BREAST CANCER – WHAT DO YOU NEED TO KNOW?

Breast cancer – a cancer that develops in the cells of the breasts is the commonest cancer in urban women and second most common cancer in rural women in India. The age of incidence is, a decade earlier in India (before menopause) when compared to western countries (after menopause). Although both men and women develop breast cancer, women are more likely to develop the disease.

The commonest risk factors are increasing age, early menarche, late menopause, a strong family history of breast cancer, obesity, radiation exposure at younger age, nulliparity, having first child birth after 30years, intake of hormonal therapy, intake of alcohol, genetic mutations, a personal history of breast diseases (atypical hyperplasia, LCIS) and a personal history of breast cancer (where the other breast is at risk). About 5-10% of breast cancers are due to inherited gene mutations. The most well-known are breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which significantly increase the risk of both breast and ovarian cancer.

The most common signs and symptoms include a painless breast lump or thickening that feels different from the surrounding tissue. The other symptoms include changes in the size, shape or appearance of the breast, changes in the skin such as dimpling, inversion of the nipple, peeling, scaling, crusting or flaking of the pigmented area of skin around the nipple, redness or pitting of the skin over the breast, presence of swelling in the axilla (lymph node enlargement), etc.,

The self-breast examination (SBE) and the clinical breast examination (CBE) should start from the age of 25 years. Mammogram can be used as both screening and diagnostic tool for breast cancer. The screening mammogram for the general population is done usually from 40 years annually. For high risk individuals such as with inherited genetic mutations the mammogram has to be done at an earlier age. Ultrasound of the breasts serves as a complimentary tool to mammogram.

Stages of breast cancer include stage I to IV, in which stage I & II are categorised as early breast cancer (disease is confined to breast/involving a regional lymph node), Stage III is locally advanced breast cancer (disease has spread to regional lymph nodes) and stage IV is metastatic breast cancer (disease has spread to non-regional lymph nodes or other parts of the body).

The treatment options include surgery (either conservation of the breasts or total removal), radiotherapy, chemotherapy, targeted therapy, hormonal therapy and immunotherapy depending on the staging of the disease and the prognostic markers. The modalities are sequenced in order to obtain high chances of cure with minimal side effects. With the advancements in the medical field, oncoplastic surgeries preserve the normal contour of the breast and give good cosmetic results to the patients. These surgeries are usually done in patients with early breast cancer.

Radiotherapy is usually given for a period of 5 weeks. With the advancements in radiotherapy, the duration of the treatment has been reduced to 3 weeks and recently, the total duration of the treatment is maximum 5 days based on Fast Forward trial for early breast cancers. This will enable the patients to resume their routine activity at the earliest with high chances of cure, minimal side effects and minimal hospital stay.

Chemotherapy can be delivered with minimal side effects with the arrival newer agents. Targeted therapy is given for Her2neu positive patients. Hormonal therapy is given for receptor positive (ER/PR) patients. Immunotherapy is usually given for the patients in whom the disease has spread to other parts of the body (Metastases)/in triple negative breast cancers.

The preventive strategies of average risk individuals include breast self-examination for breast awareness, maintaining a healthy weight, choosing a healthy diet, avoiding alcohol consumption, limiting postmenopausal hormonal therapy and screening. The preventive strategies of high risk individuals include preventive medicines (SERMS/aromatase inhibitors) and preventive surgery (prophylactic mastectomy – removal of the breasts/prophylactic oophorectomy – removal of ovaries).