October is WHO designated ‘Breast Cancer Awareness Month.’

“The only person who can save you is you” – Sheryl Crow

INTRODUCTION

Breast cancer (BC) will kill 76,000 women in India in 2015. For every two women with BC, one will die. Many of these deaths are preventable: simply by early detection. But detection often is late and thus fatal.  Lack of awareness is the major reason for late detection.

Breast cancer is the most common cancer in women in India, 27% of all cancers, closely followed by cervical cancer at 22%. Incidence, and death due to BC is more than that due to cervical cancer. BC is rising at a rapid rate. By 2030, the number of BC cases will rise to about 200,000 a year and deaths to about 100,000 a year. India has the worst survival rate from BC, and the highest number of women dying from BC, in the world. Even if we start a cancer awareness program today, 20-30 years will pass before its effect becomes discernible.

BC is now being diagnosed in younger women, in their thirties and forties.

Breast cancer cannot be prevented. But BC incidence can be reduced by a few simple lifestyle changes; and the survival rate can be improved by early detection.

WHAT IS CANCER

Our body is composed of many different types of cells. These cells grow and divide in a controlled manner to produce more cells as required by the body. Also, the older cells and the damaged cells die.

However, sometimes, the genetic material of one cell gets damaged or changed [mutation] and the cell becomes immortal: that is, it will not die. When this ancestor cell dividesits descendant cells are also immortal. This gives rise to a limitless number of immortal descendant cells. The number of cells is far in excess of what the body needs. The extra cells then form a mass that is called a tumour.

These immortal cells are called cancer cells. The cancer cells are: immortal; capable of limitless division, and thus of limitless growth in the number of cells; and capable of spreading [Metises] to other parts of the body through blood and lymph system.

There are more than 100 types of cancers. Not all cancers form tumours: cancers of the blood and the bone-marrow [leukaemia], for example, do not form tumours.

Most cancers are named for the body part in which they begin: colon cancer, prostate cancer, ovarian cancer, breast cancer and so on.

WHAT IS BREAST CANCER

Breast consists of lobules (milk producing glands), ducts (tiny tubes that carry the milk from lobules to the nipple) and blood and lymphatic vessels.

Breast cancer is a malignant tumour that starts in the cells of the breast. It begins in the ducts; sometimes in the lobules:  and rarely, in other cells of the breast.

It then spreads through the breast lymph vessels to lymph nodes under the arms and thence to other parts of the body

WHO IS AT RISK OF BREAST CANCER

Every woman is at risk of breast cancer. In India, one in 28 women will get breast cancer. Certain factors increase the risk of BC.

AGE. Cancer is a disease of old age: most cancers begin to strike at age 60 and above. But now cancer is also striking, though only rarely as yet, the teenagers. Risk of breast cancer, for example, is about 0.25% for a 30 year old woman but increases to about 11% in a seventy-year old. In different countries, breast cancer risk in a 70 year old is 54% to 154% higher than in a 30 year old. Thus, as longevity has increased, so has the cancer incidence.

HEREDITARY. If first degree relatives [mother/father/brother/sister] had cancer, the risk of cancer is increased.

GENETICS. A person can be genetically predisposed to get cancer. A woman who has a family history of breast cancer is statistically more likely to get breast cancer. However, only a small percentage, less than 0.3% of population, is genetically disposed to get cancer. And less than 3-10% of all cancers are because of genetic predisposition. In women with BRCA 1 and BRCA 2, the probability of getting breast and ovarian cancer is more than 75%. Mutations in a few other genes [PTEN, CDH 1, TP 53 etc.] also increase the risk though not as much.

OBESITY.  In obese postmenopausal women breast cancer risk is twice that of the non-obese women.

DIET. Diet contributes to up-to 80% of cancers of colon, prostate and breast; and also contributes to cancers of pancreas, lung, stomach and esophagus. Alcohol, red meat, sugar increase the risk of cancer.

Smoking, night work, no children or child born after age 30, recent use of oral contraceptives (reverts to normal on stopping), HRT, and Chemicals in environment – increase the cancer risk.

