breast cancer

the breast
breast cancer
causes of breast cancer
symptoms and diagnosis
treatment
surgical treatment: mastectomy and conservation
radiotherapy
chemotherapy
side effects of treatment
recurrent cancer, rehabilitation and follow-up
diet
when to consult your doctor
further reading


the breast


The breast consists of milk-producing glands, ducts that transport the milk to the nipple, and fat. It is covered by skin, and it lies opon the pectoral muscles. In the armpits, just under the skin, are small but very important nodules of tissue called lymph nodes. These nodes contain white blood cells* , and act as filters for stray cells such as bacteria and cancer cells.
*
but no blood!

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breast cancer

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:

Stage I tumour smaller than 2 cm
Stage II tumour not more than 5 cm, or early spread to armpit nodes
Stage III tumour larger than 5 cm, or stuck to skin/ deep muscle, or advanced spread to nodes in armpit
Stage IV tumour has spread to liver, lungs, bone etc

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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.

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symptoms and diagnosis

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.
Once a lump can be felt, it should be subjected to a biopsy. A biopsy is a technique by which cells of the lump are harvested and examined under a microscope. Biopsies are usually done with a needle, by a technique called Fine Needle Aspiration Cytology (FNAC). The accuracy of a positive test is over 99%. However, the accuracy of a negative FNAC report is only about 95%. Therefore if a lump reports negative on FNAC, it should be removed so that the remaining doubt can be cleared. The removed lump is then subjected to histological examination under a microscope.
In many patients no lump can be clearly felt, or the lumps that are felt are too indistinct for FNAC or removal. These cases are almost certainly benign. In such lumps doctors often like to increase the certainty of a benign diagnosis by obtaining a
mammogram (X-ray of the breast) an ultrasound or both. Mammograms are plain X-rays of the breast. A conventional mammography is done by imaging both breasts in two directions, below and side, and taking an X-ray. Certain types of X-ray pictures ("coarse calcifications") are more often associated with breast cancer. Based on these exams, the doctor may decide that no further tests are needed and no treatment is necessary. In such cases, the doctor may want to check the woman regularly to watch for any changes.

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treatment

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.
Treatment of breast cancer is by removal of the tumour. If the breast has been preserved, radiotherapy must be given. For all tumours other than stage I, chemotherapy is required. Older women do well with hormone therapy.

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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.

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radiotherapy

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.

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Chemotherapy

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.

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Side effects of treatment

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).
Side effects of radiotherapy. Following radiation therapy, patientsoften become very tired. The skin of the the treated area may become red and dry, tender, itchy or even weepy. The skin needs to be looked after. Creams, lotions and deodorants should be used only after consulting the doctor, and a tight bra that rubs should be avoided. Skin changes usually recover.
Side effects of chemotherapy. Loss of appetite, nausea and vomiting are common. Some anticancer drugs cause loss of hair. The hair returns when treatment is over. Other side effects are rare.

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Recurrent cancer, rehabilitation and followup

Recurrent Cancer
Cancers are notorious for recurrence after treatment. In breast cancer, recurrence depends on the initial stage. When the cancer returns only in the breast area, it is called a local recurrence, and occurs in about 15% of patients after breast conservation with radiotherapy. If the disease returns in another part of the body, it is called metastatic breast cancer (or distant disease). Survival depends on the likelihood of recurrence. 10 year survival rates are over 80% for stage I, 70% for stage II, and 40-50% for stage tumours.

Rehabilitation
After a mastectomy, most women will like to maintain the shape of the chest by wearing a padded bra. A breast can also be constructed from body tissues or silicone implants. A nipple appearance can also be created by skilful tattooing. If the reconstructed breast is smaller than the other, normal breast, the normal breast is sometimes reduced for better match. It is important to appreciate that reconstruction may take more than one operation. Silicone implants, which are often necessary, cost about Rs 20,000. The cost of breast reconstruction depends upon the number of operations needed and cost of implants.

Followup
Regular followup exams are very important after breast cancer treatment. The doctor will continue to check the woman closely to be sure that the cancer has not returned. Regular checkups usually include exams of the chest, the armpit, and neck. From time to time, the woman has a complete physical exam, blood and urine tests, mammography, and a chest x-ray. The doctor sometimes orders scans (special x-rays) and other exams as well.
A woman who has had cancer in one breast has a higher-than average risk of developing cancer in her other breast. She should continue to practice breast self-examination, checking both the treated area and her other breast each month. She should report any changes to her doctor right away.

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diet

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 !

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drugs used in this condition

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.
With the administration of anticancer drugs, many patients will need medicines to control vomiting, such as metoclopramide and ondanseteron.

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when to consult your doctor

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.

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Further reading

There are hundreds of sites on the net for information on breast cancer. Here are some of the better ones:

a detailed, well designed site for information on all aspects of breast cancer http://www.thebreastclinic.com/
self examination methods http://www.women.com/health/breastcancer/self-exam.html
and
http://www.breastcare.co.uk/examin_frame.htm
young women should get useful information here http://www.nabco.org/facts/young.htm
nicely done, informative site. Has a useful "helpful hints" section http://www.infobreastcancer.cyberus.ca/
another good site http://www.seas.gwu.edu/~tlooms/MGT243/bcr_index.htm
online support for breast cancer patients http://pages.prodigy.net/replyasap/bc/

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Author

Dr Suneet 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.
Contact Nos: 2486788, 9811052966, suneetsood@vsnl.com


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Last revised: May 12, 2000