indiacancer.org - Breast Cancer

Breast Cancer

		Breasts
		What is Breast Cancer?
		Breast Tumors
		Breast Cancer
		Causes of Breast Cancer
		Misconceptions about Breast Cancer
		Is Breast Cancer common?
		Symptoms of Breast Cancer
		Detection of Breast Cancer
		Types of treatment used
		Side effects of Treatment
		Adjusting to Breast cancer Treatment
		Relationship and Sexuality
		Child Bearing
		Contraception
		Menopause
		Follow Up

Breasts

Female breasts prepare milk for the baby. They extend from collar bone to the armpit at the side. There are large muscles behind the breasts attached to the ribs and to the shoulder joint bones.

The breast consists of milk glands supported by tissue and fat. Milk is made in the milk glands and milk sacs and conveyed through the ducts to the nipple. These glands are divided in about 20 segments radiating from the nipple.

Lymph glands are nodes in the breast and armpit and are connected by lymph ducts. These glands filter the lymph fluid drained from the breast and arm to fight infection.

The breast changes in shape and texture during monthly periods, pregnancy, age and with weight changes. They may be tender and lumpy before periods, which disappears after the period. This is normal.

The Breast

What is Breast Cancer?

The organs and tissues of the body are made up of small cells. Cancer is a disease of the cells. The cells repair and reproduce themselves normally in an orderly and controlled manner. Sometimes, this process gets out of control and the cells continue to divide and develop into a lump which is called a tumor.

Tumors can be benign or malignant.

In benign tumors, the cells do not spread to the other regions of the body and therefore are not cancerous. But they may cause problems by pressing on the surrounding organs or tissues.

On the other hand, a malignant tumor consists of cancer cells which defy the body's normal control signals and keep on dividing. These cancer cells can invade the surrounding tissue and also spread to other parts of the body through the blood stream or lymphatics. When these cancer cells reached at a new place they still go on dividing and form a new tumor and this process is called 'metastasis'.

Breast Tumors

Mostly (90%) breast lumps are benign and not cancers. There are often cysts which are sacs containing fluid which develop in the breast tissue. Another common benign breast tumor is fibroadenoma which is a collection of fibrous glandular tissue. These tumors can be treated if they are causing discomfort or are changing in someway.

If you find any unusual lump in your breast, it should always be examined. Don't delay visiting your doctor. Though most breast lumps are benign they have to be checked to eliminate the possibility of cancer, because if it is a cancer, the earlier it is treated the better are the chances of its cure.

Breast Cancer

A breast cancer is a malignant tumor or a swelling within the breast tissue. Most breast cancers begin in the milk ducts and are called DUCTAL CANCERS. If the cancer cells have not spread outside the milk duct, they are called IN SITU cancers.

If the cancer cells spread outside the duct wall into the surrounding tissues, it is termed an INVASIVE DUCTAL CANCERS.

A few breast cancers start in the milk sacs or lobes and these are termed as LOBULAR CANCERS,some growing slowly and some more rapidly.

Causes of Breast Cancer

The cause of breast cancer is not known. There is no single cause, although it is conjectured that some known and many unknown factors trigger a cancer. Breast cancer usually occurs in women over 40 years of age and the risk increases as they grow older. Though breast cancer can occur in women under 40 increasing age influences the risk. The following additional factors may mean a slightly higher risk:
	A diet high in animal fat.
	Not having children or having the first child at a late age. The exact reason for this is not known but may be due to hormone changes during pregnancy.
	Some unusual types of benign breast disease.
	Even if there are several of these situations, it does not mean that there is a certainty of getting breast cancer. They can be factored only in a small number of cases of breast cancer.
	Women with a strong family history of breast cancer have an increased chance of getting breast cancer, depending upon:
		the number of relatives affected.
		age of the relatives when their breast cancer was detected.
		what type of breast cancer they had.
	Women with a breast cancer on one side have a slightly higher chance of a new breast cancer in the other breast.

Misconceptions about Breast Cancer

	There are many misconceptions about breast cancer. The truth is...
		A bump or a blow to the breast will not cause breast cancer, although it may make one aware of an underlying lump.
		Breast cancer is not transmitted from someone who is suffering from it.
		Breast feeding does not cause breast cancer.

Is Breast Cancer common?

Breast cancer and cancer cervix are the most common cancers in women . Although unusual, men also can develop breast cancer.

