Breast cancer may sound like a death sentence to many of us. More and more women seem to be presenting with breast symptoms to a specialist. Half of the women who come to us have benign (non cancerous) conditions of the breast, and most of the time reassurance is all they need. The other half, are indeed found to have breast cancer on different tests. Breast cancer is a very much curable disease if detected early and there is no reason why one should be scared of it and hide away problems in great fear.

What is a tumour, and a cancer after all?

Swelling in the body arising from excessive growth (Mitosis) of cells is called Tumour or Neoplasm. This can be of two types - Benign (Non-cancerous) and Malignant (Cancerous). Benign tumours grow slowly at a particular site, do not invade surrounding structures and do not spread to other parts of the body. Even if they are not removed, they will rarely be lethal. Malignant tumours, on the contrary, would grow very rapidly, invade surrounding vital structures, and spread to other parts of the body and will eventually kill an individual if not treated promptly. However, the good news is if detected at an early stage and treated appropriately - they can be completely cured on many occasions. They can also be prevented to some extent by avoiding certain risk factors (e.g. avoiding smoking can prevent lung cancer, protection of skin from excessive sun burn can save an individual from certain skin cancers).

How can Breast cancer be prevented?

Like many other cancers, cause of breast cancer is still not very clear. Some probable causes:-

1.    Age - very rare before 30 years.

2.     Sex - 99% occurs in females.

3.     Diet - high intake of fat, alcohol and less intake of Vit A, unsaturated fatty acid (Soya Oil).

4.     Increased Oestrogen exposure: Delayed marriage, delayed pregnancy, no breast feeding, delayed menopause, prolonged intake of contraceptive pills.

5.     Genetic abnormality - although rare, may cause breast cancer to run in the family.

Avoiding the above avoidable risk factors may reduce the incidence to some extent. Removal of breasts (Bilateral mastectomies) may be an option for high risk individuals, as in genetic abnormalities.

What are the symptoms of breast cancer?

Lump in the breast is the commonest symptom. Some may also have lumps in the armpit. Pain and nipple discharge (especially blood stained), nipple retraction, skin changes in the breast (dimpling, ulceration, venous prominence, multiple small pits like skin of an orange etc.), swelling of arm are other symptoms. However, one should remember that many benign conditions of breast may have similar symptoms - and a doctor can confirm the diagnosis for you by a few tests.

So how is the diagnosis of breast cancer made?

The history is taken in details which usually give us a clue. This is followed by what is called, triple assessment which comprises of - clinical examination, imaging (Mammography and/or USG of breasts) and tissue diagnosis (usually by a fine needle - FNAC).

Does biopsy cause spread of

cancer?

Not at all. This is the commonest misconception. Biopsy is the mainstay of diagnosis, without which, one may be misled resulting in wrong treatment. Taking a small piece of tissue or a few cells, as on FNAC, doesn't cause dissemination of malignant cells.

This holds true for most cancers in the body. We have seen many patients disappearing from the clinic in fear of biopsies, apprehending these might reveal cancer and ruin their lives, or that the cancer might spread. Many of them eventually come back at an advanced stage when not much can be done.

So, please remember never

to refuse biopsy if advised

by clinician.

If a diagnosis of breast cancer is eventually made what are the treatments available?

It needs a multidisciplinary approach - a team effort by Surgeons, Radiotherapists, Chemotherapists and Hormonal therapists. The surgical treatment involves removal of the breast with its lump and the glands (axillary) in the armpit (Modified Radical Mastectomy). If the tumour is small and the patient is keen to have her breast preserved, breast preserving operation may be feasible where the tumour along with a rim of healthy breast tissue on all sides and the axillary glands are removed (Breast conservation Surgery). After breast conservation chances of local recurrence are slightly higher compared to mastectomy. Regular follow up is therefore essential. If there is recurrence and mastectomy is done, the long term survival remains unaffected.

After the operation, on availability of full biopsy report, a joint decision is taken in a Medical Board meeting regarding the additional (adjuvant) treatment.

This usually involves a Hormone therapy (e.g. Tamoxifen tablets), Radiotherapy and Chemotherapy.

Can a breast be reconstructed if it had been removed by surgery?

Breast reconstruction is very much feasible by plastic surgery, either at the time of mastectomy i.e. breast removal (primary reconstruction) or at a later date when the patient has completed her adjuvant treatment (delayed reconstruction).

