Carcinoma of the breast, or breast cancer as it is commonly called, is worldwide the commonest cancer in women and the single most frequently occurring malignant tumour. The cancer starts in the ducts that carry milk from the breast cells to the nipple. For some time it does not grow: this stage is referred to as a "carcinoma-in-situ". It then increases in size at a variable pace, and at some time starts to spread beyond the breast. The initial spread is to the lymph nodes in the armpit on the same side. Later, spread may also occur to the lungs, liver and bones.
Breast cancer is staged according to the extent of spread. A simplified staging of breast cancer is as follows:
causes of breast cancer
The cause of breast cancer is not known in most cases. However breast cancer is more common in persons who have a family history: i.e. a mother, sister, aunt or cousin affected by the disease. Women who have not had children or have not breast-fed their children tend to have a higher risk of developing breast cancer.
Breast cancer usually presents as a lump
in the breast. Early breast cancer usually does not cause
pain. All women should watch for a lump or thickening in
or near the breast or in the underarm area; a change in
the size or shape of the breast; a discharge from the
nipple, especially a discharge of blood, or dimpling or
puckering of the skin over the breast.
A FNAC or histology that is positive for cancer needs definitive treatment. Many treatment methods may be used for breast cancer. Treatment depends primarily on the stage, or extent of the diseaseclinical , although other factors also influence the therapy. Staging of disease is done by i. examination of the size of lump and presence of involved nodesto the , ii. determination of spread lungsby , liver, bones by X-rays, ultrasound and other tests. In the breast the cancer is treated surgery, by irradiation (radiotherapy), or by anticancer drugs and hormones (chemotherapy). A patient may need one, two or all three types of treatment.
The choices available for a particular
patient depend mainly on the stage of the tumour and on
the woman's age, and of course on her wishes. Certain
features of the cancer cells (such as whether they depend
on hormones and how fast they are growing) are also
considered. Cancer of the breast is staged from I to IV
(Table). Stages I and II are generally considered to be
early and potentially curable. Stages III and IV are said
to be advanced forms of breast cancer, although cures in
stage III are sometimes seen.
surgical treatment: mastectomy and breast conservation
Surgery is the most common treatment for breast cancer, and is needed for all patients with stage I, II or III cancer. Most patients with stage IV cancer will also need surgery. An operation to remove the breast is a mastectomy; an operation to remove only the lump is called lumpectomy, and spares the rest of the breast. In most cases the lymph nodes in the armpit are also removed, as they may contain tumour.
Mastectomy is the most effective treatment for cancer. The entire breast including the nipple is removed. The operation is safe, but is mutilating and not easily accepted by younger women. Mastectomy is the best option for tumours larger than 5 cm.
Breast conservation by lumpectomy is a an option for younger women, provided they are diagnosed early. In this procedure the tumour is removed with a wide margin of normal breast tissue. The lymph nodes in the armpit are also removed. The primary aim of lumpectomy is a good cosmetic result that is acceptable to a young female, but it is important not to leave tumour behind. By itself lumpectomy has a very high recurrence rate. However lumpectomy combined with radiation is nearly as effective as mastectomy in treating early stage breast cancer. Breast conservation requires close teamwork between the surgeon and the radiotherapist, and should be considered as a treatment option in patients who have tumours smaller than 5 cm.
For lumps larger than 5 cm the entire breast needs to be removed. For smaller lesions many surgeons prefer to preserve the breast by removal only of the lump (and some normal tissue around it, to be on the safe side). In addition, as many lymph nodes as possible in the armpit also need to be removed, because the tumour is likely to have spread there.
Radiotherapy is a technique that uses high-energy rays to destroy cancer cells. The rays are generated from radioactive minerals and focussed on the tumour bearing area. Radiation kills both normal cells as well as tumour cells. However, radiation is effective because tumour cells are killed more easily and at lower doses of radiation. Radiotherapy is usually given daily for a few weeks, until an optimal dose of radiation has been given. With the availability of effective radiotherapy, it has become possible to preserve the breast in patients with early cancer.
Chemotherapy is the use of drugs to kill cancer cells. A combination of anticancer drugs is given, with varying degrees of efficacy. In a few cases the drugs can actually make the tumour disappear. The drugs may be given orally or by intravenous injection. The advantage of chemotherapy is that it is effective on cancer cells all over the body, and is thus useful for tumours that have spread beyond the breast. Chemotherapy is usually given in a regime of two doses, followed by a gap, and repeated over a period of 6 months. Breast cancer cells, like normal breast cells, need hormones to grow. Hormone therapy is a treatment in which medicines are given to block the effects of natural hormones, and thus prevent growth of cancer cells. Like chemotherapy, hormone therapy works on cancer cells throughout the body.
Side effects of surgery.
During removal of a breast nerves are injured or cut,
therfore a woman may have numbness and tingling in the
chest, underarm, shoulder, and arm. These feelings
usually go away within a few weeks or months. Removing
the lymph nodes under the arm slows the flow of lymph. In
some women, lymph builds up in the arm and hand and
causes swelling (lymphedema).
Patients with breast cancer, before, during or after treatment, may take a normal diet. There may be a link between obesity and the risk of developing cancer. In any case obesity should be avoided, more for its risks to the heart !
The important drugs are the anticancer
agents. The most commonly used are cyclophosphamide,
5-FU, methotrexate, adriamycin, paclitaxel and etoposide.
Hormone-like drugs are also used, such as tamoxifen. Most
drugs have only a few side effects. Adriamycin can cause
toxicity to the heart, and causes the hair to fall out.
All women who detect a lump in the breast must visit a doctor immediately. Although most breast lumps are not malignant, the risks of breast cancer are so high that all lumps must be viewed with suspicion.
Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a
practising surgeon attached to Dharamshila Cancer
Hospital, Sir Ganga Ram Hospital and to Noida Medicare
Center. Formerly Professor of Surgery, Himalayan
Institute of Medical Sciences, Dehradun, Dr Sood has a
special interest in gastrointestinal surgery. He has had
an active academic career, has published several papers
in national and international journals, and is the Editor
(with Dr Anurag Krishna) of a widely acclaimed book
titled Surgical Diseases in Tropical Countries.
Last revised: May 12, 2000