Symptoms of Breast Cancer

Lump - in 90% of cases. Other signs are:
	Whole breast
		Change of size or shape.
		Dimpling or flaking of the skin.
		'Lumpy' feeling or thickening.
	Nipple
		Discharge (particularly if its bloodstained or clear).
		Rash on nipple or surrounding area (also very rare).
		Nipple inversion(not all inverted nipples are due to cancer).
		Lump or thickening.
	Arm
		Swelling of upper arm.
		Swelling of armpit.
Pain in the breast is usually not a symptom of breast cancer. In fact, many healthy women find the breast feeling lumpy and tender at different days of the month particularly before the period. Some types of benign breast lumps are painful.

Detection of Breast Cancer

	The earlier breast cancer is diagnosed and treated, the better are the long term prospects. BREAST SELF - AWARENESS (Please check the section on Breast Self Examination in Detection Techniques as well) Examine your breasts and how they normally feel at different times of the month starting in the week after the period. You can become familiar with your breast by looking at them and feeling them regularly during everyday activities like bathing and dressing. Thus you notice any changes in the breast that are not normal to you. Anything unusual in your breasts - in the size or shape of the breast, any puckering, dimpling or flaking of the skin , lump or thickening in the breast, discharge from the nipple, unusual pain or discomfort should be brought to the notice of your doctor. MAMMOGRAPHY Mammograms (breast X-rays) can often detect cancer before it has become clinically palpable or felt by the hands of the doctor and is the best method of detection for women over 50 years of age. Mammograms are advisable to all women between the ages of 40 and 69 every 2 years. Though this type of regular screening directly exposes the breasts to the small dose of X-rays, the small risk of these X-rays causing any harm is far outweighed by the benefit of detecting early breast cancer. Mammograms are not 100% foolproof. Even if the mammogram shows no cancer and yet you have a lump in your breast, you should be seen by a doctor immediately. STEPS IN DIAGNOSIS The doctor will take the medical history before doing a physical examination. He will then examine your breasts and feel for any enlarged lymh nodes under your arms and at the base of the neck. A chest X-ray and blood test may also be taken to verify your general health. The following are the specific diagnostic tests for cancer breasts: ULTRASOUND This is a painless test and takes only a few minutes. After applying a special gel on the breast, a small device ( a microphone which emits sound waves is passed over the breast surface). The echoes (reflections of the sound waves) are converted into a picture by the computer. Thus a picture is formed of the inside of the breast. This procedure is useful in women under 35 whose breasts are thick and may not give a picture on mammography. It also helps to differentiate whether the lump is a solid or a cyst (containing fluid). This test is used in addition to mammography. BIOPSY A biopsy of the tumor is done for testing the breast tissue under microscope for cancer. There are four methods by which the sample is collected:
		Fine needle aspiration.
		Core needle biopsy.
		Excision biopsy.
		Localisation biopsy.
	FINE NEEDLE ASPIRATION This is a quick and simple procedure in the outpatient of thedoctor's chambers or in the O.P.D of an hospital. With a fine needle and syringe, a sample of cells from the breast lump is collected and sent to the laboratory to verify if it contains any cancer cells. CORE NEEDLE BIOPSY In this test a slightly larger needle than used for aspiration is introduced under local anaesthesia and the doctor takes a small piece of tissue from the lump. This biopsy sample is examined in the laboratory for the presence of cancer cells. EXCISION BIOPSY In this the whole lump is removed under general anesthesia and sent to laboratory for micropic examination. It may be necessary to stay in the hospital for this purpose for a day. LOCALISATION BIOPSY This is a technique used when a tumor is diagnosed by a mammogram or ultrasound but cannot be physically felt and hence to localise the area a needle and wire are put into the breast after local anesthesia. Once the needle is placed in the correct position, it is withdrawn leaving the wire inside and this wire helps the surgeon to locate the breast tissue to be tested. The wire is later removed in the operation theatre along with the tissue to be examined in the pathology lab. HORMONE RECEPTOR TEST This test examines the cells that wre taken at biopsy to see if the cancer is sensitive to certain hormones. This is done in the pathology laboratory. This will help the specialist to determine if hormone therapy is likely to be useful in the treatment of your particular cancer. FURTHER TESTS If the test shows that you have a breast cancer, further tests are necessary to see if it has spread to other areas. It will help the doctor to decide on the best course of treatment. For this other parts of the body like bones and liver are to be checked radiologically. Not all patients need to undergo all the tests; only if the doctor suspects spread to the bones is a bone scan ordered. LIVER SCAN This is done either by ultrasound or a CT scan. In a CT scan a computerised machine takes a number of X-rays and builds them up into a picture. There is no pain in any of these scans. BONE SCAN This is done by injecting a radio-active substance usually in the arm vein. It is harmless, does not make you radio-active and completely safe for you, your children and other family members. CHEST X-RAY Just a normal X-ray of the chest to see the lungs and other contents of the chest.