Silicon implants are available, although are expensive, and do not usually last longer than 15 years. Muscle with skin maybe taken from the back (Latissimus dorsi flap) or from the tummy (TRAM flap) to reconstruct a breast. The opposite breast may have to be reduced (Reduction Mammoplasty) to match the reconstructed breast.

How does Hormonal therapy help?

As we have mentioned earlier most breast cancers are supported by the natural oestrogen hormone in body. Different medicines therefore have come up to counteract this hormone e.g. Tamoxifen, Letrozole, Anastrozole, Zoladex. Unlike surgery and radiotherapy, they act on all the present cancer cells which might have spread elsewhere in the body. Hormonal tablets are usually given for 5 years.

Is radiotherapy painful?

A. Not at all. The cancer cells are blasted by invisible irradiation from special radiotherapy machines which is absolutely painless, as if somebody is having an X-Ray taken. However, some patients may feel weak and may have a burning sensation locally after several exposures. Normally about 25 exposures are given over a month, each lasting only a few minutes.

How about chemotherapy?

Chemotherapy involves giving some chemical agents through saline which kill cancer cells,. They are usually given once  a month for 6 months. Feeling of nausea and loss of appetite are not uncommon for a few days but with different medicines now available, they can be minimized considerably. Loss of hair may occur with some chemotherapeutic drugs - but this is only temporary and hairs rapidly grow back once chemotherapy is completed.

How can one detect breast cancer early?

This is the most important issue as breast cancer is one of those cancers where a complete cure can occur if detected and treated early. In Western countries, where the risks are higher and financial constraints, are not there, routine Mammographies (X-Ray of breasts) are done in high risk age group (viz 50-64 yrs in UK) to pick up very small tumours. Unfortunately in a developing country like ours, where many still live below poverty line, this screening programme is not feasible.

Regular self-examination, mass education and presenting to doctors for any worries would be the key to early diagnosis in India. Patients with benign conditions can be re-assured and those with cancers can be started on appropriate treatment immediately at a specialized center.

Is it contagious or hereditary?

Cancer cells do not thrive even if they are injected (transplanted) to another individual. So it is by no means contagious. The family should be encouraged to stay together to provide necessary moral support to the patients especially when they are going through the stress of the treatment or when they are suffering from cancer spread (Metastasis).

Most of the times, breast cancer is not hereditary (sporadic). However, in some families two or more 1st   degree relatives (Mother, sister, and daughter) or 2nd degree relatives (aunt, niece etc.) may be found affected with the diseases. Genetic study on such families may reveal an abnormality with the genes (BRCA1, BRCA2, p53 etc.).

Close follow up is needed on such families so that if the other family members do develop breast cancer, they can be treated early with good results. Prophylactic (Preventive) mastectomies may be considered after discussion with the high risk individuals.

Where can breast cancer spread and what would be the symptoms?

Breast cancers tend to go to axillary nodes very commonly. They may, in more advanced stage, go to the neck glands, opposite breast, lungs, liver, bones, ovaries and brain. Lump in neck, opposite breast and armpits, or persistent cough, shortness of breath, backbone, tummy pain, vomiting, headache would be the symptoms in such cases. Routine follow up and appropriate tests from time to time are therefore strongly recommended.

What are the chances of being cured if one has breast cancer?

High, in early stage (upto 90%).

The chances obviously become comprised as the disease progresses but may still be upto 30% in stage III disease, if treated properly.

How to do self-examination?

(i)    Stand in front of a mirror, look for any asymmetry of breasts.

(ii)     Raise your arms up, look for any dimpling of skin, or discrepancy of rise of two breasts.

(iii)    Press on the hips, look for any asymmetry again.

 (iv)     Now lie down with the right hand behind the head. Feel the right breast with the flat of the left hand, starting near the armpit, and move circularly along the breast and finally feel the back of the nipple. Repeat this similarly for the opposite breast.

All women should check themselves regularly after they have finished their periods. At any point of self-examination if any abnormality is felt one should get herself checked by a specialist doctor. Don't hide away any problem in fear or shame. Remember, even if it is cancer - if detected at an early there is a very good chance of complete cure. n(Reprint)

The au­thor is  Consultant Surgical Oncologist & Dy Director, Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata.