• What is cancer
• What is breast cancer
• What are the warning signs of breast cancer
• Risk factors
• Early detection & Screening
• Diagnosis
• Treatment
• Follow up care
• Prognosis
• Support

WHAT IS CANCER?

In a healthy body, there are natural mechanisms that regulate the creation, growth and death of cells (called apoptosis). Normal, healthy cells in body grow in a very orderly and well-controlled way, living for a set period of time and then dying on schedule. When a normal cell dies, our body replaces it with another normal cell. Cancer cells grow in an uncontrolled manner. They forget to die and therefore the diseased cells accumulate. One malignant cell becomes two, two become four, and four become eight, and so on, until a mass of cells (a tumor) is created. Tumors remain small until they’re able to attract their own blood supply, which allows them to obtain the oxygen and nutrients they need to grow larger. Not all tumors are cancerous and not all cancers form tumors. For example, leukemia is a cancer that involves blood, bone marrow, the lymphatic system and the spleen, but doesn’t form a single mass or tumor. Cancer can also spread and invade healthy tissue in other areas of body. As a tumor grows, it promotes the formation of new blood vessels (called angiogenesis) to bring in the oxygen and nutrients it needs. Cancer cells can also leave the tumor site and travel through the blood stream and lymphatic system (the network connecting lymph nodes throughout the body) to other parts of the body, such as the liver, lungs or bones. This process of cancer cells leaving the original tumor and appearing elsewhere is called metastasis .Cancer can take decades to develop. By the time a cancerous mass is detected, it’s likely that 100 million to 1 billion cancer cells are present, and the original cancer may have been dividing for five years or more. A person with cancer may eventually die of the disease if vital organs like the liver or lungs are invaded and destroyed.

WHAT IS BREAST CANCER?

Breast cancer is the most common cancer in the women worldwide. In India it is the second most common cancer in females after cervical cancer. There are about 85000 new breast cancer cases every year and about 45000 deaths. There are several types of breast cancer. The name of the cancer is based on the origin and characteristics of the tumor. Ductal carcinoma arises in the breast ducts. Lobular carcinoma arises in the breast lobules. Paget’s disease starts in the nipple. Typically, these cancers are said to be either in situ or invasive. Carcinoma in situ stays “in place” where it started. It has not invaded into surrounding breast tissue, nor has it spread to other parts of the body, and it is very curable.

WARNING SIGNS OF BREAST CANCER

A change in the look or feel of the breast.
• change in the size or shape of the breast.
• lump or thickening in the breast, the area surrounding the breast or the underarm.
• warm sensation in the breast.

A change in the look or feel of the nipple.
• A nipple turned inward or sunken into the breast.
• The shape of the nipple becomes irregular.
• A rash on the nipple or areola.
• Nipple tenderness, increased sensitivity or pain.
• Nipple discharge.
• Blood or fluid other than breast milk secreted from the nipple.
• A change in the look or feel of the skin on the breast, nipple or areola.
• Dimpling of the skin on the breast (appears like the skin on an orange).
• The appearance of irritated, red, scaly, or swollen skin on the breast, nipple, or areola.

Breast pain. Although breast pain is usually associated with benign breast disease rather than breast cancer, it can be a symptom of either condition.

It is important to discuss any of these symptoms with a health care provider as soon as possible so that if breast cancer is present, it is more likely to be diagnosed at an early stage when it is most treatable.

WHAT ARE THE RISKS OF GETTING BREAST CANCER?

The causes of breast cancer are not fully known. However, health and medical researchers have identified a number of factors that increase a woman’s chances of getting breast cancer. These are called risk factors. Risk factors are not necessarily causes of breast cancer, but are associated with an increased chance of getting breast cancer. Importantly, some women have many risk factors but never get breast cancer, and some women have few or no risk factors but do get the disease. Being a woman is the number one risk factor for breast cancer. There are some risk factors you can control, and others you cannot. Remember, even if you do not have any of these risk factors, you can still develop breast cancer.

BREAST CANCER RISK FACTORS

• getting older — the older you get, the greater your risk of breast cancer
• a previous biopsy showing hyperplasia or early cancer (carcinoma in situ)
• a mother, daughter or sister who has had breast cancer
• a personal history of breast or ovarian cancer
• a personal history of benign breast problems
• starting menopause after age 55
• never having children
• having your first child after age 30
• never doing breast feeding
• being overweight after menopause or gaining weight as an adult
• lack of exercise
• excessive exposure to the radiation
• having more than one drink of alcohol per day
• currently or recently using combined estrogen and progesterone hormone replacement therapy (HRT)

EARLY DETECTION AND SCREENING

The goal is to find breast cancer as early as possible, when it’s most treatable.

