DONATEBREAST CANCER
Overview
Facts
- Most common cancer in women throughout the world.
- Commonest cancer in women in India
- One in eight women will develop breast cancer in her life
- One women dies of breast cancer every eight minutes
What is Breast Cancer ?
Any abnormal growth in breast which has a potential to spread elsewhere is breast cancer. Almost every women feels some kind of changes in her breast during her life, some type of lumps and bumps but fortunately most of them are harmless, however every lump in breast warrants a careful clinical examination and further investigations if required.
Signs and Symptoms of Breast Cancer
Most of the breast cancers present as a painless lump which is slowly increasing in size over a period of weeks and months. Since it is painless to start with therefore it is neglected for a long time and patients present late. Other features include retraction of nipple, nipple discharge, eczematous lesion on nipple and areola. dimpling of skin or orange peel like appearance. In advanced stage the lady may present with a large mass with ulceration, bleeding and pain. She may also present with a mass in armpit due to enlarged lymph nodes.
Screening and Diagnosis of Breast Cancer
How to diagnose Breast Cancer ?
- Almost 99% of breast cancer can be diagnosed by TRIPLE ASSESSMENT
- Clinical breast examination
- Imaging- Mammography, Ultrasound of breast, MRI of breast
- Histopathology- Core needle biopsy of breast lump either directly or under the guidance of ultrasound to determine the type of tumor and receptor status.
“It’s a MYTH that biopsy spreads Cancer”
Once the diagnosis of breast cancer is made , now it is the time to stage the disease which tells us whether it has spread to other parts of body or not. It determines the plan of treatment and the outcome of disease.
How to Stage Breast cancer ?
- Clinical staging – includes clinical examination and imaging studies like chest X ray, Ultrasound of abdomen, Skeletal survey or sometimes even PET CT scan
“ PET CT Scan does not diagnose cancer but stages it”
- Pathological staging- is done after the removal of tumor and lymph nodes , The pathological examination gives us the other information of tumor and number of involved nodes and its characteristics which determine further treatment and outcome.
Stage I – Small tumor localized to breast only
Stage II – Tumor in breast and axillary nodes on the same side
Stage III – Locally advanced Breast cancer ( LABC)- Large tumor in breast which may involve skin or chest wall or multiple fixed nodes in axilla, neck or inside the chest.
Stage IV – The cancer has spread to other parts of body like liver, lung, bone, brain etc.
‘Breast Cancer can spread to any part of the body’
Treatment of Breast Cancer
Breast cancer management is MULTIMODALITY, all methods of treatment– Surgery, Radiation and Medical oncology are required to treat breast cancer optimally. The sequencing of treatment is the most essential part to get the best outcome.
Surgery
It is the mainstay of treatment for early stage breast cancer . It removes the tumour with adequate margins along with removal of lymph nodes from axilla.
In today’s era, the breast can be conserved and reconstructed with good cosmesis in majority cases. Mastectomy is occasionally required these days, unless patient demands it.
“There is no difference in overall outcome in Mastectomy and Breast Conservation”
Different types of oncoplastic surgeries are available to reconstruct the breast as near normal as possible without any additional problems.
Sentinel node biopsy can also be performed when indicated in breast cancer, it avoids the chance of swelling of the arm(Lymphedema).
Radiation therapy
Radiotherapy has withstood the test of time and has become part and parcel of overall treatment. Radiotherapy adds onto the benefit both in terms of progression free survival and overall survival. Radiation treatment nowadays is meticulously planned on planning CT scans and delivered with daily imaging conformations of the planned areas to be treated leaving very little chances for toxicities. Radiation oncologists have been able squeeze the treatment to 3 weeks rather than the conventional 5 weeks with equivalent results both in terms of tumor control as well as from toxicity point of view.
Chemotherapy/ Hormonal therapy/ Targeted Therapy
Breast cancer is not one disease but it includes variety of histopathological malignancies that requires different approaches to treatment. The research is continuously ongoing in medical field with newer agents being added to the treatment armamentarium every year increasing the chances of survival and responses. New additions in targeted therapies include not only novel oral therapies like Cyclin dependent kinase (CDK) inhibitors, PIK3CA inhibitors and small molecule tyrosine kinase inhibitors but also various parenteral molecules in form of monoclonal antibodies and antibody drug conjugates(Discuss the drug details with your treating doctor).
Early stage breast cancer is mostly subjected to loco-regional treatment in form of surgery and radiation while chemotherapy is contemplated to control micro metastatic disease and prevent recurrences. However, all early breast cancers may not require chemotherapy. Some of the early cancers like hormone negative may be treated with chemotherapy first followed by surgery. In some of triple negative subset of breast cancer addition of immunotherapy (Atezolizumab/Pembrolizumab) has changed entirely the way in which patients were previously counseled for outcome and now the survival of this dismal subset has also improved even in metastatic stage.
