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Health Corners
Breast Cancer

Breast is one of the leading sites of cancer in women. In India it is the second most common type of cancer in women.

  • Who is at risk?

  • Symptoms

  • Diagnosis

  • Staging

  • Treatment Options

  • Prevention

  • Who is at risk

    It is easier to list the type of women who are more likely to get breast cancer than identify “causes”. Higher incidence is noticed in:

    • Women whose mothers or sisters have had it. The risk is increased if their relatives have had cancers occurring before menopause. There seems to be familial connection. (However, the converse does not seem to be true: there may be no family history in about 90% of women with cancer of the breast.)
    • Women who have not borne children.
    • Women whose first pregnancy occurred after the age of 35 years.
    • Women with certain diseases of the breast like fibrocystic disease that alters the structural pattern of the breast tissue.
    • Women who have cancer in one breast (they are at increased risk of developing cancer in the other)
    • Women who consume alcohol.
    • Women who are on high doses of oestrogen after menopause.
    • Women with cancer of the body or the uterus.

    It is also to be noted that late menarche and artificial menopause are associated with lower risk. Oral contraceptives do not increase the risk of breast cancer.

    Symptoms

    The common symptoms are:

    • Presence of a painless lump in the breast.
    • In some cases nipple discharge, enlargement of the nipple, itching and pain
    • Hardness or enlargement of the breast.
    • Shrinking of the breast
    • Back pain, bone pain, jaundice or weight loss (these are late manifestations and indicate spread of cancer to several sites in the body.)

    Very rarely a swelling in the underarm or arm may be the first complaint.

    Diagnosis

    Early detection helps to prevent the spread of cancer and increases the chances of a cure. The earliest way of detecting breast cancer is through a mammography. Your doctor may also want you to undertake other diagnostic tests.

    Regular self examination might help you detect the presence of cancer. If you think any of the symptoms are present visit an oncologist.

    Self Examination

    If you are in the high risk group please perform the following examination periodically. All women above forty should be alert to breast cancer symptoms. Examine yourself 7 to 8 days after your menstrual period.

    1. Remove you clothing above the waist, and then sit or stand in front of a mirror. Let you arms hang loosely by your sides. Examine your breasts carefully in the mirror, looking for any changes in size or shape. Look also for any dimpling or puckering of the skin, and for any changes in the outline of the breasts.
    2. Raise both arms above your head. Examine your breasts from different angles: look for any changes since your last self examination. Checks the nipples, too, for any signs of discharge or bleeding.
    3. Now lie down on your bed with your head on a pillow. Put a folded towel or small pillow under your right shoulder, and put your left hand behind your head. Use your right hand to examine your left breast. Keep your fingers together and use the flat part of the fingers, not the tips, to feel the breast tissues.

      Imagine the breast as having four quarters and start by examining the upper, inner quarter as shown in the photograph. Starting at the breast-bone, press gently but firmly and use small circular motions with your hand, looking for any lump or thickening or anything unusual. Work your way slowly to the nipple. Examine the area all around the nipple, too.

      • Now, using the same technique, examine the lower, inner quarter of your left breast. Start from the breast-bone and also from the ribs below the breast, and again work your way slowly to the nipple.

        You will find a ridge of firm flesh in this quarter. This is perfectly normal.

      • Move your left arm from behind your head and bring it down to your side. Explore the lower, outer quarter with your right hand, working your way from the ribs below and at the side of the breast, inwards to the nipple.
      • In the same way, examine the upper, outer quarter.
      • And finally use the flat part of your fingers to feel under your armpit. Search for lumps or swellings. You have now completed the examination of you left breast.
    4. To examine the right breast, put the folded towel under you right shoulder, and place your right hand behind your head. Use your left hand to explore your right breast quarter by quarter, just as you did for your left breast. Start with the upper inner quarter, and work your way around the circle. Don’t forget to move your right arm down to your side before examining the outer half of the breast.

    Mammography

    Breast cancer takes many years to develop.

    Mammography is the only reliable method of detecting breast cancer before a lump can be felt by a patient.

    It is like an x ray examination of the breast. Modern techniques give high quality results with low radiation exposure.

    You will be expected to undress above the waist. You will have to remove all neck ornaments. The procedure will take about 20 minutes and you will get the results on the same day, or the next.

    Women in high risk groups should go in for yearly exams after the age of 20. All other women are advised to go for yearly screening after the age 40.

    Other Diagnostic Tests

    Ductography

    This test is advised especially if there is discharge from the nipple.Ductography is a type of x ray taken after a dye has been injected. The dye shows if there are blocks in the ducts in the breasts.

    Breast Ultrasound

    This method uses high frequency sound waves to outline a part of a body. A breast ultrasound is advised in some cases (as in where breast tissue is dense).

