Breast cancer affects one in eight women during their lifespan, and it would be wrong to term it as a disease that hits only the women folk. Although it’s exceptional, breast cancer does strike the opposite sex too. Hence, to create awareness about the disease among the youth, October is observed as Breast Cancer Awareness Month globally.
In an exclusive interview with Salome Phelamei of Zeenews.com, Dr Vathsala HT, MBBS, MS-General Surgery, (MCh) from PGIMER, Chandigarh, discussed a wide range of issues on breast cancer and its risk factors, treatment and prevention.
What is breast cancer?
It is a cancer that arises from the breast tissue. Usually it originates from the lining of milk ducts (ductal carcinoma), or the lobules that produces milk (lobular carcinoma).
What are the different types of breast cancer and which one is the most aggressive?
a) Invasive Epithelial Cancers
Invasive lobular carcinoma
Invasive ductal carcinoma:
Tubular carcinoma
Mucinous or colloid carcinoma
Medullary carcinoma
Adenoid cystic carcinoma
b) Sarcomas (arise from supporting tissue)
Invasive ductal cancer, or infiltrating ductal carcinoma, is the most common form of breast cancer and accounts for about 50% to 70% of invasive breast cancers. Medullary variant tumors are uniformly of high grade, estrogen receptor and progesterone receptor negative, and negative for the HER-2 cell surface receptor so more aggressive.
Inflammatory breast cancer (IBC) is an aggressive form of locally advanced breast cancer that affects approximately 5% of women with breast cancer. It is clinically and pathologically different form of locally advanced breast cancer in that it is rapidly growing.
IBC diffusely involves of the lymphatic channels in the breast and overlying skin. It clinically manifests as redness, edema, and warmth of the breast as a result of lymphatic obstruction, indistinguishable from infection/inflammation of the breast.
These patients tend to treated as breast infection before being diagnosed as having cancer. There may be no mammographic abnormality beyond skin thickening, or any palpable mass, thus further adding to the confusion. Nearly all women have lymph node involvement at the time of diagnosis and more than a third already have metastases.
Despite advances in multimodality treatment, the prognosis of patients with IBC is poor, with a median disease-free survival of about 2.5 years.
Signs and symptoms of breast cancer
The most common symptom is a painless lump for a short duration. Enlarged lymph nodes located in the armpit can also indicate presence of breast cancer.
Indications of cancer other than lump may include changes in breast size or shape, dimpling or puckering of skin, nipple inversion, or spontaneous single-nipple discharge.
Treatment
The mainstay of treatment of breast cancer is surgical removal of cancer along with a margin of normal tissue. Depending on size and stage of cancer, wide local resection or radical removal of breast and axillary nodes can be done. Chemotherapy and radiotherapy can be used as adjuvant to surgery or as primary therapy for locally advanced cancers.
Hormone positive cancers are treated with long-term hormone blocking therapy.
Stage 1 cancers and ductal carcinoma in situ have an excellent prognosis and are generally treated with lumpectomy radiation. HER2 positive cancers should be treated with trastuzumab.
Stage 2 and 3 cancers with a progressively poorer prognosis and greater risk of recurrence are treated with surgery (lumpectomy or mastectomy with or without lymph node removal), chemotherapy (plus trastuzumab for HER2+ cancers) and sometimes with radiation (particularly following large cancers, multiple positive nodes or lumpectomy).
Stage 4, metastatic cancer, (i.e. spread to distant sites) has poor prognosis and is managed by various combination of all treatments from surgery, radiation, chemotherapy and targeted therapies like trastuzumab.
Risk factors for breast cancer
The primary risk factors for breast cancer are female sex, early menarche and late menopause, low parity, lack of childbearing, older age at first child birth, or no breast feeding, higher hormone levels, and those patients who are on hormone replacement therapy.
Smoking tobacco may increase the risk of breast cancer with the greater the amount of smoking and starting early in life the higher the risk.
Other risk factors include previous history of breast cancer and family history. The risk is higher if her family member has had breast cancer before age of 40.
Certain breast changes like proliferative breast disease, atypical ductal/lobular hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes have increased breast cancer risk.
Mutations of genes such as BRCA1 and BRCA2 have lifelong risk of developing breast cancer between 50% and 70%, and they tend to arise at younger age and most often are of aggressive variety.
How is breast cancer detected?
A clinical or self breast exam involves systematic palpation of breast for lumps or other abnormalities and is the simplest, effective and costs almost nothing.
Mammographic screening uses X-rays to examine the breast for any uncharacteristic masses or lumps. Ultrasound, MRI can also be used to detect breast cancer.
Once a mass is recognized, a FNAC or Trucut Biopsy, excisional biopsy may be used to confirm the diagnosis before proceeding to definitive therapy.
Which treatment is best for inflammatory breast cancer (IBC)?