No discussion is complete without considering cost of treatment and the sad side of story is the cost of these newer molecules which is mostly unaffordable for majority of the general population. Even though characterized as ‘low-cost’ by global standards, it still remains unaffordable for the majority of the population.
Risk Factors of Breast Cancer
There are certain risk factors which you can not change while some life style changes may protect you from Breast cancer
Non Modifiable:
- Age – The risk of breast cancer increases with age, peaking in fifth decade. But recently we have seen that more and more younger females are developing breast cancer . No age is bar for breast cancer.
- Gender – Female gender is more prone for breast cancer though 1% of all breast cancers occur in men too.
- Family History- 5-10% of breast cancers run in families.. If a lady is carrying breast cancer gene then it is possible that half of her children may get that breast cancer gene.
“ Having Breast cancer gene does not mean that the lady will have breast cancer surely, it is just that there is a higher chance of getting breast cancer and some other cancers than the risk in general population”.
“Your father may also carry the breast cancer gene, so Paternal history is equally important.”
- Personal history of breast cancer- if there is a history of breast cancer, there are increased chances of having breast cancer on the other side.
- Radiation therapy to the chest.
Modifiable:
- Weight- increase in weight predisposes to breast cancer
- Diet- Eat plenty of vegetables and fruits. Avoid processed meat, charred and smoked food.
- Alcohol consumption- Increases the risk
- Exercises- Prevent breast cancer
- Exposure to Estrogen- This female hormone increases the chance of developing breast cancer. It can act through following ways-
- Hormone replacement therapy
- Early menarche – starting menstrual cycle early in life ( before 12 years )
- Late menopause- after 55 years
- Nulliparity
- Late age of first child birth
- Pregnancy and Breast feeding reduces the risk of breast cancer
How Breast cancer is different in India ?
- Early age of diagnosis in Indian women
- Higher number of high grade tumors and higher stage of presentation
- Higher proportion of patients who do not respond to hormonal treatment
- Higher number of inflammatory breast cancers
- Higher number of mastectomy than conservation
The Outcomes in Breast Cancer
The outcome or prognosis in breast cancer depends on –
- Stage of cancer
- Hormone receptor status and Her 2 neu status
- Comorbidities
- Biological behaviour of the tumour
The outcome is individualized, no two cancers behave similar, so the treatment is customized for each and every patient.
Prevention & Cure of Breast Cancer
Ways to reduce your breast cancer risk (WHO)
- Do not smoke
- Control your weight
- Limit or avoid alcohol
- Breastfeed
- Be physically active
- Avoid radiation exposures
Ways to reduce your breast cancer risk (WHO)
20—39 Yrs age—Breast self examinatio
Clinical breast examination every 3 years.
40yrs onwards—Annual screening Mammogram
Genetic Testing
- Woman has family history of known BRCA-1/BRCA-2 mutation
- Personal history of breast cancer and --Age younger than 45 years --One or more close blood relatives with breast cancer, pancreatic cancer, prostate cancer --Triple negative in less than 60 years of age
Genetic counselling is done before these tests.
Lifetime risk of developing breast and ovarian cancer in BRCA ½(mutated)is very high, so prophylactic surgery is recommended after the age of 35 -40 yrs.
How is RGCIRC Different
At RGCIRC we see around 1800 breast cancer patients every year. The facilities include-
- Screening of Breast cancer
- Imaging- Digital, mammography , Tomosynthesis, MRI , CT scan
- Nuclear Medicine- PET CT Scan, Bone scan, Sentinel node mapping, Scintimammography
- Image guided biopsies – USG guides, Stereotactic biopsy, MR guided, Vacuum assisted breast biopsy ( VABB)
- Histopathology including immunohistochemistry and Fish testing
- Molecular Testing- BRCA testing and other genetic mutation testing and counselling
- Surgery, Radiation and Medical Oncology
- Rehabilitation by Physiotherapy
- Survivorship Program- Maitri and The Pink Clinic
All the patients are seen by dedicated Breast cancer management team which includes Surgical , Medical and Radiation oncologists along with Radiologist, Pathologist and Nuclear medicine specialist. The cases are discussed in TUMOR BOARD to decide the best treatment protocol for them and then they are explained the treatment plan.
DO’s after Surgery
- Maintain a healthy weight
- Drink lots of water(8 to 10 glasses)
- Exercise regularly
- Plan pregnancy before 35 years of age
- Breastfeed your baby
DON'Ts after Surgery
- Eat lots of sugary food
- Take counterfeit hormones
- Eat junk food, food with saturated fat
- Alcohol, smoking use
- Sedentary lifestyles
Questions patient would like to ask to doctor
Questions to ask about surgery
Questions to ask about radiation therapy
Questions to ask about Chemotherapy, hormone treatment?
- What tests will I have? How often will they be repeated? Will my insurance pay for these tests?
