Basics of Breast Cancer

Important Information about Breast Cancer

• Breast cancer (cancer of the breast) is one of the most common cancers in women.
• Most cases occur in women over the age of 50.
• If you notice any lump or change to your normal breast then you should see a doctor promptly.
• If breast cancer is diagnosed at an early stage, there is a good chance of a cure.
• In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative. However, treatment can often slow the progress of the cancer.
What is important is that you get to know your own breasts – how they look and feel – and report any changes promptly to a doctor.

What is Breast Cancer
• Breast cancer is one of the most common cancers in females
• Around one in eight women develop breast cancer at some stage in their life.
• Most develop in women over the age of 50 but younger women are sometimes affected.
• Breast cancer can also develop in men, although this is rare.
• Breast cancer develops from a cancerous cell which develops in the lining of a milk duct or milk gland (lobule) in one of the breasts.
• There are some ‘sub-types’ of breast cancer which are important to know as the treatment and prognosis (outlook) vary depending on the exact type of the cancer.
Types of Breast Cancer
Broadly it is divided into
• Non-invasive and Carcinoma in situ
Some people are diagnosed when the cancerous cells are still totally within a duct or lobule. These are called ‘carcinoma in situ’ as no cancer cells have grown out from their original site.
Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer
• Invasive cancer
Most breast cancers are diagnosed when a tumor has grown from within a duct or lobule into the surrounding breast tissue. These are called ‘invasive’ breast cancers.
Invasive breast cancers are also divided into those where cancer cells have invaded into local blood or lymphatic vessels and those that have not.

A carcinoma in situ is easier to treat and has a better outlook than an invasive cancer.

Grade of the cancerous cells
A sample of breast cancer tissue can be looked at under the microscope. As a rough guide, the lower the grade, the better the cancer is likely to respond to treatments such as chemotherapy and radiotherapy.

• Grade 1 – the cancer cells tend to be slow growing and less ‘aggressive’.
• Grade 2 – is a middle grade.
• Grade 3 – the cancer cells tend to be fast growing and more ‘aggressive’.

Presence of receptors
Some breast cancer cells have receptors, which allow certain types of hormones or proteins to attach to the cancer cell. The types of receptor tested for are:
• Hormones
Tests on a sample of breast cancer cells can show if they contain estrogen receptors or progesterone receptors. (Estrogen and Progesterone are female hormones.)
Treatment can block the hormone receptors in these cancers
• Her2
Some breast cancer cells have receptors for a protein known as HER2.
Cancers having high levels of these receptors are called Her2 positive.
Stage of the cancer
• This does not describe a type of cancer, but describes how much the cancer has grown and whether it has spread.
• As a general rule, the earlier the stage, the greater the chance of a cure
Causes of Breast Cancer
• A cancerous tumor starts from one abnormal cell.
• The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell.
• This makes the cell abnormal and multiplies ‘out of control’
Risk factors
Although breast cancer can develop for no apparent reason, there are certain ‘risk factors’ which increase the chance that breast cancer will develop.
• Ageing – The risk of developing breast cancer roughly doubles for every 10 years of age. Most cases develop in women over the age of 50.
• Where you live – The rate of breast cancer varies between countries. This may reflect genetic or environmental factors.
• Family history – This means if you have close relatives who have or have had breast cancer. In particular, if they were aged under 50 when diagnosed.
• If you have had a previous breast cancer.
• Being childless, or if you had your first child after the age of thirty.
• Early age of starting periods.
• Having a menopause over the age of 55.
• Taking HRT (hormone replacement therapy) for several years (in women over 50 years) leads to a slightly increased risk.
• Having dense breasts.
• A past history of some benign breast diseases.
• Lifestyle factors – little exercise; obesity after the menopause; excess alcohol.
Family history and genetic testing
• About 1-2 in 20 cases of breast cancer are caused by a ‘faulty gene’ which can be inherited.
• Breast cancer which is linked to a faulty gene most commonly affects women in their 30s and 40s.
• The genes BRCA1 and BRCA2 are the commonest faulty genes.
• If you have any of the following in your family, you might want to see to your doctor.
Three close blood relatives (from the same side of the family) who developed breast or ovarian cancer at any age.
Two close relatives (from the same side of the family) who developed breast or ovarian cancer under the age of 60.
One close relative who developed breast cancer under the age of 40.
A case of breast cancer in a male relative.
A relative with cancer in both breasts.
Note: most cases of breast cancer are not due to an inherited faulty gene.

