Breast Cancer

Breast Cancer

Breast Cancer

What is Breast Cancer?

The female breast is essentially made up of milk-producing glands called as lobules and tiny tubes called ducts which carry the secreted milk from lobules to the nipple. The rest of the tissue is designated as Stroma the supportive structure of an organ consisting of fatty and connective tissue which surrounds the lobules, ducts and the blood vessels and lymphatic vessels.

Functions:

  • Women's breasts are made of specialized tissue that produces milk (glandular tissue).
  • Breasts milk provides complete nutrition to an infant.
  • Breast milk contains carbohydrate (lactose), fats and proteins as well as micronutrients.
  • Breast secretions also ensure that the newborn has a significant amount of immunological protection in the form of maternal antibodies, chemical mediators, vitamins, and enzymes.

Breast Cancer

Cancer is caused due to uncontrollable growth of abnormal cells that start invading the normal cells around them. When these abnormal tumor cells are present in the breast, they lead to breast cancer. Majority of breast cancers have ductal or lobular origin and only a small number of breast cancers originate in other tissues. In Breast Cancer, apart from the primary tumor, the involvement of Lymph Nodes assumes great importance with respect to the spread of cancer to different tissues (metastases).

Though it is a disease that affects primarily women, men can get it, too. But don’t worry! Regular screenings and mammograms (an x-ray exam of the breast that is used to detect and evaluate breast changes) can help in early detection and prevention of the cancer’s spread through timely or early treatment.

Types of Breast Cancer

  • Ductal carcinoma in situ
    It is a non–invasive breast cancer. Cancer cells can be found in the lining of the breast milk duct. Ductal carcinoma in situ is very early cancer that is highly treatable, but if it’s left untreated or undetected, it can spread to the surrounding breast tissue.
  • Invasive ductal carcinoma
    Also referred as infiltrative ductal carcinoma, it is the most common type of breast cancer. It starts in a milk duct of the breast, breaks through the wall of the duct, and grows into the fatty tissue of the breast.
  • Invasive lobular carcinoma
    It is the second most common type of Breast Cancer. It starts in the milk-producing glands (lobules) and cancer cells in the lobules have spread into the surrounding breast tissue.
  • Inflammatory breast cancer
    It is a rare type of inflammatory Breast Cancer, aggressive and fast growing in which cancer cells infiltrate the skin and lymph vessels of the breast. It often produces no distinct tumor or lump that can be felt. But when the lymph vessels become blocked by the breast cancer cells, symptoms begin to appear.
  • Metastatic Breast Cancer
    Metastatic breast cancer is also classified as Stage 4 breast cancer. The cancer has spread to other parts of the body. This usually includes the lungs, liver, bones or brain.
  • Paget’s disease of the breast
    An uncommon type of Breast Cancer condition affecting the skin of the nipple and often the areola, which is the darker circle of skin around the nipple. Most people with Paget disease evident on the nipple also have one or more tumors inside the same breast.
  • Tubular
    It accounts for almost 2% of all Breast Cancer diagnosis. Tubular carcinoma cells have a distinctive tubular structure when viewed under a microscope. It is usually found on a mammogram and appears as a collection of cells that can feel like a spongy area of breast tissue. Typically, this type of breast cancer is found in women aged 50 and above and usually responds well to hormone therapy.
  • Mucinous Carcinoma
    Mucinous carcinoma represents approximately 1% to 2% of all breast cancers. The main differentiating features are mucus production and cells that are poorly defined. It also has a favorable prognosis in most cases.

Occurrence rate

In India, we are now witnessing more and more numbers of patients being diagnosed with breast cancer to be in the younger age groups (in their thirties and forties). Breast cancer is now the most common cancer in most cities in India, and 2nd most common in the rural areas.

Anatomy of Breast Cancer

What are the general symptoms of Breast Cancer?