MENOPAUSE. Late menopause increases the risk.

REDUCING THE RISK

Healthy weight, physical activity – brisk walking, cycling, swimming – 45-60 minutes five or more days a week, Breast feeding, no red meat, less sugar and less alcohol lowers the risk.

Controversy about whether diet rich in whole grains, fruits, vegetables and legumes and low in total fat (butter, oil), more vitamins, Marine Omega 3 fatty acids (found in seafood (e.g. fish oils) and in walnut, seeds, flaxseed oil etc.), and antiperspirants and bras reduce the risk.  Abortion and Breast Implants have no effect.

Selective Estrogen Receptor Modulators such as tamofoxien reduce BC risk but increase the risk of thromboembolism and endometrial cancer.

So eat well and exercise and you would have done your bit to reduce your cancer risk.

EARLY DETECTION

Since cancer-prevention is not possible, the saying, “prevention is the cure” is amended to “early detection is the cure.”

Only about 10% of cancer deaths are because of primary tumour. Most of the deaths are because of metastasis – spreading of the cancer to other parts of the body. Once metastasis happens, it is very difficult to treat. Early detection of cancer is therefore of utmost importance.

Several ways of early detection:

  1. SELF-EXAMINATION OF BREASTS

More than 80% cancers are detected by women doing self-examination of breasts. The examination should be done every month, 5-7 days after menorrhoea. Do the examination as shown in the three pictures. Look for the following:

  1. Lumps in breast (less than 20% are cancer) or in lymph nodes in armpits.
  2. Thickening of breasts
  3. One breast becoming larger than other
  4. A nipple changing position or shape or becoming inverted
  5. Discharge from nipple
  6. Constant pain in part of breast or armpit
  7. Swelling beneath the armpit or around the collarbone

picture3

In case of palpated anomaly, consult your gynecologist.

The limitations of self-examination are:

  1. Only 20% women do self-examination of breasts.
  2. The tumour/changes are large by the time they are felt and this delay in detection can adversely affect the treatment outcome.
  1. IMAGING TECHNIQUES

Early detection of cancer is required and is possible by using Imaging Techniques. Four Imaging Techniques are available:

  1. X-ray (Mammography)
  2. Ultra sound (Sonography)
  3. MRI
  4. Computer Assisted Detection (CAD)
  5. CT-scan
  6. PET

A visual inspection by endoscopy can also be done.

MAMMOGRAPHY.

X-rays examination. Small neoplasmatic tissue formations can be seen.

SONOGRAPHY

Sonography is done in addition to Mammography to rule out possible cysts and to estimate the size of the tumour. However, tumours smaller than 5 mm cannot be detected.

MRI

MRI is used to find out if the breast has been affected by more than one tumour.

COMPUTER ASSISTED DETECTION (CAD)

CAD is used to point out possibly diseased regions. It is used mainly as a second opinion to the report of the doctor.

LIMITATIONS OF IMAGING

  1. Imaging techniques magnify the tumour much as the magnifying glass magnifies the letters in a book. Normal letter size, called font, is 12. If the font size is halved, that is made 6, you may still be able to identify the letter. But if the font is reduced still further, say to 3 or 4, you will not be able to identify the letter even with the magnifying glass. In a similar way, the imaging techniques cannot identify tumours that are small.
  2. The QUALITY of cancer is more important than the QUANTITY. A small tumour can be more dangerous than a large tumour.  Imaging can tell the quantity of the tumour, that is, its size, but cannot tell the quality of the tumour.
  3. Most of the time, Imaging cannot even tell whether a tumour is cancerous or not.

CONFIRMING CANCER

The only absolute way to confirm cancer is by biopsy: a small tissue from the tumour is taken and microscopically examined to check for cancer.

TYPES OF BIOPSY

  1. Punching Biopsy. Done in a locally-sedated state.
  2. Needle Biopsy. Done with a syringe and a special needle. As painful as venepuncture.
  3. Advanced Breast Biopsy Instrumentation (ABBI). Done with X-ray to ensure localisation of target. Only a few doctors are experienced in this technique.

