Breast Cancer

Synonyms: Breast carcinoma.

Symptoms: Changes in the size, shape, or appearance of the breast, breast discharge, breast pain, and presence of a lump in the breasts.

Risk Factors: family history of breast cancer, age greater than 40 years, gender, previous history of radiation therapy, obesity, smoking and alcohol.

Prevalence: Currently, 2.3 million people worldwide are diagnosed with breast cancer. In India, the total number of individuals (women) living with breast cancer is 28%. 

Severity: Severe

Which doctor to consult: Oncologist, radiation oncologist, oncosurgeon.

Overview: 

Breast cancer is a medical illness characterized by uncontrolled, out-of-control growth of the breast cells, leading to tumour formation. As a result,  this condition is also known as breast tumour. These cancer-causing cells can travel to other areas of the body and frequently involve lymph nodes and healthy breast tissue.

This cancer, which affects a large number of women, is the second most prevalent type in women. But men and children can also develop breast cancer sometimes. Breast cancer symptoms include changes to the breast or nipples, lumps under the armpit, and pain in the breast or nipples that should not be disregarded.

Breast tissue that has ducts, which are tiny tubes, and lobules, which are milk-producing glands, is affected by breast cancer. There are various screening tests for breast cancer detection in the market. Treatment of breast cancer includes surgery (removal of the whole breast or only a part of the breast tissue or a lump in the breast is removed), medications like chemotherapy, radiation and hormonal therapy.

Types:

There are different types and subtypes of breast cancer:
1. Invasive ductal carcinoma (IDC): It is one of the most common types of breast cancer in which the cancerous cells start developing in the tiny tubes called milk ducts and can spread to the nearby breast tissues

2. Lobular breast carcinoma (LBC): It is the second common breast cancer that begins in the milk producing glands called lobules of the breast and can spread to the nearby breast tissues.

3. Ductal carcinoma in-situ (DCIS): This condition is similar to invasive (infiltrating) ductal carcinoma. The only difference include unlike IDC, the cancerous cells does not spread to other nearby parts in ductal carcinoma in-situ.

There are less common type of breast cancers such as:

• Inflammatory breast cancer: It is a rare disease in which the cancer cells block lymph vessels in the skin of the breast due to which the breast often looks swollen, red and inflamed.
• Paget’s disease of the breast: It is a rare type of breast cancer in which less than 4% of breast cancer women get diagnosed with this disease. This condition mostly affects the skin of the nipple which looks like a rash.

Symptoms:

It is said that most breast cancer patients may not observe the symptoms in the early stage, however, there may be few changes in your breast which can be seen. These changes can help in early detection of breast cancer. The most common signs and symptoms of breast cancer include:

•    Breast pain/tenderness
•    Breast discharge
•    The presence of the lump in the breast
•    Painful, inverted or enlarged nipple
•    Change in the size and appearance of the breast
•    Bleeding from the nipple.
•    Swollen lymph nodes.

Causes/Risk factors:

• Age: If you are older, especially above 50 years of age, then you can be at higher risk for breast cancer.
• Gender: Most women are at greater risk for developing breast cancer than men.
• Family history: If any of your family members especially your mother, daughter, or sister have a history of breast or ovarian cancer, then you are at the greatest risk for developing breast cancer.
• Underlying conditions: If you have dense breasts, attained early menarche or delayed menopause, did not conceive for a long duration or became pregnant after 30 years of age, or are obese are considered to be one of the causes of breast cancer.
• Smoking: Avoid smoking as it can also be one of the risk factors for hyperthyroidism.

• Medical history: Generally women receiving hormonal therapy after menopause or had any history of radiation therapy especially to the neck, chest and head are also at risk of getting breast cancer.

  Complications:

Breast cancer can lead to a range of complications, particularly if it progresses or spreads. Some of the potential complications associated with breast cancer include:

• Metastasis: The cancer may spread to other parts of the body, such as the bones, lungs, liver, or brain, which can lead to further health issues and symptoms specific to those areas.
• Lymphedema: After surgery or radiation therapy, there can be swelling in the arm or chest area due to lymph fluid build-up.
• Pain: This can be a direct result of the cancer itself or as a side effect of treatments like chemotherapy, surgery, or radiation therapy.
• Bone complications: If cancer spreads to the bones, it can cause bone pain, fractures, and spinal compression, leading to additional pain and mobility issues.
• Treatment-related complications: These can include side effects from chemotherapy, hormone therapy, targeted therapy, and radiation, such as fatigue, nausea, hair loss, and increased risk of infections

Individuals with breast cancer need to work closely with their healthcare team to monitor for these complications and manage them effectively. Treatments and supportive care can help alleviate symptoms and improve quality of life. If you or someone you know is dealing with breast cancer, it’s crucial to stay informed about potential complications and communicate regularly with healthcare providers about any new or worsening symptoms.