Signs and Symptoms of Breast Cancer

  • Lump in the breast
    The most common and usually the first sign of Breast Cancer is the ‘Lump’ in the breast. Usually, the lady herself finds it out first.
    • The lump related to Breast Cancer may be tender but usually without pain.
    • The lump may sometimes feel hard and irregular in shape. It may appear distinctly different from the rest of the breast tissue.
    • Peculiarly, the lump does not disappear or change in size with the menstrual cycle.
    • Cancer related lump is firmly attached to the skin or the chest wall and does not move.
  • Lump in the Armpit
    • A lump in the armpit may be spotted because of the axillary lymph node involvement.
    • Axillary lump occurs mostly because of the spread of cancer.
    • The lump may be hard, tender, or painless.
  • Skin Changes
    • Dimpled Skin: It means hollowness or formation like a pit or depression in the breast.
    • Puckered Skin: It means with creases or crumpled.
    • A thickening and dimpling of the skin may occur.
  • Inflammatory Breast Cancer
    • Inflammatory Breast could be an indicator of breast cancer.
    • Persistent itching in the breast or the nipple, which is (often) not relieved by medications or medicated ointments or creams for local application.
  • Nipple Changes
    • Nipples are normally pointed outwards. However, nipples may also be pointed inwards (inverted). However, if normal nipples get inverted, it could be a cause of concern and the person should ideally see a doctor for consultation and medical opinion.
  • Discharge from Nipples
    • Although many noncancerous conditions may cause it, better to find out the reasons.
    • Discharge from a single nipple, especially if it occurs without squeezing it, and especially if containing blood may be a sign of Breast Cancer.
  • Paget’s Disease (a type of Breast Cancer):
    • Crusting, ulcers or scaling on the nipple may be a sign of some rare types of breast cancer, such as Paget disease of the nipple.

LATE SIGNS AND SYMPTOMS

  • Bone Pain
  • Nausea
  • Loss of Appetite
  • Weight Loss
  • Jaundice
  • Pleural Effusion: (buildup of fluid around the lungs)
  • Shortness of Breath
  • Cough
  • Headache
  • Double Vision
  • Muscle Weakness

It is important to note that pain can more often be a symptom of non-cancerous (benign) tumor. Yet, one should not be complacent but needs to be vigilant and get examined by a doctor to ascertain it.

While any or all these symptoms may not always end in breast cancer, it is advisable to consult a healthcare professional when any of these symptoms appear. Mammograms may help in detecting breast cancer before the appearance of a symptom. However, it must be stressed that mammograms are not always successful in discovering breast cancer. That does not mean you should not take one! Any prevention is better than cure. So, go out there, make that visit, consult your doctor and take a step closer to knowledge and, perhaps, relief!

What are the general causes of Breast cancer?

A person’s chances of getting breast cancer are calculated based on certain “risk factors”. Risk factor may refer to anything from age to habits to genetics. However, the presence of these risk factors doesn’t necessarily mean that one shall definitely be diagnosed with Cancer, but the probability of getting affected by Cancer increases many folds.

  • Gender: Women are 100 times more likely to get Breast Cancer than men.
  • Ageing: The chances of breast cancer increases with increasing age. Hence, going for mammogram tests in the 40’s is a smart move.
  • Early onset of menstruation (before age 12) and/or late onset of menopause (post-55).
  • Late or no pregnancy: Having children after the age of 30 can be a cause of breast cancer.
  • Genes: Breast Cancer is considered to be hereditary 5-10% of the time. If there is any occurrence of Breast Cancer in the family tree then cancer diagnostic tests can be done for early detection and action. Inherited mutations in certain genes, such as BRCA1 and BRCA2 increase the risk of breast and ovarian cancer.
  • If the Cancer is present in one breast, then the chances of developing cancer in the other breast are 3 times more likely.

