What Is Breast Cancer?

The breast is made up of lobules, ducts, and fatty tissue (stroma). When breast cells start dividing and growing without any control, breast cancer occurs. If these cancerous cells are confined within the ducts (Ductal Carcinoma in Situ), it is non-invasive breast cancer. At this stage, cancer can be detected early and can be treated with a good chance of cure. When cancer spreads beyond the ducts or lobules into the surrounding tissues, it is palpable and enters the invasive stage. Cancer in the invasive stage can spread to the neighboring lymph nodes and if left untreated to other areas of the body

Who is at risk?

Breast cancer has become the number one cancer in women in metropolitan cities. The incidence is rapidly rising with 1 in 30 women in urban women likely to suffer from breast cancer during their lifetime. If you have any of the following:

• A family history of breast cancer (mother, sister, aunt, or grandmother)
• Men are not completely immune to breast cancer with an incidence of 1% of all breast cancers
• Women above the age of 40 years
• A personal history of breast cancer or history of benign breast lesions
• Previous radiation exposure (childhood cancers) Younger age at menarche and late menopause
• First pregnancy after the age of 30 years
• Used hormone replacement therapy after menopause Used oral contraceptives recently for more than 10 years
• Most importantly- If you feel a lump!

Please consult a doctor you feel may be at risk!

Early Symptoms of Breast Cancer

Usually, there is no pain or symptoms associated with the early stages of breast cancer. But breast cancer may present as any of the following signs or symptoms:

• A lump or change of overlying skin in or near the breast or in the underarm
• Change in the size or shape of the breast
• Blood or unusual nipple discharge
• Nipple retraction (nipple turned inward into the breast) nipple ulceration
• Red angry looking swollen breast

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Please do consult a doctor if you have any of the above mentioned signs or symptoms.

You cant catch breast cancer-it is not infectious. Stress/injury to the breast doesn't cause breast cancer.

How is breast cancer diagnosed?

Breast cancer does not spell doom anymore with modalities to pick up the disease early. There are three ways to detect and confirm the presence of breast cancer.

• Clinical Examination, a suspicious lump or change that is noted on clinical examination by a doctor
• Imaging: To confirm the suspicion, the doctor may advise a mammogram (with or without ultrasound). In select cases, an MRI of the breast may be advised in case of any discrepancy or in complex cases to understand the extent of the disease in high-risk patients
• Biopsy: To confirm the diagnosis, the doctor may remove a sample of the 'suspicious area' in your breast with the help of a wide bore needle to be looked at under a microscope. A biopsy is the only conclusive way to confirm if cancer is present. There are multiple techniques of obtaining a biopsy depending on a case-by-case basis as decided by your doctor - Fine Needle Aspiration Cytology (FNAC), Core Needle Biopsy, Excision Biopsy, Stereotactic (Mammography Guided) Biopsy, Vaccum Assisted Breast Biopsy (VABB).

Metastatic Workup: few other investigations are done to assess the spread in other parts of the body. These include:

• Blood Tests
• X-ray Chest
• Ultrasound Abdomen Bone Scan (if required)
• CT Chest & Abdomen (if required) PET Scan (if required)
• Self-Breast Examination forms an important part of the early detection of Breast Cancer.

What are the treatment options?

There are several modalities of treatment-these include Surgery, Chemotherapy. Radiation Therapy. Targeted Therapy and Hormonal Therapy. These are usually used in combination and the sequence of all these modalities is determined based on:

• Stage of the breast cancer
• Menopausal Status
• Hormone Receptors (ER/PR) status in the Tumor Presence/absence of HER2neu overexpression.

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A)Stage 0: Treatment depends on the kind of cancer the patient has

Surgery is the usual line of treatment for this stage of Lumpectomy (removal of only the cancerous cells with a safe margin of normal tissue). The patient if not keen on saving her breast can undergo a Mastectomy (removal of the entire breast).

Radiation Therapy is needed when a lumpectomy is done, to lower the risk of cancer returning to the breast. Surgery is the usual first line of treatment for this stage

B) Stage 1: Early-stage breast cancer when cancer has not spread beyond the breast

Small Tumours: Lumpectomy (removal of only the cancerous cells with a safe margin of normal tissue) In other cases, or if the patient is not keen on saving her breast, then she can undergo a Mastectomy (removal of entire breast)

Sentinel Lymph Node Biopsy: Removal of a few lymph nodes in the armpits to confirm the presence of cancer Prior to the procedure, a radioisotope is injected in the vicinity of the tumour to locate the sentinel lymph node A blue dye (Isosulfan Blue) is also injected at the time of surgery to identify the first node to which the tumour drains.

Radiation Therapy is needed when lumpectomy is done, to lower the risk of cancer returning to the breast Women in this stage who undergo a mastectomy require radiation if their axilla shows evidence of cancer.