Prevention:

Preventing breast cancer involves a combination of lifestyle choices, medical strategies, and awareness of one’s personal risk factors. Here are some measures that may help reduce the risk of developing breast cancer:

• Maintain a healthy weight: Being overweight or obese can increase the risk of breast cancer, especially after menopause.
• Exercise regularly: Physical activity can help you maintain a healthy weight, which helps prevent breast cancer.
• Limit alcohol: The more alcohol you drink, the greater your risk of developing breast cancer.
• Breastfeed: Breastfeeding might play a role in breast cancer prevention. The longer you breastfeed, the greater the protective effect.
• Limit dose and duration of hormone therapy: Combination hormone therapy for more than three to five years increases the risk of breast cancer. If you’re taking hormone therapy for menopausal symptoms, ask your doctor about other options
• Avoid exposure to radiation and environmental pollution: Some medical-imaging methods, such as computerized tomography, use high doses of radiation, which have been linked with breast cancer risk
• Genetic counselling and testing: If you have a strong family history of breast cancer or other cancers, your doctor may recommend genetic counselling and testing for BRCA or other gene mutations

It’s important to note that while these measures can reduce the risk of breast cancer, they cannot eliminate it. Regular screenings and self-examinations are crucial for early detection, which can greatly improve the chances of successful treatment. Always consult with a healthcare professional to understand your personal risk and the best preventive measures for you.

When to see a doctor:

You can visit an oncologist or an oncosurgeon if you have any symptoms such as breast pain/tenderness, breast discharge, presence of a lump, change on breast size and shape, swelling around the nipple or bleeding. Based on your physical examination and the signs and symptoms, your doctor will advise diagnosis.

Diagnosis

The breast cancer condition has certain tests that can prove the disease before starting further treatment. This includes: 

1. Physical examination of the breast

Breast self-examination (BSE): 

• As the name implies, breast self-examination is a self-administered breast cancer screening test which can be done by yourself at home. All women above the age of 15 should perform this once a month, as it typically takes 5 to 10 minutes.

• Hold your shoulders straight and your hands by your sides while standing topless in front of a mirror. 

• Examine your breasts in the mirror to spot any physical changes, such as puckering, dimpling, or inversion of the nipple, as well as adjustments to their size, shape, or symmetry. 

• To check for changes in the breast, raise your hands and place the palms on the back of the head. Lift one breast at a time and repeat

• Use the pads of your fingers—not the tips—to feel your breasts. Similar to how you would massage the area, apply pressure and move your fingers in a circular motion over the breasts. Move toward the armpits, the middle of the breastbone, and the collarbone while doing this.

• Examine your breasts both in the shower and while you're lying down. When having a shower, using soap and water helps your fingers slide over the skin more easily, allowing you to feel the breasts more easily.

• Repeat the action, putting one hand over the back of the head and using the other to massage the breast. Finally, give the nipple a light squeeze to see if any discharge occurs.

  2. Clinical breast examination (CBE)

  A physician/oncologist or a nurse will perform the clinical breast exam (CBE). In this exam, the doctor feels the breasts with his or her hands to check for lumps, hardness, discharge from the nipples, and other changes. Women who are more susceptible to breast cancer should have it done every six months, or as soon as there is any anomaly or indication of breast cancer. You should schedule a CBE very away to look into any abnormalities you see during BSE.

  3. Mammography 

  In basic terms, mammography is an X-ray of the breast tissue. After the age of 40, it should be done annually by all women, or more frequently if your doctor recommends it. Mammography on its own is not helpful for women who have large breasts. It must be done in conjunction with ultrasonography in these women, or as directed by your physician.

  4. Magnetic resonance mammogram 

  When it comes to screening women who have a high risk of breast cancer, such as those who have a BRCA gene mutation, it is thought to be superior to mammography and CBE. This technique takes images of the breast and looks for anomalies using radio waves and magnetic fields. MRI is utilized as a screening method in conjunction with mammography and CBE for women in high-risk groups. Breast MRIs are not recommended for women with an average risk of cancer since they may appear abnormal even in the absence of malignancy. 

  5. Other tests

  If the screening tests reveal any abnormalities, the lady may be advised to undergo additional testing to determine the cause of her problem. This includes: 
  
  

• Excision biopsy: To examine a mass of tissue, it is excised. This is employed to identify the cell types implicated in breast cancer. 

• Fine needle aspiration cytology, or FNAC: Fluid is extracted from breast tissue using a fine gauge needle to be examined under a microscope. 

• CT scan: This is useful for determining if breast cancer has spread to other areas of the body.

Treatment:

There are different types of breast cancer. Hence the treatment for breast cancer will be different for every individual patient. To address breast cancer, a few common parameters should be considered before deciding the treatment procedure. This includes the type of cancer, location of cancer in the breast, size of the tumor, stage of cancer, age of the patient, whether the tumor has spread to other parts of the body, menopausal status of the women, presence of any genetic mutations, hormonal receptors or proteins on the cancer cells and general fitness of the patient.

Based on all these parameters your oncologist will decide or customise the best treatment plan for you. There are different treatment plans for breast cancer. Your doctor may advise one or more than one treatment plans for your recovery. 