Other risk factors include:

  • Dense breast tissue: Dense breasts have more connective tissue than fatty tissue, which can sometimes make it hard to see tumors on a mammogram. Women with dense breasts are more likely to get Breast Cancer.
  • Hormone Therapy: Taking hormones to replace missing estrogen and progesterone in menopause for more than five years raises the risk for Breast Cancer. The hormones that have been shown to increase risk are estrogen and progestin when taken together.
  • Contraceptives: Certain forms of oral contraceptive pills have been found to raise Breast Cancer risk.
  • Diethylstilbestrol: a drug given to women to lower chances of miscarriage in the mid-90s.
  • Intake of alcohol/tobacco is directly proportional to the increase in risk of getting breast cancer.
  • Obesity: Older women who are overweight or obese have a higher risk of getting Breast Cancer than those at a normal weight.

Lowering the risk of Breast Cancer

Breastfeeding may lower the risk of Cancer, according to research. Exercises seem to lower chances of developing Breast Cancer. According to a study in Women’s Health Initiative brisk-walking as little as 1.25 to 2.5 hours per week can reduce the risk by 18%! So grab those running shoes!

What are the stages of Breast Cancer?

Stage or Grade of Breast Cancer is largely determined by the findings such as

  • whether the tumor is local
  • spread to the nearby lymph nodes
  • spread to the distant organs.

TNM system is widely used to stage Breast Cancer:

  • T refers to tumor size.
  • N describes lymph node status.
  • M indicates whether the cancer has metastasized.

The stages of Breast Cancer are explained in details below:

  • Stage 0:
    Describes non-invasive Breast Cancers. There is no evidence of cancer cells out of the part of the breast, in which they started.
  • Stage I:
    Describes invasive Breast Cancer in which cancer cells are invading surrounding breast tissues.
    • Stage IA:
      • the tumor measures up to 2 centimeters
      • the cancer has not spread outside the breast and no lymph nodes are involved
    • Stage IB:
      • Small groups of cancer cells ranging from 0.2 millimeters - 2 millimeters are found in the lymph nodes.
      • There is a tumor in the breast that is no larger than 2 centimeters, and there are small groups of cancer cells ranging from 0.2 millimeter to 2 millimeters in the lymph nodes.
  • Stage II:
    • Stage IIA:
      • No tumor can be found in the breast, but cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in the lymph nodes near the breast bone.
      • The tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes.
      • The tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.
    • Stage IIB:
      • The tumor ranges from 2 cm to5 cm and small groups of Breast Cancer cells ranging from 0.2 mm to 2 mm are found in the lymph nodes.
      • The tumor ranges from 2 cm to 5 cm, it has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the breastbone
      • The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes
  • Stage III:
    • Stage IIIA:
      • Tumor of any size could be spotted in the breast or sometimes there might not be a tumor at all. Cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone.
      • The tumor is larger than 5 cm and small groups of Breast Cancer cells ranging from 0.2 mm to 2 mm are found in the lymph nodes.
      • The tumor is larger than 5 centimeters; cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone.
    • Stage IIIB:
      • The tumor may be any size and has spread to the chest wall and/or skin of the breast.
      • May have spread to up to 9 axillary lymph nodes OR
      • May have spread to lymph nodes near the breastbone
    • Stage IIIC:
      • There may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast AND
      • The cancer has spread to 10 or more axillary lymph nodes OR
      • The cancer has spread to lymph nodes above or below the collarbone OR
      • The cancer has spread to axillary lymph nodes or to lymph nodes near the breastbone
  • Stage IV:
    Stage IV describes invasive Breast Cancer that has spread beyond the breast and nearby lymph nodes to other organs of the body, such as the lungs, distant lymph nodes, skin, bones, liver, or brain.
Survival rates for Breast Cancer?

Survival rates indicate an average outcome of large number of people who had the disease, but they cannot precisely predict the expectancy of any particular case. The survival rate of Breast Cancer when detected at an early stage is quite high and if the detection is delayed till the last stage then the chances of survival drop significantly. Since, the symptoms of Breast Cancer are quite evident being aware of the condition aids in early detection.