Symptoms of breast cancer
• A breast lump
The usual first symptom is a painless lump in the breast.
Note:
Most breast lumps are not cancerous.
Most breast lumps are fluid filled cysts or fibroadenomas (a clumping of glandular tissue) which are benign.
However, you should always see a doctor if a lump develops as the breast lump may be cancerous.
• Other symptoms
Other symptoms which may be noticed in the affected breast include:
Changes in the size or shape of a breast.
Dimpling or thickening of some of the skin on a part of a breast.
The nipple becomes inverted (turns in).
Rarely, a discharge from a nipple occurs (which may be bloodstained).
A rare type of breast cancer causes a rash around the nipple which can look similar to a small patch of eczema.
Rarely, pain in a breast.
Note: pain is not a usual early symptom. Many women develop painful breasts and this is not usually caused by cancer.

The first place that breast cancer usually spreads to is the lymph nodes (glands) in the armpit. If this occurs you may develop a swelling or lump in an armpit. If the cancer spreads to other parts of the body then various other symptoms can develop.
Diagnosis of breast cancer
• Initial assessment
If you develop a lump or symptoms which may be breast cancer, a doctor will usually examine your breasts and armpits to look for any lumps or other changes.
You will normally be referred to a specialist.
Sometimes a biopsy of an obvious lump is arranged, but other tests may be done first such as:
Mammogram. This is a special X-ray of the breast tissue which can detect changes in the density of breast tissue which may indicate a tumors.
Ultrasound scan of the breast.
MRI scan of the breast. This is more commonly performed on younger women, especially those with a strong family history of breast cancer.
• Biopsy – to confirm the diagnosis
A biopsy is when a small sample of tissue is removed from a part of the body.
The sample is examined under the microscope to look for abnormal cells.
A specialist may take a biopsy with a needle which is inserted into the lump and some cells are withdrawn (FNAC –Fine Needle Aspiration Cytology).
Sometimes the doctor may be guided as to where to insert the needle with the help of a mammogram or ultrasound scan.
Sometimes a small operation is needed to obtain a biopsy sample.
The biopsy sample can confirm or rule out breast cancer. Also the cells from a tumor can be assessed and tested to determine their grade and receptor status.
• Assessing the extent and spread
If you are confirmed to have breast cancer, further tests may be needed to assess if it has spread.
For example, blood tests, an ultrasound scan of the liver, chest X-ray, a bone scan or other types of scan. This assessment is called ‘staging’ of the cancer.
The aim of staging is to find out:

1. How large the tumor has grown.
2. Whether the cancer has spread to local lymph nodes in the armpit.
3. Whether the cancer has spread to other areas of the body.

Finding out the stage of the cancer, the grade of the cells and the receptor status of the cancer help doctors to advice on the best treatment options.
It also gives a reasonable indication of outlook.

The treatment for breast cancer

• Treatment options which may be considered include surgery, chemotherapy, radiotherapy and hormone treatment.
• Often a combination of two or more of these treatments is used.
• The treatments used depend on:
The cancer itself –
its size and stage (whether it has spread),
the grade of the cancer cells, and
whether it is hormone responsive or contains Her2 receptors, AND
The woman with the cancer –
age,
whether or not she has achieved menopause,
her general health and personal preferences for treatment.