- What If I am pregnant or want to become pregnant?
- How will my biopsy be performed? What else might be done at this time?
- What will happen if I do nothing?
- What are the possible complications and side effects?
- Am I a candidate for a clinical trial? Can I join a clinical trial at any time?
- What are my treatment choices? What are the benefits and risks? Which treatment do you recommend and why?
- Does the order or sequence of treatment matter?
- How much will this treatment cost me? How much will my insurance pay for this treatment? Are there any programs to help me pay for treatment?
- Will I miss work or school? Will I be able to drive? When will I be able to return to my normal activities?
- What are the chances my cancer will return after this treatment? How will it be treated if it returns?
- I would like a second opinion. Is there someone you can recommend? Who can help me gather all of my records for a second opinion?
- Are their any support groups available to help me during and after treatment?
- How much of my breast will be removed? What will it look like afterwards?
- What other organs or tissues might be removed during surgery? What will this mean in terms of my recovery?
- What kind of surgery will I have? Will I have more than one surgery?
- How long will it take me to recover from surgery? When will I be able to return to work?
- What other side effects can I expect from surgery? What complications can occur from this surgery?
- What treatment will I have before, during, or after surgery?
- How do you compare breast saving surgery VS mastectomy? The Pros and Cons of each method of treatment?
- When and How can reconstruction of breast be done.?
- What type of radiation therapy (RT) will I have?
- How many treatment sessions will I require? Can you do a shorter course of RT?
- What side effects can I expect from RT?
- What are the Do’s and Dont’s before and after RT?
- Can I take bath and apply soap on chest during RT treatment?
- Can I wear Bra during radiation?
- What are the side effects of Chemo treatment and hormonal treatment?
- How will it be administered?
- How long will these side effects last? Do any side effects lessen or worsen in severity overtime?
- What is PORT and PICC line? What do I need?? What care is needed for PORT and PICC lines? For how much time they are kept in body ? What care is needed for them?
- When should I contact emergency department ? Will my treatment team be able to communicate with the ER team?
- What medicines can I take to prevent or relieve side effects? Can I take alternative therapy along with chemotherapy?
- How will I be monitored during chemotherapy?
- What are some of the likely permanent side effects that I might have from the treatment?
- What dietary restrictions are needed during treatment?
- What lifestyle modifications are required during and after treatment?
Patient may ask to doctor
- What tests will I have? How often will they be repeated? Will my insurance pay for these tests?
- What If I am pregnant or want to become pregnant?
- How will my biopsy be performed? What else might be done at this time?
- What will happen if I do nothing?
- What are the possible complications and side effects?
- Am I a candidate for a clinical trial? Can I join a clinical trial at any time?
- What are my treatment choices? What are the benefits and risks? Which treatment do you recommend and why?
- Does the order or sequence of treatment matter?
- How much will this treatment cost me? How much will my insurance pay for this treatment? Are there any programs to help me pay for treatment?
- Will I miss work or school? Will I be able to drive? When will I be able to return to my normal activities?
- What are the chances my cancer will return after this treatment? How will it be treated if it returns?
- I would like a second opinion. Is there someone you can recommend? Who can help me gather all of my records for a second opinion?
- Are their any support groups available to help me during and after treatment?
Patient may ask about surgery
- How much of my breast will be removed? What will it look like afterwards?
- What other organs or tissues might be removed during surgery? What will this mean in terms of my recovery?
- What kind of surgery will I have? Will I have more than one surgery?
- How long will it take me to recover from surgery? When will I be able to return to work?
- What other side effects can I expect from surgery? What complications can occur from this surgery?
- What treatment will I have before, during, or after surgery?
- How do you compare breast saving surgery VS mastectomy? The Pros and Cons of each method of treatment?
- When and How can reconstruction of breast be done.?
Patient may ask about radiation therapy
- What type of radiation therapy (RT) will I have?
- How many treatment sessions will I require? Can you do a shorter course of RT?
- What side effects can I expect from RT?
- What are the Do’s and Dont’s before and after RT?
- Can I take bath and apply soap on chest during RT treatment?
- Can I wear Bra during radiation?
Patient may ask about Chemotherapy, hormone treatment?
- What are the side effects of Chemo treatment and hormonal treatment?
- How will it be administered?
- How long will these side effects last? Do any side effects lessen or worsen in severity overtime?
- What is PORT and PICC line? What do I need?? What care is needed for PORT and PICC lines? For how much time they are kept in body ? What care is needed for them?
- When should I contact emergency department ? Will my treatment team be able to communicate with the ER team?
- What medicines can I take to prevent or relieve side effects? Can I take alternative therapy along with chemotherapy?
- How will I be monitored during chemotherapy?
- What are some of the likely permanent side effects that I might have from the treatment?
- What dietary restrictions are needed during treatment?
- What lifestyle modifications are required during and after treatment?