Can Breast Cancer be detected early?

Breast Cancer is sometimes found after symptoms appear, but many women with Breast Cancer have no symptoms. This is why regular Breast Cancer screening is so important.

  • Physical exam and history: The body is thoroughly examined to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Clinical breast exam (CBE): The breast is closely observed by a doctor or health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual.
  • Mammograms: A mammogram is an x-ray of the breast that looks for changes that may be signs of Breast Cancer. Mammograms are the best Breast Cancer screening tests and all women are recommended to get it done to ensure complete safety. Women with any of the risk factors are recommended to go for a mammogram once every year.
  • Breast Ultrasound: Breast ultrasound uses sound waves to make a computer picture of the inside of the breast. A gel is put on the skin of the breast and an instrument called a transducer is moved across the skin to show the underlying tissue structure.
  • Breast MRI Scans: The MRI machine is called an MRI with dedicated breast coils. MRI uses strong magnets instead of radiation to make very detailed, cross-sectional pictures of the body.
  • Biopsy: Biopsy is the removal of a small amount of tissue for examination under a microscope. There are different kinds of breast biopsies. Some of them are mentioned below:
    • Fine needle aspiration biopsy: In this procedure, a very thin, hollow needle attached to a syringe is used to withdraw a small amount of tissue from a suspicious area.
    • Core needle biopsy: In this procedure, a larger needle is used to sample breast changes
    • Surgical (open) biopsy: In rare cases, surgery is needed to remove all or part of the lump for testing. This is called a surgical biopsy or an open biopsy. Most often, the surgeon removes the entire mass or abnormal area as well as a surrounding margin of normal- breast tissue.

      There are 2 types of surgical biopsies:
      • Incisional biopsy The removal of part of a lump or a sample of tissue.
      • Excisional biopsy The removal of an entire lump of tissue.
  • Lymph node biopsy: If the lymph nodes under the arm are enlarged, a doctor may need to check them for cancer spread. Most often, an enlarged lymph node is biopsied at the same time as the breast tumor.

Earlier the detection the better is the outcome of therapy (prognosis).About 70% of the patients are offered Breast Conservation Surgery and approximately 5% overall also undergo breast reconstruction.

About 35% of those cases are Locally Advanced cancers requiring Multi-Modality Treatment.

What are the Treatments available?

Right Diagnosis is the first step towards getting Right Treatment as various treatment options exist, which vary depending upon the spread of the disease, whether to nearby region or to distant organs (metastases) and the stage of the disease. Tata Memorial Hospital (TMH) from Mumbai is one of the leading cancer treatment centers in the world and amongst the oldest in India.

The Breast (Cancer) Unit of the Tata Memorial Hospital diagnoses about 4400 new Breast Cancer cases per year, 60% of which are operable ones. The unit performs on an average 45 Breast Cancer surgeries per week.

Treatments available are dependent on the stages of cancer. Primary treatments available are as follows:

  • Surgery to remove the breast. It is the most effective treatment when the spread of cancer is limited to the cells of the breast.
    • Breast-conserving: Surgery is an operation to remove the cancer and some normal tissue around it, but not the breast itself.
    • Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy
    • Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.
  • Radiation therapy: Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:
    • External radiation therapy uses a machine outside the body to send radiation toward the cancer.
    • Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

    The way the radiation therapy is given depends on the type and stage of the cancer being treated.
  • Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.
  • Hormone therapy: It is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing.
    • Hormone therapy with tamoxifen is often given to patients with early localized Breast Cancer.
    • Hormone therapy with a luteinizing hormone-releasing hormone (LHRH) agonist is given to some premenopausal women who have just been diagnosed with hormone receptor positive Breast Cancer.
    • Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone receptor positive Breast Cancer.
    • Other types of hormone therapy include megestrol acetate or anti-estrogen therapy such as fulvestrant.
  • Targeted therapy: It is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibodies, tyrosine kinase inhibitors, cyclin-dependent kinase inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and PARP inhibitors are types of targeted therapies used in the treatment of Breast Cancer.
Is there curative treatment for Breast Cancer?

