.
Chemotherapy does not distinguish between normal dividing cells and cancerous dividing cells and hence produces a lot of side effects. On the other hand immunotherapy, also called biological response modifier or targeted therapy or biotherapy, is a new but effective approach to cancer treatment as it targets cancer cells specifically. The first immunotherapy compound to gain acceptance in breast cancer therapy was Herceptin. It is a monoclonal antibody; monoclonal means it will target only the breast cancer cells producing that particular antigen against which the antibody is used.
Apollo Hospitals offer the following programme for Breast care
• Screening, diagnosis, treatment and follow-up of benign and malignant breast diseases.
• Diagnostic evaluation and treatment may include :
Stereotactic and ultrasound guided core biopsy
Needle localization biopsy
• Breast conservative surgery (Breast saving surgery / Breast removal surgery) .
• High risk screening, genetic testing and counseling.
• Multidisciplinary treatment with medical and radiation oncologists.
• Breast irradiation by IMRT.
• Sentinel Lymph Node Biopsy.
• Reconstructive Surgery.
DIEP Flap Reconstruction
Laparoscopic L.D. flap reconstruction
• Pre-operative and post-operative education.
• Lymphedema and occupational and physical Therapy.
• Private counseling and support groups.
Reach to Recovery
One to one counseling by breast cancer survivors
• Prosthesis and bra fitting.
• Participation in clinical trials for the most advanced breast cancer diagnosis and treatment.