Current treatment approaches emphasize aggressive use of combined-modality treatment, including neo-adjuvant chemotherapy, mastectomy, and radiation therapy, with hormonal therapy in estrogen-responsive tumors. The results of such multimodality treatment now show relapse-free survival rates of 50% or higher at 2-3 years. Research is going on some of new promising therapeutic agents, such as lapatinib -a Her2neu receptor antagonist, VEGF receptor antagonists and tipifarnib a farnesyltransferase inhibitor to name a few.
What is the survival rate for IBC?
Prognosis describes the chance that a patient will recover or have a recurrence of disease. IBC is more likely to have spread to other areas of the body at the time of diagnosis than non-IBC cases. As a result, the 5-year survival for patients with IBC is between 25 and 50 percent, which is significantly lower than the survival rate for patients with non-IBC breast cancer.
While breast cancer is the most common cancer among women, the cases have doubled in India in the last two decades. The number of women estimated to be dying from breast cancer in our country has also been gradually intensifying (48,170 women died of breast cancer in 2007 against 50,821 in 2010), what is the cause of this increasing rate and how can it be prevented?
Causes for this increasing trend may be multi-factorial like lack of exercise, adapting sedentary life style and western food habits leading to obesity. Increasing tobacco use and alcohol consumption by teenage girls in urban areas further add to the risk for breast cancer. Reduced breast feeding, irrational use of hormone replacement therapy and oral contraceptive pills also contribute to this increasing trend in India.
Prevention can be at multiple levels- Primary, secondary and tertiary.
Primary prevention means reducing risk factors leading to cancer like adopting healthy life habits, exercise and weight reduction, vitamins and anti-oxidants consumption, avoiding alcohol and tobacco etc. We also need to promote health by increasing awareness among the youth, especially in rural areas.
Secondary prevention is early detection and cure before it causes significant morbidity with self and clinical breast exams, regular mammographic surveillance after 30yrs, and undergoing appropriate therapy. In a country like India, we need to encourage women to be open and talk about their problems with primary care provider.
Tertiary prevention means limitation of disability and reducing disease-related complications with radical surgery, chemo-radiotherapy etc.
Breast cancer is now more widespread in young ladies, (the average age of developing the disease has shifted from 50 - 70 years to 30 - 50 years in India). What is the reason behind the `age shift`?
One reason for this early detection could be increasing awareness and openness among us, although there is a definite rising incidence of breast cancer in India as you have quoted above.
This may be because more and more women in India are going to work out of their homes, which allows them to get exposed to various risk factors like late age at first childbirth, fewer children and shorter duration of breast-feeding. Among these, the first one is the most important. In addition, early menarche, late menopause and increasing irrational use of hormone replacement therapy add to the risk to some extent.
What would be the appropriate type and timing of treatment for breast cancer during pregnancy and lactation?
In the first 3 months of pregnancy, if patient decides to continue with it, then radical mastectomy with axillary lymph node dissection is necessary. Mastectomy is recommended over lumpectomy and radiation at this stage of the pregnancy, as radiation, which is part of breast conserving therapy is not safe during pregnancy. After surgery chemotherapy is given in the second trimester. Chemotherapy should not be given during the first trimester. It is important to note that if radiation and hormonal therapy are necessary, they should wait until after the baby is born.
If breast cancer is found during the second trimester of pregnancy, the guidelines recommend either mastectomy or lumpectomy, with axillary lymph node dissection. Chemotherapy could be started before surgery.
If diagnosed with breast cancer in third trimester either mastectomy or lumpectomy, with axillary lymph node dissection can be done. Chemotherapy can be safely used if needed. Radiation and hormonal therapy, if needed will be given after the baby is born.
If breast cancer is detected during lactation, she will be treated as per the stage, but she will have to avoid feeding if chemotherapy is instituted.
If breast cancer is there in my family history, when should I start seeing a doctor?
Recommendations for women in a family with a breast and ovarian cancer syndrome include monthly breast self-examination beginning at 18 to 20 years of age, semiannual clinical breast examination beginning at age 25, and annual mammography beginning at age 25, or 10 years before the earliest age at onset of breast cancer in a family member.
In those with BRCA1 or BRCA2 mutations in addition to annual screening, MRI is added by some doctors for early detection.
Prevention of breast cancer
Low fat and meat consumption along with increased intake of vitamins and antioxidants
Exercise regularly and reduce weight
Reduce alcohol consumption
Do not use tobacco
Breast feeding
Monthly Self-breast examination
Annual Clinical breast examination
Hormone Replacement Treatment to be only taken under close supervision
Mammographic surveillance usually from age 30yrs
Medication-Tamoxifen is an estrogen antagonist with proven benefit for the treatment of estrogen receptor positive breast cancer. Furthermore, tamoxifen reduces the incidence of a second primary breast cancer by 50% in women who received the drug as adjuvant therapy for a first breast cancer.
Prophylactic bilateral mastectomy may be considered in patients with BRCA1 and BRCA2 mutations.