Types of treatment used

		The first aim is to treat cancer found in the breast by surgery with or without radiation therapy which may later be used to treat the cancer in the breast
		If there is any chance that the breast cancer might spread to other parts of the body extra treatment that is "adjuvant treatment" may be necessary. Hormone therapy and chemotherapy may be offered to some women as adjuvant treatment. Your specialist will plan your treatment depending on your age, general health, type and size of tumor, nature of the cancer and whether it has spread beyond the breasts. Your personal preferences about the treatment and your lifestyle will also form part of the planning procedure.
	Each patient will be having a different treatment because they have different types of breast cancers. SURGERY Sometimes, a definite diagnosis cannot be made before the operation and the surgeon has to remove the lump to be examined later under microscope. If necessary a further operation may be arranged a few days later giving you more time to prepare yourself. Sometimes, the lump removed is examined under a microscope with the patient still under anesthesia. In the next room, the lump is frozen and the frozen section is examined by a pathologist to determine if it is cancerous. If it is found cancerous, the surgeon proceeds to further operation straightaway. It is now possible to have smaller operations as compared to total removal of the breast (mastectomy). Breast surgery will leave a scar which depends on a number of factors. It is usually possible to learn from the doctor before hand what their breast will look like after surgery. TYPES OF BREAST CANCER SURGERY MASTECTOMY For some the most appropriate treatment is a mastectomy (removal of the whole breast) A simple mastectomy removes only the breast. But in an invasive breast cancer, a mastectomy, together with removal of lymph glands is still necessary. This may also be necessary with a large cancer. BREAST CONSERVING SURGERY In this surgery, the breast lump with some surrounding normal breast tissue is removed. Usually, the nipple is not removed. This is sometimes called a lumpectomy or a wide local excision. Breast conserving surgery is possible with early detection and when the lump is small. The surgeon must remove the whole tumor and the adjacent margins of the breast tissue removed must be clear of cancer cells. In most women the appearance of the breasts after lumpectomy is good. PARTIAL MASTECTOMY (also a form of breast conserving surgery) It is similar to lumpectomy but more breast tissue is removed. It may be more noticeable, particularly in women with small breasts. In women with large breasts, it is less noticeable. LYMPH GLAND REMOVAL (AXILLARY CLEARANCE) With both breast conserving surgery and mastectomy, the surgeon will usually remove some of the lymph glands under the arm to check if any cancer cells have already spread from the breast. Even if the glands cannot be felt, they may still contain cancer cells which can be detected with a microscope. The glands will be examined by the pathologist . If there are any cancer cells in the lymph gland, the doctor will advise if you need any additional treatment such as chemotherapy or hormone therapy.Sometimes even radiation therapy may have to be considered. BREAST RECONSTRUCTION This is often possible for women who have had a mastectomy. Sometimes, at the same time as the mastectomy and in others, after a month or even years after the original operation. If you wish to have breast reconstruction, discuss it with your doctor at the beginning of your treatment so that they can tell you about different possibilities. RADIATION THERAPY Radiation tharapy uses high energy X-rays to destroy cancer cells sparing the normal cells as much as possible. Radiation therapy may be given after surgery to prevent recurrence of cancer in the remaining breast or the chest wall. Teletherapy or external radiation is given by a machine remote from the body, while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiation therapy is also employed for palliation i.e control of symptoms in advanced breast cancer. Radiotherapy, after initial planning, usually takes 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible, depending upon the modality of radiation used. Some women may be advised extra treatment after surgery and/or radiation therapy, called adjuvant therapy, to reduce the risk of the cancer spreading or recurring. This is decided considering:
		The size and type of the breast cancer.
		Whether the breast cancer is sensitive to the female hormones estrogen and progesterone.
		Whether cancer cells are present in the lymph glands.
		Age.
		General health.
	The adjuvant therapy could be chemotherapy or hormone therapy. CHEMOTHERAPY Besides local therapy, the best attempt to contol cancer cells circulating in the body and lodged at places other than the breast is by using systemic therapy (therapy which effects all the systems in the body) which is in the form of injections or oral medication. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner, each set of drugs being repeated every 3-4 weeks. Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. HORMONE THERAPY Hormones are substances formed naturally in the body to regulate the cell function. The female hormone estrogen is formed in the ovaries and plays a very important role throughout a woman's life. Estrogens, however, can enhance the multiplication of breast cancer cells in some women. Tamoxifen is an 'anti-estrogen' synthetic hormone commonly used in breast cancer. It prevents estrogen from attaching to breast cancer cells and cause their multiplication. Tamoxifen is taken as a tablet once or twice a day. Aminoglutethimide is a drug that prevents tissues of the body producing pre hormone, which is converted into estrogen. This can be used to treat breast cancer in women who have achieved menopause after Tamoxifen has been used. Aminoglutethimide may cause side effects like rash or drowsiness. This drug was reserved to treat breast cancer which had spread. However, this drug is rarely used these days.