Chemotherapy is a treatment with intravenous medications that target the cancer cells present anywhere in the body It is given to lower the risk of cancer returning Women who are young and have larger cancers are more likely to need this treatment Targeted therapy can be given in breast cancers where Her-2-neu oncoprotein is overexpressed. Drugs like Trastuzumab and Lapatinib are now being used to target this receptor & prevent the multiplication of these cells.

Hormone therapy is given after surgery in women who have a hormone receptor-positive type of cancer (tumours that depend on estrogen to grow). This treatment is available in tablet form to be taken once daily. In Pre-menopausal women, the drug is Tamoxifen while in post-menopausal women the preferred drug is an aromatase inhibitor (anastrozole, letrozole, exemestane).

Targeted Therapy: Targeted therapy is used in breast cancer only if certain proteins or genes are seen in the cancer cell. These proteins help in the process of cancer growth. Targeted therapy is given to block the effect of these genes or proteins.

C) Stage 2: Early stage breast cancer when the cancer is contained within the breast and neighboring lymph nodes.

Treatment options are similar to stage 1 cancer.

Chemotherapy and Targeted therapy can be given prior to surgery to shrink the size of the tumour (neoadjuvant chemotherapy). If it shrinks enough then breast conservation can be performed.

Radiation Therapy is needed when a lumpectomy is done, to lower the risk of cancer returning to the breast. Women in this stage who undergo a mastectomy usually require radiation when the tumours are 5cms, cancer found in more than 1 lymph node under the arm especially if there are other associated unfavorable factors on histopathology, tumour is close to the rib cage or chest wall muscles or skin.

D)Stage 3: Locally advanced Cancer, when cancer still has not spread far beyond the breast and neighboring lymph nodes

Neoadjuvant Chemotherapy is commonly given first. Surgery, Chemotherapy, and Radiation Therapy are usually given to treat stage 3 breast cancer. Targeted therapy and Hormone Therapy are also added if indicated.

E)Stage 4: Cancer has spread elsewhere in the body bones, brain, lungs, liver, or other sites

As multiple areas are involved, a multimodality treatment is required. The objective is to slow down the spread and prolong life. Chemotherapy, hormone therapy, or targeted therapy is the main treatment here.

Tailored treatment as per patient:

• Modified Radical Mastectomy with Reconstruction:

Those women who are unhappy with the idea of losing their breasts and are suitable for immediate breast reconstruction can choose this option so that they wake up with a breast after surgery. A Plastic surgeon is involved in this case and utilizes your own tissues to create a breast form that closely matches your opposite breast, if required an artificial implant may also be used. He or she can help you decide what would be the best site from where to acquire the flap from your body for the reconstruction. It may not feel like your normal breast and may not match your natural breast exactly but can be extremely satisfying in the way you look. If you don't want to get your breast reconstructed in the same sitting, you can get a delayed reconstruction done about 1-2 years after the completion of treatment. This procedure requires you to stay in the hospital for about 5 days.

• Lumpectomy with Oncoplasty:

After a breast conservation surgery in case of large volume defects. Oncoplastic Surgery can be performed to help preserve the breast shape, and improve aesthetic outcomes for the patient, and can be performed at the same time as the tumor is removed With oncoplastic procedures symmetry and other aesthetic issues are addressed to minimize both physical and emotional trauma that may arise during breast cancer treatment Oncoplastic Surgery to done may depend on the size of the defect after the tumour has been excised and may vary from simple breast mobilization to local flaps that may be rotated into the breast up till Latissimus dorsi muscle (back muscle mobilization into the breast to fill larger defects)

• Fertility Preservation:

Chemotherapy and Hormone Therapy are known to have an adverse effect on the fertility of women. Young breast cancer patients, who would want to have children after their breast cancer treatment is complete should discuss methods of fertility preservation with their doctors. The fertility preservation methods improve the chances of successful pregnancy after treatment is complete

How can I detect a recurrence early?

After your treatment is completed, you will be asked to come for a follow-up every 3-6 months with your doctor. At each follow up you will be carefully examined by your doctor and will be required to perform a Mammogram once every 18 months. Unless you are symptomatic, you are not required to undergo any additional investigations.

There is no need to repeat all investigations at every follow-up!

What can I do to detect breast cancer early?

Participate in local screening programs

• Monthly self-breast examination
• Discuss the benefits and limitations of doing a yearly mammogram above the age of 40 years
• Consider doing a mammogram once every two years after the age of 50 years

Genetic Counselling:

If you have a family history of breast or ovarian cancer, then there is a possibility that you might have a genetic mutation such as BRCA1, BRCA2, or other inherited mutations. Hence going through genetic counseling will help you understand the chances of having the mutation, the need for testing, and risk management strategies once tested. Genetic counselors provide information, resources, and support to your family.

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