    Biopsy

    The above methods can detect masses, calcification or other abnormalities. But to know if any of these is cancerous, a biopsy has to be performed.

    In a biopsy, a small incision is made or the breast is pierced with a needle and a sliver of the tissue and fluid is extracted. A pathologist examines this under a microscope to confirm the presence or absence of cancer.

    Staging

    Cancer treatment and outcome depend on the stage the disease has progressed to.

    The conventional staging system known as the TNM (Tumour, Node, Metastasis) system is used to indicate the spread of breast cancer.

    The following chart indicates the stages in breast cancer. (Letters on the left are the code letters for each stage.)

    Size and Spread of Tumour

    Tx Primary tumour cannot be assessed
    To No evidence of primary tumour
    Tis Carcinoma in situ- intraductal carcinoma, pagets disease of the nipple with no tumour
    T1 Tumour 2 cm or less in greatest dimension
    T1a 5 cm or less
    T1b More than 0.5 cm but not more than 1 cm
    T1c More than 1 cm
    T2 Tumour more than 2 cm but not more than 5 cm
    T3 Tumour more than 5 cm
    T4 Tumour of any size with direct extension to the chest wall or skin
    T4a Extension to chest wall
    T4b Oedema, ulceration, skin satellite nodules
    T4c Both T4a and T4b

    Involvement of the Nodes

    Nx Regional lymph nodes cannot be assessed
    No No regional lymph node metastasis
    N1 Spread to movable same side axillary node
    N2 Spread to same side axillary node fixed to one another or to other structures
    N3 Spread to same side internal mammary nodes

    Metastasis, or the Spread to other organs

    Mx Presence of distant metastasis cannot be assessed
    Mo No distant metastasis.
    M1 Distant metastasis (includes metastasis to same side supraclavicular nodes)

    Depending on the size of the tumour, nodal involvement and metastasis the following stages have been defined by the American Joint Committee on Cancer.

    Stage 0: Very early breast cancers are called carcinoma in situ. These can be of two types. Ductal carcinoma in situ (DCIS) or Lobular carcinoma in situ (LCIS). In DCIS, cancer cells are located within a duct and have not invaded into the surrounding fatty breast tissue.

    Lobular carcinoma in situ (LCIS) is also called lobular neoplasia. Abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules.

    The following pattern is also defined as Stage 0

    Tis, No, Mo

    Stage I

    T1*, No, Mo

    *T1 includes T1mic

    Stage IIA

    To,N1,Mo

    T1, *N1,** Mo

    T2,No,Mo

    *T1 includes T1mic

    **The prognosis of patients with pN1a disease is similar to that of patients with pNo disease

    Stage IIB

    T2, N1, Mo

    T3, No, Mo

    Stage IIIA

    To, N2, Mo

    T1, *N2, Mo

    T2,N2,Mo

    T3,N1,Mo

    T3,N2,Mo

    *T1 includes T1mic

    Stage IIIB

    T4,Any N, Mo

    Any T, N3, Mo

    Stage IV

    Any T, Any N, M1

    Treatment

    If treated, patients at Stage 0 have a very good chance of cure. The five year survival rate for patients treated at this stage is 100%.

    Curative treatment is advised for stages I and II. A part of the breast where the lump is present or the entire breast and some of the chest tissue might be removed surgically. Radiation and chemotherapy may also be given.

    For advanced stages, like stage III B and IV and for recurrent disease, treatment focuses and reducing the damage and the progress of the disease. Here too, surgery, chemo and radiation therapy may be advised.

    Follow up

    Patients who have been treated for breast cancer should be followed for life. The follow up should be once in three months for first three years. The later visits may be done every six months for five years. As most patients develop recurrence in the opposite breast the follow up visits should concentrate on the screening for this.

    Women who have undergone mastectomy (removal of breast) may want to undergo breast reconstruction surgery performed by plastic surgeons. Reconstruction can be with your own tissues or with implants.

    Preventive steps

    Breast cancer cannot be “prevented” as some diseases can, by a vaccine or medicines. However, the changes that take place leading to cancer, if detected early enough, can be treated in the pre cancerous stage. Early detection and treatment can prevent the spread of cancer. It may even save the patient from mutilating surgery.

    The following measures can be defined as preventive steps:

    • Awareness is important. Find out if you are at risk.
    • If you are in the risk group, consult an oncologist. Go for preventive screening regularly.
    • All women above thirty are to perform self-examination periodically. When in doubt, a doctor should be consulted.
    • Do not delay diagnosis. Just wishing the symptoms away, will only make matters worse.

    The responsibility for detecting breast cancer lies primarily on the woman herself.Today, reconstruction of the breast is not a problem, if a breast cancer patient desires it. Loss of breast to cure cancer may be tragedy, but loss of life is more tragic.

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