BREAST CANCER

Breast cancer is the commonest cancer among women worldwide. It has garnered a lot of attention world-wide and is an active area of pharmacologic and epidemiologic research. Several celebrities are actively supporting breast cancer awareness campaigns.
A few decades ago, breast cancer was largely a cancer of the Western world and not the commonest cancer in India (cervical cancer was the commonest cancer). However, with westernization of the Indian lifestyle, breast cancer incidence started rising and today it has surpassed cervical cancer in urban Indian women. In some of the cities in India, breast cancer makes up for about 25-30% of all cancer cases. The incidence of breast cancer in urban Indian women is ______________and in rural women is ____________.
The growth and development of breast tissue is under hormonal influence. Consequently, hormonal factors play a major role in causation of breast cancer. Early menarche, late menopause, infertility and use of exogenous hormones (pills) are some of the main risk factors for breast cancer. The incidence of Breast cancer rises with increasing age. Postmenopausal women receiving hormone replacement therapy are more prone to breast cancer. Breast cancer may be hereditary, though this occurs in a small proportion of patients. Women with a family history of breast, ovary or uterine cancer are at an increased risk of breast cancer compared to other women with no such history.
Breast cancer often presents as a painless (or sometimes painful) lump which increases in size over a period of time. Though this symptom is easy to spot, most women tend to ignore breast lumps assuming them to be normal variations. Some women do not report this symptom out of fear. Absence of pain causes delay in reporting in a significant number of patients. It needs to be noted that a cancerous lump may be painless or painful and hence, every lump needs to be reported. As mentioned above, age is an important risk factor for breast cancer. A young pubertal girl may notice one or many breast lumps which are often benign (non-cancerous) and represent hormonal changes in the breast. But a lump in a postmenopausal woman needs to be viewed as a potentially malignant lump.
In addition to a breast lump, women with breast cancer may present with nipple discharge, bleeding through the nipple, thickening of skin over the breast lump, retraction of the nipple and increase in the size of the breast. Some women may present with an advanced disease wherein there may be an ulcer or wound over breast with bleeding. Breast cancer often spreads to the axilla (arm-pit) and hence some women may present with a swelling in the arm-pit or neck and swelling of the arm on the affected side. In very advanced cases, where the cancer has spread to other organs, women may present with abdominal pain, weakness, nausea, backache, headache of epileptic fits.
A woman with a suspected breast cancer is advised the ‘Triple Test’- Clinical Examination, Mammography and Tissue diagnosis.
A Clinical examination is a physical examination performed by a clinician. A trained clinician can suspect breast cancer (or exclude the possibility) by a thorough physical examination. In addition, he can obtain important information about the glands in the arm-pit and neck and possible spread of cancer to other parts of the body.
A Mammography is similar to an X-Ray examination of the breast. This tells the size and location of the lump and information about other lumps which may not be felt by the clinician’s hand. It also gives information about the opposite breast. These findings play an important role while planning treatment for breast cancer.
A tissue diagnosis is the ultimate test for cancer. This is done by obtaining cells from the breast lump using a fine needle (Fine Needle Aspiration Cytology- FNAC) or removing a small piece using a tru-cut biopsy technique. The sample thus obtained is examined by a pathologist who can accurately diagnose whether the lump is cancerous or not.
In addition to these test, additional investigations may be performed to evaluate the extent of spread of breast cancer. These include an abdominal ultrasonography, chest X-Ray, bone scan and/or scans of other parts of the body as per the treating doctor’s judgement.
Surgery is the mainstay of treatment of breast cancer. A complete removal of breast alongwith glands in the axilla (arm-pit)- Modified radical Mastectomy- is one of the commonest surgeries performed for breast cancer. In some women, in case the breast lump is small enough and the woman desires to salvage her breast, a breast conserving surgery may be performed where only a part of the breast with glands in the axilla are removed.
Chemotherapy is an important aspect of breast cancer treatment and has brought about improvement in survival of patients with breast cancer. Most (but not all) patients receive chemotherapy after surgery for breast cancer. In some patients, upfront surgery may not be feasible due to large size of the tumour. Such patients are offered chemotherapy and surgery is performed once the tumour is downsized.
Radiation therapy is given to all patients who undergo a breast saving surgery. In addition, some women who have undergone complete removal of the breast may also need Radiotherapy to prevent the disease from reoccurring at the same site. Radiation therapy is given as a daily treatment, usually 5 days a week for 5-6 weeks. It Is advisable to commence radiation therapy within 6 months of surgery.
When a woman undergoes a biopsy (or removal of breast cancer tissue as a part of surgery), the pathologist examines it for expression of hormone receptors. These receptors determine the need of additional hormonal therapy for breast cancer. Women whose breast cancers express Estrogen and/or Progesterone receptors are amenable to treatment by hormonal treatment, which is usually in the form of tablets which need to be consumed daily for 5-10 years.
Screening for breast cancer definitely helps in detecting cancer at an earlier stage and has shown to improve results of treatment. Most people believe that breast cancer screening begins after 40 or 50 years of age. In reality, it recommended that breast cancer screening should begin at the age of 20 years using a simple method- self breast examination. This examination can be performed by women on themselves is to be done once every month. Mammography as a screening modality is widely accepted but the exact age of starting screening mammography is actively debated. However, a woman should discuss about mammography with her doctor after the age of 40. Mammography is definitely recommended for all women over the age of 50.
The outcomes of breast cancer treatment have improved dramatically over the past few decades. Diagnosis at an early stage is an important factor in curing breast cancer and hence women should remain vigilant and should report any breast lump promptly to their treating doctors. Adopting a healthy lifestyle helps preventing breast cancer. Keeping one’s weight near normal, regular exercise, avoiding tobacco and alcohol and ensuring fresh fruits and vegetable in daily diet goes a long way in preventing breast cancer.

- Oncologist in Pune | Cancer Specialist | Dr. Chetan Deshmukh