Microscopic examination of biopsy is sufficient; but in a few rare cases specialized lab tests are required.

CANCER TREATMENT

Even small localised tumours have the potential of metastasis and therefore need to be treated. The treatment is surgery, medications (hormonal therapy and chemotherapy), radiation and immunotherapy.

Surgery offers the single largest benefit. Used along with chemotherapy and radiation, the local relapse rate is reduced and the overall survival rate may increase.

SURGERY

Mastectomy:  remove whole breast.

2Quadrantectomy: remove quarter breast.

3Lumpectomy: remove small part of breast.

Breast Reconstruction Surgery or breast prostheses: to simulate breast.

Neo-adjuvant, that is prior to surgery, and Adjuvant that is after and in addition to surgery, medication is used as part of treatment. For example, Neo-adjuvant use of aspirin may reduce the mortality from Breast Cancer.

Adjuvant Therapies are:

Radiation (negative effect on normal cells) to kill cancer cells in tumour bed and regional lymph nodes that may have escaped surgery. It reduces the risk by 50 – 66 % (i.e., 1/2 to 2/3 reduction of risk). It is confined to region being treated. But only solid tumour can be treated.

  1. Therapies using drugs/agents etc.
  1. Chemotherapy (negative effect on normal cells). Uses drugs, usually two or more drugs in combination, to destroy cancer cells.
  2. Targeted Therapy that became available in 1990s that uses drugs that inhibit enzymes.

iii.                Monoclonal Antibody Therapy in which the agent is an antibody

  1. Immunotherapy that uses patient’s immune systems to fight cancer using drugs.
  2. Hormone Blocking Therapy. Uses Estrogen Receptors (ER +) Tamoxifen and Progesterone Receptors (PR +) Anastrozole that block the receptors.
  3. Experimental Cancer Treatment
  4. Gene Therapy
  5. Ultrasound Energy.

vii.             Alternative Medicine.

Patients with good prognosis are offered less invasive treatment – e.g. lumpectomy + radiation + hormone.

Patients with poor prognosis are offered more aggressive treatment – extensive mastectomy + radiation + chemotherapy + adjuvant medication.

TREATMENT SUCCESS RATE

If the cancer is detected early, that is at Stage 1, prognosis is excellent and usually chemotherapy is not required.

If detected in Stage 2 & 3 prognosis is progressively poorer with a greater risk of recurrence.  Surgery, chemotherapy, and radiation are required.

If detected in Stage 4, that is metastatic cancer (spread to distant sites), prognosis is poor.  Surgery, radiation, chemotherapy, and targeted therapies are used. But the 10-year survival rate is 5% without treatment and 10 % with optimal treatment.

In India, more than 60% of the BC’s are diagnosed at stage III or IV. Hence the low survival rate.

PSYCHOLOGICAL AND EMOTIONAL ASPECTS

Cancer patients need psychological and emotional support. Besides the family, such support can be provided by support groups who are trained and experienced in providing such support. ‘Cancer Sahyog’ is one such support group in India.

CONCLUSION

Cancer is a 3200 year old disease. It is endogenous, a part of life-process. So it can neither be eradicated, nor prevented, nor cured.

As yet.

Over the past 2000 years, the survival rate for many cancers has improved dramatically: life expectancy increased by 20-30 years. But for a few other cancers – metastatic pancreas cancer, metastatic breast cancer, inoperable gallbladder cancer – improvement has been marginal: life extended by just a few months.

Late detection of cancer is fatal. The causes for late detection are many but lack of awareness is the principal cause. Other main causes are: patient being shy, social stigma and doctors’ ignorance because of which the treatment is delayed. An awareness program will address all these issues

Present state of our knowledge makes us believe that cancer prevention or cure is not possible because cancer is a product of the processes essential to the life process.

Will some radical discovery in the future make cancer prevention and cure possible? We don’t know. But we can always hope.

Because as Richard Clauser, Director, NCI, USA, says about the future of cancer cure, “There are far more good historians than there are prophets.”

 

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