Monthly Breast Self Exam (BSE) : By doing breast self-exams once a month, women can become familiar with the way their breasts look and feel normally and thus may be able to recognize changes, such as thickening, lumps, and spontaneous nipple discharge or skin changes, such as dimpling or puckering. Any time a woman discovers a new lump that feels different from the rest of the breast or one that is different from what she has felt before, she should have it checked by a health care provider.

Clinical Breast Exam : Clinical breast exams are physical examinations done by physicians or other trained medical staff.

Mammogram : A mammogram is an X-ray picture of the breast. A mammogram can find cancer when it is still small and easier to treat. Health and medical experts recommend that all women get a mammogram on a regular basis — every year for women age 40 and over (and perhaps earlier if you have a family history of breast cancer). A mammogram is done in a medical facility like a hospital or Radiology clinic. A radiologist will look at the X-ray picture for signs of breast cancer or other breast changes. A radiologist can compare your X-rays from year to year to see if there have been any changes. Mammograms are very accurate, but they are not perfect. They can find a lump much smaller than you or your doctor can feel.

DIAGNOSIS

Biopsy is the only way to definitively tell if something is cancer or not. A biopsy is a procedure that removes a sample of cells or tissue from the breast to be tested. The cells or tissues that have been removed are examined under a microscope to look for signs of cancer. A biopsy is generally not painful but you may feel some discomfort.

There are two main types of biopsies: needle biopsy and open surgical biopsy.
Needle biopsy : Because it is fast and simple, this method is often done first. If the doctors cannot feel the lump, special equipment is used to guide the needle to the area.
– Fine needle aspiration — A thin, hollow needle is used to remove a few cells from the breast lump. It can be done in an outpatient setting and only takes a few minutes.
– Core needle biopsy — A thicker, hollow needle removes a small amount of tissue. As with fine needle biopsy, when a core needle biopsy is done for an abnormal area found by mammogram, ultrasound imaging or stereotactic mammography is needed to accurately guide the needle to the suspicious area. The skin is nicked with a scalpel so the needle can enter.

Open surgical biopsy : An open surgical biopsy is a surgical procedure that removes the abnormality from the breast. It is done in a hospital or outpatient setting with anesthetic. Most women are able to go home the same day. – Excisional — The entire lump plus some surrounding normal tissue are removed. This is the most common type of open biopsy and the most accurate way to diagnose breast cancer. Although the primary purpose is to diagnose cancer, a biopsy can also be a surgical treatment to remove cancer. – Incisional — Only a portion of the lump is removed. It is most often done on women with advanced stage cancer whose tumors are too large to be removed by excisional biopsy.

STAGING

After initial diagnosis, different blood tests and X rays etc. are done to find out the exact stage of the disease. Staging is the process of finding out how far the cancer has spread. This is very important because breast cancers at different stages are treated differently. Breast cancer almost always begins in one breast and, if left untreated, can spread to lymph nodes or other tissues in the chest (including the other breast). Breast cancer can also metastasize (or spread) throughout the body, to the bones, brain, liver, or other organs. Tumor size, lymph node involvement and extent of the spread of the cancer are taken into considerations to characterize the exact stage of the cancer. Generally there are four stages with stage I indicating early-localized disease and stage IV being late stage, spread out disease with involvement of organs other than the breast.

TREATMENT

Surgery
Surgery is the oldest form of cancer treatment and it remains an important part of cancer treatment today. Surgery is now often combined with other types of treatment such as radiation, chemotherapy and hormone therapy to achieve greater success.

Types of breast cancer surgeries :
There are two main types of surgeries for breast cancer: breast conserving surgery (lumpectomy) and mastectomy. With breast conserving surgery, the surgeon tries to spare and preserve as much of the breast tissue as possible. With a mastectomy, the entire breast is removed. Research has shown breast conservation with lumpectomy followed by radiation therapy to be an equally effective treatment as mastectomy for early stage breast cancer.

Radiation therapy
Radiation therapy (also called radiotherapy) is the use of high-energy rays, usually X-rays, to kill cancer cells. Radiation is very effective in killing fast growing cells like breast cancer. Most often it’s given after surgery to stop the growth of any cancer cells that may remain. This lowers the chance of the cancer returning (recurrence).

The most common radiation treatment for breast cancer is external radiation therapy. It uses a large machine to direct a beam of radiation at the cancer site from outside the body. A typical course of treatment is 5 days a week for 5 to 7 weeks. During this time, a woman receives small amounts of radiation daily to the entire breast or chest wall if the breast has been removed; and, if necessary, the lymph nodes. By using small amounts of radiation daily, less damage is caused to normal cells, allowing them to recover more quickly. After the first course of treatment, a “boost” dose of radiation is given in the same area of the breast where the tumor was removed.