Diagnosing Breast Cancer early is the key to optimum treatment and a better prognosis, i.e. outcome of therapy Breast Cancer is highly treatable when detected at an early stage. However, the recurrence rate of Breast Cancer is also high, so proper care needs to be taken even after complete treatment and regular inspections and examinations needs to be done at least once a year to avoid the turmoil again.

How frequently should one visit a doctor for an early diagnosis?

In case of experiencing any of the mentioned symptoms or having a prior or familial history of Breast Cancer, a physical examination by a specialist is recommended once in a year.

How can I as a patient know it early?

Diagnostic methods include a screening mammogram and clinical breast examination. Sometimes, Breast Cancer can even be diagnosed with a simple self-examination, when lumps on or near the breasts are felt. However, not every change in the breast is a sign of Breast Cancer. It is advisable to visit the doctor nonetheless as more information is needed for an accurate diagnosis.

Breast Self Examination (BSE) One can use this method at home to check for lumps once a month.

(Adapted from the American Cancer Society by Health Gate Editorial Staff)

For a menstruating woman, the best time to do BSE is 2 or 3 days after the period ends. These are the days when the breasts are least likely to be tender or swollen. For woman who have undergone menopause, any day of the month is suitable to do a BSE. For those taking hormones, consulting the doctor about BSE would be helpful.

Here are 5 efficient self examination tests that can be done at home:

Step 1

Stand in front of a mirror that is large enough for you to see your breasts clearly. Check each breast for anything unusual. Look for a discharge from the nipples and check the skin for

  • puckering,
  • dimpling, or
  • scaliness.

Steps 2 and 3

Check for changes in the shape or contour of your breasts. As you do these steps, you should feel your chest muscles tighten.

Step 2 - watching closely in the mirror, clasp your hands behind your head and press your hands forward.

Step 3 - press your hands firmly on your hips and bend slightly toward the mirror as you pull your shoulder and elbows forward.

Step 4 - gently squeeze each nipple and look for a discharge.

Step 5 - raise one arm. Use the pads of the fingers of your other hand to check the breast and the surrounding area—firmly, carefully, and thoroughly. Some women like to use lotion or powder to help their fingers glide easily over the skin. Feel for any unusual lump or mass under the skin.

Feel the tissue by pressing your fingers in small, overlapping areas about the size of a dime. To be sure you cover your whole breast, take your time and follow a definite pattern: lines, circles, or wedges.

Pay special attention to the area between the breast and the underarm, including the underarm itself. Check the area above the breast, up to the collarbone and all the way over to your shoulder.

Here are some tips on patterns that you can use:

  • Lines:
    • Start in the underarm area and move your fingers downward little by little until they are below the breast.
    • Then move your fingers slightly toward the middle and slowly move back up.
    • Go up and down until you cover the whole area.
  • Circles:
    • Beginning at the outer edge of your breasts, move your fingers slowly around the whole breast in a circle.
    • Move around the breast in smaller and smaller circles, gradually working toward the nipple.
    • Don't forget to check the underarm and upper chest areas, too.
  • Wedges:
    • Starting at the outer edge of the breast, move your fingers toward the nipple and back to the edge.
    • Check your whole breast, covering one small wedge-shaped section at a time.
    • Be sure to check the underarm area and the upper chest.

Step 6 - repeat step 5 while you are lying down. Lie flat on your back, with one arm over your head and a pillow or folded towel under the shoulder.

Step 7 - you may want to repeat step 5 in the shower. Your fingers will glide easily over soapy skin, so you can concentrate on feeling for changes underneath.

It is recommended that all women over the age of 20 examine their breasts once a month. One must not forget that delaying the diagnosis of Breast Cancer would not change the diagnosis, it can only worsen the outcome.

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