Breast Cancer

 

Overview

Breast cancer is one of the most common cancers; it is the most common type of cancer in women. The lifetime risk of a woman developing breast cancer is approximately 1 in 10.

The majority of breast cancers (81%) occur in women over the age of 50. Exactly why some people get breast cancer and some don't is not fully understood. Research suggests that breast cancer is caused by a combination of different factors, many of which are beyond our control.

Most breast cancers happen by chance but a small number of people diagnosed with breast cancer (5%) have inherited a fault in one of the known breast cancer genes; BRCA1, BRCA2 or TP53. 

 

 

The three main risk factors for breast cancer are ones we can’t do anything about:

  • Gender; being a female.

  • Getting older mainly after the age of 50.

  • Significant family history; especially first degree family members.

 

There are other observed risk factors that are less significant like

  • Previous personal history of breast cancer.

  • Increased hormonal exposure like early menarche, late menopause, Hormonal Replacement Therapy.

  • Life style: excessive alcohol intake, smoking, diabetes and obesity.

 

 

The lifetime absolute risk of developing breast cancer is 1 in 10 for a woman who lives to be around 84. This also means that 7 out of 8 women will not develop breast cancer in their lifetime, and the risk for younger women is much lower.

 

Early detection of breast cancer improves survival and increase the chances of breast conservative surgery where only the cancer with safety margin is removed leaving a relatively normal looking breast behind.

 

Mammograms are the cornerstone investigation for the detection of breast cancer. New Zealand provides a free 2 yearly screening mammogram for women aged 45 through to 69, through Breast Screening Aotearoa.

 

 

Symptoms of Breast Cancer:

 

In the early stages the breast cancer gives no symptoms it can be only detected by radiological assessment like mammogram, Ultrasound and MRI. Later on a lump can be felt in the breast, mostly it’s a new lump that the woman did not have before. As this lump starts to grow it can give changes on the skin like a pull, redness or a visible lump.

A very large breast lump can ulcerate, bleed or discharge offensive fluid.

Nipple discharge can occasionally be an indication of a breast cancer.

 

As the cancer grow it will start to spread, the most common first station would be the lymph nodes in the axilla (armpit), then it can spread to any part of the body like the Liver, Bones, Lungs etc.

 

Although much complained off, breast pain is not a common presenting symptom for breast cancer.

 

For More information about Breast pain click here

 

Diagnosis:

 

The diagnosis of breast cancer is made by a combination of:

  • Clinical examination: A palpable lump is assessed by an experienced medical personal.

  • Radiological examination: Any combination of mammography, ultrasound or MRI.

  • Histological assessment where a sample of the tissue (biopsy) is studied under the microscope.

 

Management of Breast Cancer:

 

The treatment modalities of breast cancer are:

  • Surgical Treatment

  • Radiotherapy

  • Chemotherapy

  • Hormonal therapy

 

The treating Specialist will assess each patient individually and determine which modality to start with. Such a decision might require a discussion at a Multi-Disciplinary Team Meeting (MDT meeting) where specialists from each different modality discuss an individual case and determine the sequence of treatment.

 

Other supporting specialities will be involved in the management like Physiotherapy, Occupational therapy, Psychotherapy dependent on each case.

 

Most women would start their treatment with surgery then progress to the other modalities dependents on the characteristics of the breast cancer and the status of the lymph nodes.

 

 

Surgical Treatment of Breast Cancer:

 

This is divided to:

  • Surgery for the cancer in the breast

  • Assessment and management of the lymph nodes

  • Management of the other breast if required

 

Surgery for the Cancer in the Breast

 

  • Wide excision: This is removal of the cancer with a safe margin followed by radiotherapy. Patients suitable for this treatment are those with a relatively small cancer and the capability to leave a good cosmetic results. Radiotherapy is a must after this type of surgery. If the cancer is too small to be felt by examination then a Hook-wire Localization will be used to help finding the lesion during this type of operation. Fore more information click here

 

  • Mastectomy: Removal of the whole breast. Used if the cancer is big, multiple cancers or simply patient preference. Radiotherapy is not usually required for every case after a mastectomy. The end result will be a flat chest with a one single transverse scar.

 

Which Operation is better?

 

Your surgeon will advise you of which operation is suitable in your case. In certain cases both operation are suitable. Both operation give equal long term survival, provided the patient complete the radiotherapy session required after wide excision. 