Chemotherapy
Chemotherapy is the use of anti-cancer drugs to treat cancer. It can be used to treat cancer by stopping the growth of cancer and by killing cancer cells that have spread to other parts of the body. There are many different chemotherapy drugs used today. Some drugs work better in combination than alone. A few anti- cancer drugs are taken by mouth or injected into the muscle or fat tissue below the skin, but most are injected into a vein. Treatments can be given at doctor’s office or in the hospital — depending on the type of chemotherapy. Drugs are generally given weekly or once every third week, with a rest period to allow your body to regain strength. The length of the cycle will depend on the type of drugs used.

Hormone Therapy
Hormones flowing in bloodstream can attach themselves to breast cancer cells and help those cells grow and multiply. The purpose of hormone therapy is to prevent hormones from doing this by keeping them from being produced and/or attaching to cancer cells that may remain after surgery. When a woman is diagnosed with breast cancer, tests are done to determine if the cancer is positive for estrogen and progesterone receptors. These receptors are the parts of a cancer cell that attach to estrogen or progesterone. If a cancer is found to have either of these receptors, hormone therapy is recommended to help prevent the spread or recurrence of breast cancer. There are several types of hormone therapy. The first type involves the use of drugs, such as tamoxifen. These drugs attach to the estrogen receptor inside the breast cancer cells and prevent your natural hormones from stimulating cancer cell growth. Another type of hormone therapy involves stopping the ovaries from producing estrogen, the hormone that may promote breast cancer growth. If the ovaries are removed, or their function turned off with a hormonal treatment, then these hormones are greatly reduced. A third class is the aromatase inhibitors, which prevent fat, muscle cells and the adrenal glands from producing estrogen in postmenopausal women.

Targeted Therapies Targeted therapies attack specific molecular agents or pathways involved in the development of cancer. For example, the drug trastuzumab (Herceptin) targets a particular gene’s protein called HER2/neu that appears on the surface of some cancer cells. Unlike chemotherapy drugs, targeted therapies can destroy cancer cells with minimal effect on healthy cells. One of the drawbacks to these therapies is that they only work on cancers that exhibit the specific agents they were designed to target. Therefore, many cancers are not eligible for treatment with these therapies. The growing range of targeted therapies offers much promise for current and future breast cancer treatments.

FOLLOW UP

Patients with breast cancer, have a higher risk for developing a new breast cancer than someone who has never had breast cancer. That is why it is important to get the follow-up treatment and care. With proper follow-up, doctors can keep track of how the patients are recovering — including taking care of side effects. In addition, if there is a local (in the breast, chest wall or lymph nodes) recurrence of breast cancer, it can be detected early when treatment has the best chance to succeed.

Recommendations for follow-up care Guidelines for follow-up of breast cancer treatment:

• Continue to have regular mammogram.
• Have a physical examination performed by a doctor every 4 to 6 months for 5 years.
• Perform breast self-exam (BSE) every month.
• Understand which symptoms should be reported immediately.
• Have regular pelvic exam.
• Non-standard tests: While there is not enough evidence that the majority of women will benefit from them, these tests are helpful in evaluating any symptoms of possible recurrence. These tests include complete blood counts and blood chemistry profiles, bone scans, and ultrasounds or CT scans of the liver, chest X- rays and breast cancer tumor marker tests.

Symptoms that should be reported to the doctor
– Any changes in the remaining breast(s) and chest area, unusual pain, loss of appetite or weight, changes in menstrual periods, unusual vaginal bleeding or blurred vision.
– Dizziness, coughing that does not go away, hoarseness, shortness of breath, cough, headaches, backaches or digestive problems that are unusual or that do not go away.

PROGNOSIS

A prognosis is a prediction. It is a doctor’s best estimate of the chance that a woman will live free of breast cancer. In determining prognosis, doctors consider how well other patients with a similar type and stage of breast cancer have done when receiving the same treatment. Some factors doctor will consider when determining prognosis are:

* Characteristics of cancer – The size, the type, receptor studies, grade, proliferation rates and stage
* Age – Whether the woman has gone through menopause
* General health – How well treatment might work

SUPPORT
No woman should face breast cancer alone. Getting the support is important to well being and coping with breast cancer. Patients need different kinds of support at different times during treatment and recovery.

– Informational support — providing with information about breast cancer. This might include finding facts about type of breast cancer, gathering information about treatment options or talking to others that have had similar experiences.
– Emotional support — looking after emotional well being. This might include listening, chance to express feelings or just being there when a friend is needed.
– Practical support — helping with specific tasks. This might include rides to clinic appointments, helping with cooking or cleaning etc.

(Dr. Neeeraj Mahajan is a medical oncologist working at Seidman Cancer Center at Case Western Reserve University in Cleveland, OH, USA. He is native of Jammu, J&K, India and did his medical training at Govt. Medical College in Jammu. Subsequently he moved to US and did his post-graduation studies in multiple fields. He is American board certified in Internal Medicine, Geriatrics, Palliative Medicine, Hematology and Oncology.)