Breast cancer is the most common cancer in women who do not smoke. It is malignant neoplasm of the breast. It is estimated that one woman in nine will develop breast cancer in her lifetime and will have 3.5% chance dying from it.
How is Breast Cancer Diagnosed?
About 90% of the cases of breast cancer are discovered by breast self examination by patient them self. Screening is the method of diagnosing cancer at early stages before it produces any signs or symptoms which reduce the mortality by 50%. Positive diagnosis can be made by obtaining tissue for microscopic examination. The American cancer society recommends that all women should perform breast self examination monthly. In addition women from 20-40 years ages should visit the clinician every 3 years and women above 40 years every years. The risk of developing breast cancer increases with age.
Breast Self Examination:
- Observe for symmetry, lumps, dimpling, nipple discharge or failure of nipple erection.
- Gently squeeze nipple and observe for secretion and nipple erection after each nipple is gently stimulated.
- While leaning forward, observe breast as they are reflected in mirror to detect irregularities, retracted areas especially one side only.
- Feel for nodes irregularities and tenderness both in breast and axillaries nodes.
Symptoms of Breast Cancer:
Most women present with painless increasing mass which may also be associated with nipple discharge, ulceration and in inflammatory cancer edema and Erythema may be seen. There may be some non-specific symptoms such as weight loss, fatigue, anorexia, back or bone pain. This usually indicated more advanced stage of breast cancer.
Advanced Breast Cancer:
When breast cancer has advanced edema, redness, nodularity, ulceration of skin, presence large primary tumors which are fixed to chest wall, enlargement, shrinkage or retraction of the breast, marked axillary lymph nodes supra clavicular lymph nodes enlargement, edema of same sided hand or distant metastasis may be seen. 1-2 movable non-tender less than 5mm nodules are not suggestive of metastasis but nodules greater than 7mm usually contains metastasis. Axillary lymph nodes that are fixed to skin or deep structure indicates advanced disease.
What other disease you should consider?
There are several other diseases which may also gives same symptoms and signs as breast cancer. So these diseases can be excluded by obtaining a tissue biopsy of the site. Some other diseases to consider are:
- Mammary dysplasia (cystic disease of the breast)
- Fibro adenomas
- Intraductal papilloma
- fat necrosis
Risk factors of Breast Cancer
Breast is the most common site of cancer in women and accounts for second cause of death in women, first being lung cancer. Some risk factors of breast cancer are followings:
- The most important being dietary factors especially high fat content (eg. red meat which have high saturated fat and protein content)
- Women with previous cancer of uterine
- It is more common in whites than non whites
- Early menarche (less than 12 years) and late natural menopause (greater than 50 years are at high risk.
- Late menarche and artificial menopause are at lower risk.
- Women who had cancer of one breast are high risk of developing the other.
- There is some evidence that administration of estrogen to post menopausal women has slightly increase risk of cancer but with higher dose and long term use.
- Late first child birth (after 35 yrs) may also increase risk of developing breast cancer.
Treatment of Breast Cancer:
The type of treatment whether surgical, chemotherapy or combination of both therapies is determined by the extent of disease, patient age and her decision.
Early Breast Cancer Treatment:
Surgery with wide local excision and breast conservation or mastectomy with or with out re-construction is done. Amount of breast tissue to be removed still remains controversial. At one time radical mastectomy was done routinely although still performed, modified radical mastectomy, simple mastectomy or lumpectomy. Lumpectomy only removes cancerous portion of breast and axillary nodes. Radio therapy is given to conserve the breast after wide local excision to reduce local recurrence.
Adjuvant Systemic Treatment:
Tamoxifen adjuvant therapy immediately following surgery is beneficial for estrogen-progesterone receptor positive disease and has reduced the relative risk of women dying from breast cancer by 25%. Most commonly therapy with cyclophosphamide and 5-Flurouracil plus methotrexate for 5 months reduces the absolute by 10% and relative risk of death by 20%.
Advanced Breast Cancer Treatment:
Patient with establish metastasis disease may require endocrine therapy, chemo therapy or radiotherapy. The treatment is not curative but may be of great palliate benefits and consistent often with many years of good quality life. Recently addition of anti HER2 antibodies to chemo therapy has produced a modest survival advantage.
Endocrine Therapy for Advance Breast Cancer:
Women who have high level of estrogen receptor and progesterone in their tumor have greater chances of responding to endocrine therapy. A range of hormonal manipulations are as follows:
For premenopausal patients
- Suppression of ovarian function by means of oophorectomy, radiation-induced ovarian ablation
- Anti-oestrogen, Tamoxifen
For post menopausal women
- Aromatase inhibitors (anastrozole)
Chemotherapy for Breast Cancer:
Patient who are unlikely to respond to hormonal therapy or who fail to respond to endocrine therapy or who requires rapid response are given chemo therapy. The most common regimen used is:
- CMF (cyclophosphamides, Methotrexate, 5-fluorouracil)
- MM (mitoxantrone and methotrexate)
- Doxyrubicin and cyclophosphamide
- Paclitaxel or docetaxel used as single agent or in combination with an antracycline where initial therapy has failed or is inappropriate.
Side effect of Chemotherapy
- Nausea, vomiting
- Hair loss
- Mucositis (eg. oesophagitis, diarrhea)
Drugs Specific Side Effects:
- Anthracyclines causes cardio toxicity
- 5-fluorouracil causes skin dermatitis
Poor Prognostic Factors for Breast Cancer
- Young age
- Pre-menopausal women
- Tumor size
- Metastasis of tumor
- Oestrogen and progesterone receptor negative
- Positive nodes.
Should I see the doctor after my treatment?
After primary therapy, patients with breast cancer should be followed for life for at least two reasons:
- To detect recurrences and to observe the positive breast for secondary carcinoma.
- Local or distant metastasis occurs frequently with in the first 3 years. So during this period patient is examined every 6 months. Thereafter, every 6-12 months for 5 years, then after every 12 months.