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All you need to know about
BREAST CANCER

Breast cancer is the most common cancer in women worldwide and in India. Approximately 1.6 lakh women are diagnosed each other with this cancer.

Incidence and demographics :

The incidence of Breast Cancer is rapidly increasing in India. In the last 25 years, the incidence has doubled in the urban population. WHO predicts that by 2020, India will be at par with the US and Europe in terms of the lifetime risk of Breast cancer. Now, an estimated one lakh women get diagnosed with Breast Cancer every year in India. The number is expected to touch 2 lakhs by 2020. In Chennai, Breast Cancer accounts for 1 in 3 cancers in women and cervical cancer 1 in 5. The age group of 25 yrs to 50 yrs accounts for 50% of the cases of Breast Cancer.

What is Breast Cancer?

Cancer is an uncontrolled growth of cells, which serves no useful purpose. Cancer arises in the breast from the lobules, which secrete milk, and from the ducts, which convey milk to the nipple. Accordingly the cancer is called a lobular or ductal carcinoma respectively. If the cancer has not breached the lining membrane of the lobule or duct, it is called a Lobular or Ductal carcinoma insitu, an earlier stage of cancer.

Symptoms :
  • A Painless breast lump
  • Lump in the armpit
  • A spontaneous discharge from the nipple,
  • Deformity or indrawing of the nipple,
  • Rarely by symptoms of distant spread such as bone pains, cough and jaundice.
Risk factors :

Non-modifiable risk factors:

  • Age [incidence increases with age]
  • Family history
  • Early menarche i.e. attainment of menses [< 12yrs] and late [> 55yrs] menopause.
Modifiable risk factors:
  • Postmenopausal obesity
  • Use of Hormone replacement therapy at menopause,
  • Alcohol consumption
  • Lack of physical activity
  • High fat diets.

Smoking has not been conclusively proven to cause breast cancer, though there are many benefits of stopping.

Protective factors:
  • Early age of first pregnancy [< 30 yrs of age]
  • Multiple pregnancies
  • Breast feeding [4.3% decrease in risk for every 12 months of feeding]
  • Despite such a large amount of research, a risk factor is identified in only about 50% of breast cancers.

The increasing incidence in India is attributed to multiple factors, including increasing life expectancy [30 million people over the age of 65], increased detection through mammography, westernization with its accompaniments, including high fat diets and processed and red meats and life style choices [no child or late age of conception, short duration of breast feeding due to work related pressures].

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Screening:

Screening is a process of applying simple tests in asymptomatic persons to detect cancer at an early stage so as to reduce the death from cancer.

Screening for breast cancer is by Mammography, wherein of low dose X-rays are applied to the breast to detect abnormalities in its structure. It is recommended that all women over the age of 40 undergo mammographic screening.
Mammography detects cancers an average of 1 - 3 yrs before clinically evident, when the cancer is small and easier to cure.
Clinical Breast Examination [CBE] done by an experienced doctor must precede the mammogram and complements Mammography. The other important component to early detection is Breast Self Awareness, wherein the woman is aware of the appearance and feel of her breasts and reports immediately for any changes to her doctor. BSE or breast self examination, performed monthly is proven to be less effective than self awareness and is no longer routinely recommended by the American Cancer Society.
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Summary of recommendation for Screening:

Age 20-39:

  • Clinical breast examination every 3 years
  • Breast self-examination (optional)

Age 40 and over:

  • Annual mammogram
  • Annual clinical breast examination (preferably prior to Mammogram)
  • Breast self-examination (optional)
Prevention:

At present breast cancer is not preventable. Measures to reduce its occurrence include avoiding weight gain especially postmenopausal obesity, regular physical activity [30 minutes of intentional activity 5 times a week], reducing or avoiding alcohol intake, eating plenty of fruits and vegetables and chemoprevention using Tamoxifen, a drug which blocks the effect of hormones on the breast.

Treatment:

The treatment of breast cancer is multimodal employing surgery, chemotherapy and radiotherapy in various combinations.

Surgery forms the mainstay of localized breast cancer and may consist of lumpectomy with removal of the nodes in the armpit, or mastectomy, which involves removal of the entire breast and the lymph glands; a procedure done for large tumours or multiple tumours. radiotherapy is use of x-rays or electron beams to destroy any cells remaining after surgery in the operated area. It is a must when the breast is conserved and may be required after mastectomy for large tumours or when multiple nodes are involved. The combination of lumpectomy, removal of nodes and postoperative radiation is called Breast Conservation therapy; it has equivalent long-term results as mastectomy.
Chemotherapy is use of drugs injected into the veins to destroy circulating cancer cells before they can grow. Almost all women require chemotherapy after surgery [Adjuvant Chemotherapy]. Chemotherapy may also be given before surgery to shrink the tumour [Neo adjuvant setting], so as to enable breast conservation. It is also the treatment for recurrent or widespread [metastatic] breast cancer.
Hormone therapy involves use of drugs, which either block the hormones from acting on tumour cells or reduce the production of these hormones. Tamoxifen and Aromatase inhibitors [Anastrazole and Letrozole] are the common drugs used.
Targeted therapy involves the use of drugs, which bind selectively to a protein HER-2/neu overexpressed in some breast cancers, which offers improved survival to such patients.
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Survival :

The 5-year survival for localized disease is 99%, for regional disease [with nodes] 84% and 23% for widespread disease.

The overall survival for the group as a whole is 89% at 5 years [American Society of Clinical Oncology data]. Mammography by increasing the number of early cases, would therefore improve survival.
In the long term, education with increase of public awareness and encouraging more women to participate in screening is the only way forward for controlling and curing this disease
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Case capsule:

When Anupama [name changed] a 30-year-old woman who presented to us with a breast lump, was told she had breast cancer, she was devastated.

Her doctors allayed her fears and she underwent surgery, which removed her cancer, but preserved her breast, followed by radiation and chemotherapy. It is more than 5 years since the treatment was completed and her disease is in remission. She understands she was lucky to have come for treatment at an early stage to a center of excellence and is leading a healthy and productive life. She counsels colleagues and friends to undergo regular check ups for breast cancer. Read More...