1. Chemotherapy:

This treatment is the involvement of medications which can be given either orally (through mouth) or parenterally (through intravenous route) or both. It is one of the most effective methods in which the medication helps to kill the growth of cancer cells. Some of the most common medicines include cyclophosphamide, fluorouracil, vinblastine, vinorelbine, gemcitabine, capecitabine, etc. Side effects of chemotherapy include fever, hair loss, loss of appetite, diarrhoea/constipation, extreme fatigue, risk of infections, etc.

Using a combination of medications for a predetermined number of cycles over a predetermined period is what your doctor refers to as a chemotherapy schedule/cycles. The schedule can be followed once a week for two, three, or four weeks. Most of the time, you can have chemotherapy regimens in a single day and return home or have to spend in the hospital in certain situations.

2. Radiation therapy: 

As the name implies, this therapy uses high-energy rays to kill the cancerous cells. This procedure is mostly used to treat metastatic (cancer cells which spread to other parts of the body) breast cancer, after breast cancer surgery to lower the risk of cancer recurrence, after mastectomy or when the cancerous mass is huge enough. There are different types of radiation procedures such as

• External beam radiation therapy: It is one of the most commonly used procedures in which radiation is given outside the body via a machine.
• Intraoperative radiation therapy: In this therapy, the radiation is sent via the probe in the operation room.
• Brachytherapy radiation: This therapy is given by placing the radioactive substances into the tumor.

The radiation therapy team will determine the radiation dosage, its location, and the radiation exposure to the surrounding tissue. In radiation therapy, the radiographer will advise you to lie on the breast board by either raising your arms over the head or not. Then the person will fix the machine using the marks on your body or shell to place you in the right position. Once everything is set up, images will be taken and you need to hold your breath for a few minutes. The most common side effects of radiation therapy include fatigue, redness on the skin, pain at the site of radiation, etc.

3. Immunotherapy:

Immunotherapy is a promising treatment approach for breast cancer that works by enhancing the body’s immune system to recognize and destroy cancer cells more effectively. It is used mainly to prevent the spread of cancerous cells to others parts of the body, stop the growth of cancer cells, etc. Some of the examples of immunotherapy drugs include pembrolizumab, atezolizumab and many more. Some of the common side effects of immunotherapy include fatigue, skin rash, and more serious autoimmune reactions.

4. Hormonal therapy: 

Hormonal therapy, is a form of treatment for breast cancer that either lowers estrogen levels in the body or stops estrogen from aiding the growth of breast cancer cells.  It is recommended for women with tumors that are hormone receptor-positive (HR+), which means the cancer cells have receptors that attach to estrogen and progesterone, helping them grow. Injections or tablets are the available forms of medication used in hormone therapy. 

When it comes to medications, such as tamoxifen or aromatase inhibitors like anastrozole, doctors typically recommend them for a maximum of five years, however, fulvestrant is administered as an injection once a month. The common side effects of hormonal therapy include hot flashes, fatigue, mood swings, and a risk of blood clots. 

5. Targeted therapy: 

Targeted therapy for breast cancer is a form of treatment that uses drugs or other substances to precisely identify and attack cancer cells, usually while doing little damage to normal cells. These therapies target the specific genes, proteins, or the tissue environment that contributes to cancer’s growth and survival.

Recently human epidermal growth factor receptor (HER2) therapies have been used in the treatment of breast cancer. It is mainly used before surgery, after surgery, if breast cancer recurs or for secondary breast cancer. About 15% to 20% of breast cancers have too much of a protein called HER2 on their cells. Examples of targeted therapy include

• Trastuzumab: for non-metastatic HER2-positive breast cancer.
• Pertuzumab: for HER2-positive breast cancer in combination with trastuzumab & chemotherapy
• Neratinib: for higher-risk HER2-positive, early-stage breast cancer.

The most common side effects of targeted therapy include nausea, vomiting diarrhoea, fatigue, mouth sores, skin rash, etc. The side effects of this therapy mainly depends on dose of the medicine, type of the medicine, and overall health of the patient.

6. Surgery:

It is a common treatment for breast cancer and is often the first line of treatment. The type of surgery depends on the size and stage of the cancer, whether it has spread, and other factors. Here are the main types of breast cancer surgery:
•    Lumpectomy: Also known as breast-conserving surgery, this procedure involves removing the tumor and a small margin of surrounding tissue while leaving the rest of the breast intact.
•    Mastectomy: This surgery involves removing the entire breast. There are several types of mastectomy, including total mastectomy, skin-sparing mastectomy, and nipple-sparing mastectomy.
•    Sentinel lymph node biopsy: If breast cancer is suspected to have spread, this procedure can identify the first few lymph nodes into which a tumor drains (sentinel nodes) and remove them for testing.
•    Axillary lymph node dissection: If cancer is found in the sentinel nodes, additional lymph nodes may be removed from the armpit to help prevent the spread of the disease.
•    Reconstructive surgery: After a mastectomy, some women choose to have breast reconstruction surgery to rebuild the shape of the removed breast.
It’s important to discuss all surgical options with a healthcare provider to understand the risks and benefits of each procedure and to make an informed decision that aligns with personal preferences and medical advice. Recovery times and post-surgical care will vary depending on the type of surgery and individual circumstances.