Side effects of treatment

	SURGERY Besides the usual consequences of surgery like pain, the patient may have soreness along the upper arm, which usually settles after a little while. If lymph nodes are removed during surgery from under your arm or if you have radiation therapy to the armpit, the hand and arm are susceptible to infection. Even a small cut or scratch may induce flow of lmph from other parts of the body, making the area swollen and sore. This is called lymphoedema.Take great care of your hands, avoiding acts which might produce scratches. This reduces chances of infection. If you get any swelling or feel pain or tenderness in your arm or hand, consult your doctor immediately. RADIATION THERAPY Besides lymphoedema mentioned above, the effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction employed. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis, in which the skin covering the radiated area becomes red, dry, itchy and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. Radiation may also cause nausea and vomiting, diarrhoea and urinary discomfort. There may also be fall in the blood cells, which are needed by humans to fight infection. Usually, the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. CHEMOTHERAPY The various drugs used in chemotherapy cause a varied spectrum of side effects. The severity and variability of these side effects are very individualistic, changing from patient to patient. Some of the common side effects are:
		Discomfort and the passage of blood during urination.
		Skin rashes.
		Loss of hair.
		Diarrhoea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most of these effects are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist (chemotherapist) will usually be able to reduce the severity and spectrum of the side effects. The psychology of the patient is very important during chemotherapy. The better psychologically prepared the patient is, the better are his/her chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked /raw food.Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

Adjusting to Breast Cancer treatment

For most women, the diagnosis and treatment of breast cancer is a major stress in their lives.They have fears about the future and about the effects of treatment, leading to anxiety or sadness. Some may feel relief after completing their treatment. For those who have further treatment, it takes a long time to return to their normal way of life. But most return back to normal as time passes.

Adjusting to the loss of a breast or a part of it is a challenge to most women. After a mastectomy, only reconstruction will restore the breast. 6-8 weeks after surgery, a false breast (weighted breast prosthesis) can be fitted. With such a properly fitted prosthesis, and bra, no one can tell that one has had a mastectomy.

Relationships and Sexuality

Treatment for breast cancer can affect intimate relationships, increasing the need for reassurance.

Some women may feel loss of interest in sex as they feel tired or worry about the breast cancer or its treatment. A change in their appearance like loss of hair and the loss of a breast may make them feel unattractive, thus fearing rejection from their partner. Sometimes, the husband avoids sex for fear of hurting her or for fear that sex will be different. Some husbands find it difficult to look at the women's chest or the women may fear that this is the case.

It can be useful to obtain medical assistance for sexual problems.

Child Bearing

If one wants a child, the woman and her husband should discuss with the doctor who knows your full medical history and can tell you the risks and implications. The longer you are free of the disease, the lesser are the chances of the breast cancer to recur. However, you must carefully consider what will happen if breast cancer recurs after having a baby and you have an extra responsibility on hand.

Unfortunately, women with their ovaries removed or rendered non-functional after chemotherapy will not be able to have children conventionally. However, new possibilities are open with in vitro fertilization and embryo donation. Your cancer and fertility specialists can advise you properly.

Contraception

Since breast cancer may be affected by hormones, women who have had breast cancer are advised not to take contraceptive pills. Sometimes, progesterone only pills may be used.

Barrier methods of contraception like condoms or diaphragm are suitable. Spermicides may also be used to give extra contraceptive protection.

The hospital family planning department or your GP can fit you with a diaphragm or intra-uterine device (IUD), which are effective. Some women or their husbands prefer to be sterilized.

Menopause

When menstruation stops it is called menopause. This normally occurs between 45-55 years of age, but can be earlier or later. Women with their ovaries removed or made non-functional by chemotherapy will have an early menopause. Some women have unpleasant side effects of menopause like hot flushes or vaginal dryness.

Hormone replacement therapy(HRT) using estrogen combined with progesterone is the treatment for these symptoms. Till recently, women who had breast cancer were advised not to take HRT. However, it is now felt that an estrogen-progesterone combination pill may be less likely to cause problems than estrogen alone.Consult your doctor for more details.

Follow up

The importance of follow up cannot be over emphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of the treatment is over, then he/she is cured. It must be stressed here that breast cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem while it is still early, so that it can be nipped in the bud.And the only way to do this is to follow up when the doctor calls you for your next visit.

Each such visit will include a detailed history, a physical examination, a chest X-ray, an ultrasonography or CT scan and various blood studies including tumor marker studies wherever indicated.