About a quarter of all cancers in women in India are breast cancers. It can be a devastating diagnosis for any woman, but over the last few decades, there have been steady improvements in treatment. It would be safe to say that if diagnosed early, most women can be “cured” of this cancer. The key is early diagnosis. In the next few paragraphs, I have given a brief overview of this cancer, and tried to answer some of the common and pertinent questions people ask.
Most women when faced with this diagnosis ask why did it happen. Medical science is still unable to give an exact cause; but some risk patterns have been identified over time. Most women who develop breast cancer are over 50. However we are increasingly seeing younger women with this cancer. Women who have started menses early (below 12 years of age) or have a late menopause (after 50 years age), are at a slightly higher risk. Women who have used some types of oral contraception are at a slightly higher risk. However the risk reduces when women stop the oral contraception. Excessive alcohol intake, smoking, being overweight also increase the risk. There are other risk factors but in an individual woman, it is difficult to say which risk factor caused the cancer.
Patients often ask whether they developed breast cancer due to a family history. Most women who get breast cancer don’t have a family history of it. If you have just one female relative who has been diagnosed with breast cancer over the age of 40, your risk is unlikely to be very different from other women the same age as you. But, sometimes breast cancer can run in families. Only a very small proportion of women with breast cancer (5–10%) have a breast cancer gene that increases the risk of breast cancer. The two genes most often found in hereditary breast cancer are called BRCA1 and BRCA2.
A universal question is what are the symptoms of breast cancer in women? These include
- a lump in the breast
- a change in the size or shape of the breast
- dimpling of the skin or thickening in the breast tissue
- a nipple that’s turned inwards
- a rash on the nipple
- discharge from the nipple
- swelling or a lump in the armpit
A lump in the breast is the most common symptom of breast cancer. Of note, most breast lumps are not cancerous. They are usually cysts or benign tumours. But it is important to get a lump or any of these symptoms checked by a doctor immediately. If a lump or other symptom is caused by breast cancer, the earlier treatment starts, the more successful it’s likely to be.
What tests are done to detect the cancer and why? The doctor requests some tests to confirm or refute the diagnosis, find out how far it has spread and also how aggressive it is. The doctor will first examine the woman’s breast, and the lymph glands in the armpits and around the neck. The lymph glands are examined because this cancer usually spreads first to the lymph glands and then goes anywhere else.
One of the first tests is a mammogram. It is a low-dose x-ray of the breast. Mammograms are usually useful in women over 40. In younger women, the breast tissue has less fat, so a mammogram cannot detect changes easily. An ultrasound is used instead. This uses sound waves to build up a picture of the breast. It can show if a lump is solid (made of cells) or is a fluid-filled cyst. It is possible to do an ultrasound of the lymph nodes as well. If any of the nodes look abnormal, the doctor will do a fine needle aspiration on the node or nodes. This is when the doctor removes a small piece of tissue or cells from the lump or abnormal area.
A CT scan of the thorax and upper abdomen helps to look at the lungs and liver. A bone scan looks at the bones. This helps to determine spread of the cancer.
A biopsy is done from the breast where the lump is present. Some tissue is taken out and sent to the pathologist who confirms the cancer, says how aggressive it is and also tells us whether it will respond to hormone treatment.
What is hormone treatment? Breast cancer cells often have receptors (proteins) that hormones or other proteins can attach to and stimulate the cancer to grow. A pathologist will do tests on the cancer cells to find out if receptors are present and what type they are. This test may done before treatment starts.
Some breast cancers have high numbers of receptors for the protein HER2 (human epidermal growth factor 2). They are called HER2 positive breast cancers. About 20-30 % women with early breast cancer have HER2 positive cancer. A drug called trastuzumab can then be used.
Will one doctor be seeing me throughout? This is one cancer where a truly multi-disciplinary approach is needed. A surgeon, medical oncologist, radiation oncologist, pathologist, radiologist all play an equally important role in treatment.
What treatments are available? Surgery is the main treatment for breast cancer. Traditionally the whole breast was removed, but now a part of the breast can be removed with equally good results. In both these operations, lymph nodes in the armpit are removed. Breast reconstruction can be done at the same time as these operations or later.
Sometimes, chemotherapy is given before surgery to shrink the cancer, making it easier to remove. This is called neo-adjuvant treatment.
What additional treatment after surgery is needed? One or more of the following treatments may be offered after surgery to reduce the risk of the cancer coming back. Radiotherapy-this gets rid of any cancer cells that may have been left behind. Chemotherapy-if the cancer was in the lymph nodes or there were some other points mentioned in the pathology report, then chemotherapy is also given. Women who do not have a hormone responsive cancer are also offered chemotherapy. Hormonal therapy-If the cancer is oestrogen-receptor positive, hormonal therapy is given for several years. This is just a tablet to be taken at a fixed time daily. Targeted therapy- some women who have HER2 positive breast cancer, have treatment with targeted therapy with trastuzumab along with chemotherapy.
Research is going on with all cancers and particularly with breast cancer. Better treatments are being available all the time.
How can other women in my family prevent breast cancer? Every woman above 50 should have a mammogram taken every 2-3 years. If there are early changes in the breast these will be picked up early. A good radiologist needs to report these mammograms. The earlier they are picked up, the treatment will also be less aggressive and less expensive. And the woman can get back to her usual activities sooner.
In summary, breast cancer if detected early, can be properly treated by a team of doctors and the woman can then enjoy a long and disease free life.
Dr Arunansu Kar
MD, Diploma in Oncology (London)
Consultant – Medical Oncology
NH Westbank Health & Wellness Institute, Howrah