 

Assessment and management of the lymph nodes:

 

  • Sentinel Node biopsy: The node or two that first drain the cancer area and would most likely to pick up the cancer cells are removed an tested under the microscope. If these are negative then no further surgery required. If they are positive for cancer then the patient would require the Axillary Node Dissection. For more information about Sentinel Node Biopsy click here

 

  • Axillary Node dissection: All the nodes within a certain anatomical area in the axilla (armpit) are removed. This is done for patients with positive Sentinel Node Biopsy or clinically involved nodes.

 

Management of the other breast:
 

In certain cases the other breast need to be assessed with Mammogram/Ultrasound or MRI. This might be done before or after the cancer treatment. This will need to be arranged on case by case bases according to the the individual case.

 

Sentinel Lymph Node Biopsy:

 

This is removal of few lymph nodes for testing.  The lymph nodes chosen are those that drain the cancer area; thus these nodes are the first site for the spread of breast cancer.

 

To identify these nodes a small amount of radioactive Technetium, and blue dye are injected into the breast on the day of operation. During the operation radioactivity and the dye are detected in the nodes. Those nodes are removed and subjected to a thorough examination under the microscope.

 

This technique is used to replace routine axillary node dissection, used more often in the past, which is not required in most patients and can end up with swelling of the arm (Lymphedema) in around 4% of patients. Axillary node dissection is still required if the sentinel nodes prove to have cancer in them.

For more information click here

 

Chemotherapy after Breast Cancer :

 

Chemotherapy is required for many cases, a very imprtant indication would be lymph nodes involevement with breast cancer, or when the cancer have certain criteria that make it suitable for chemotherapy. In majority of cases the decision for chemotherapy is made after surgery is completed, when all information  (size, grade, lymph node status etc) are available for assessment. In few cases chemotherapy is required before the operation to help shrink the tumour. One rare type of breast cancer (inflammatory cancer) is treated with chemotherapy in the first instance. 

 

Radiotherapy after Breast Cancer :

 

Radiotherapy is required after wide excision operations, it is proven to reduces the risk of local recurrence in the remaining breast tissue by 80%. Radiotherapy is indicated when there are lymph nodes involvement (3-4 or more). Radiotherapy is also used when the cancer is close to the surgical margins.

Fore more information click here

 

 
Hormonal Therapy after Breast Cancer:

 

Different types of hormones (Tamoxifen, Arimidex, femera) are used mostly to reduce the risk of Breast cancer recurrence. These are in the form of a tablet a day; which the patient takes for few years. Each cancer is tested for hormone receptors and if positive this modality of treatment can be used.

 

Complications and Side effects:

 

Surgical complication are uncommon, these can be divided into Anaesthesia related and Surgery Specific.

Anaesthesia related as cardiac events, chest infection and allergic reactions, the anaesthetist will assess the patient risk and give them the appropriate advise.

The surgery specific complications include bleeding (5%), wound infection (5%) and the more common Seroma which is fluid accumulation under the wound for which drains are put in during the operation to reduce the incidence of this complication.

Lymphoedema (arm swelling) is significant in around 4%, and is more common after the need for axillary dissection followed by radiotherapy. 

 

Radiotherapy is associated with fatigue, localized skin irritation for which Flamazine is prescribed for few weeks, the tissue will feel firmer, there is a small risk of Cardiac toxicity associated with left chest irradiation. Radiotherapy is known to increases the risk for lymphedema. Foremore information about Radiotherapy click here

 

Chemotherapy causes fatigue, nausea and vomiting, this is self-limiting and recover few days after the completion of the course. Some drugs cause numbness or tingling sensation due to nerve irritation, this is usually recover few days after completion of the treatment. Chemotherapy may cause hair loss. The hair grow back after the treatment but the hair colour and texture may change. Bone marrow suppression can happen with a drop of the white cell count and platelets, increasing the risk of infections and bleeding, the oncology team will closely monitor the blood counts and will take action accordingly making sure the blood count will recover before commencing further chemotherapy.

 

Hormonal therapy may be associated with side effects like hot flushes and  gastric upset. Certain types of hormonal treatments can increase bone fragility which is assessed before commensing such a treatment. while others can casue blood clots in the legs, Your doctor will discuss these possible complications with you.

 

 

Falah El-Haddawi