Surgery
• The types of operation which may be considered are:
Breast-conserving surgery. This is often an option if the tumor is not too big.
A ‘lumpectomy’ (or wide local excision) is one type of operation where just the tumor and some surrounding breast tissue is removed.
It is usual to have radiotherapy following this operation.
This aims to kill any cancer cells which may have been left in the breast tissue.
Removal of the affected breast (mastectomy).
This may be necessary if there is a large tumor or a tumor in the middle of the breast.
It is often possible to have breast reconstruction surgery to create a new breast following a mastectomy.
This can often be done at the same time as the mastectomy, although it can also be done months or years later.
There now are many different types of reconstruction operations available.
Whatever operation is done it is also usual to remove one or more of the lymph nodes in the armpit. These lymph nodes are where breast cancer usually first spreads to.
The lymph nodes which are removed are examined under the microscope to see if they contain any cancer cells.
This helps to accurately stage the disease and helps to guide the specialist as to what treatment to advice following surgery.
Alternatively, a sentinel lymph node biopsy may be performed.
This is a way of assessing if the main lymph nodes draining the breast cancer contain cancer. If they are clear then the remaining lymph nodes in the armpit will not need to be removed.
Radiotherapy
• Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue.
• This kills cancer cells, or stops cancer cells from multiplying.
For breast cancer, radiotherapy is mainly used in addition to surgery. When radiotherapy is used in addition to surgery it is called ‘adjuvant radiotherapy’.
• New techniques for radiotherapy are currently in use which reduce the toxicity and duration of treatment
Chemotherapy
• Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying.
• When chemotherapy is used in addition to surgery it is known as ‘adjuvant chemotherapy’.
• Chemotherapy is sometimes given before surgery to shrink a tumor so that surgery may have a better chance of success and also a smaller operation may be performed. This is known as ‘neoadjuvant chemotherapy’.
• The type of chemotherapy given may depend on the type of cancer.
• New gene tests are being developed to help doctors decide which women will benefit the most from chemotherapy.
• Chemotherapy may also be used for some women to treat breast cancer which has spread to other areas of the body.
Hormone treatments
• Some types of breast cancer are affected by the female hormone estrogen (and sometimes progesterone).
• These hormones stimulate the cancer cells to divide and multiply.
• Most estrogen and progesterone is made by the ovaries.
• Treatments which reduce the level of these hormones, or prevent them from working, are commonly used in people with breast cancer.
• This hormone treatment works best in women with ‘hormone responsive’ breast cancer, but they sometimes work in cancers classed as non-hormone responsive.
• Hormone treatments include:
Estrogen blockers.
Tamoxifen has been available for many years and is still widely used.
It works by blocking the estrogen from working on cells. It is usually taken for five years.
Aromatase inhibitors.
These are drugs which work by blocking the production of estrogen in body tissues.
They are used in women who have gone through the menopause.
GnRH (gonadotrophin releasing hormone) analogues.
These drugs work by greatly reducing the amount of oestrogen that you make in the ovaries.
They are usually given by injection and may be used for women who have not yet reached the menopause.
An alternative which may be considered for women before the menopause is to remove the ovaries (or to destroy them with radiotherapy). This stops estrogen from being made.
Trastuzumab
• Trastuzumab (also known as Herceptin) is a treatment that may be given to women who have a large number of HER2 receptors in their cancer.
• It is a type of drug called a monoclonal antibody.
• It works by attaching to HER2 receptors on the surface of breast cancer cells and thereby stopping the cancer cells from dividing and growing.

Why I felt the need to have a blog site dealing with cancer information and second opinion

During my career as a clinical oncologist for the past 15 years I have come across numerous patients and their family members, who when faced with the cruel fact that either he/she or a person very close to their heart has been diagnosed with cancer, are utterly confused and disoriented. They are at their wit's end about their next step.
The patient himself/herself goes through a series of psychological upheavals starting with the feeling that the diagnosis is incorrect and thereafter moving onto the feeling of hopelessness culminating into the feeling of "Why Me Of All Persons ?". In other words the state of mind of the patient does not allow him/her to think rationally about the further course of action. The patient's family, on the other hand, is devastated by the diagnosis and are running from pillar to post to find out the ways and means of treatment. Opinions start to flow in from every possible corner about the doctor to see, the drugs to use, the alternative medicine resources, anecdotes, how bleak is the future and what not leaving them utterly confused.
Navigating through all these when the patient and the family decide to see a doctor, an oncologist to be precise, the busy doctor, sitting in his office, takes a moment to glance through the papers pertaining to the diagnosis and starts prescribing the treatment. This may not happen in the developed countries but it certainly happens days in and days out in the developing and the underdeveloped countries where the doctor-patient ratio is appalling. The doctor does not have the time and more so does not have the inclination to listen to the patient's story and counsel the patient. The family and the patient had jotted down so many things that they wanted to ask the oncologist but could not gather the confidence and the courage to ask him. The patient is in no state of mind to cajole the doctor and even if somebody from the family gathers the courage to put up a question to the doctor, curt comes the reply,"It is beyond your comprehension" or "You could have become a doctor yourself to understand these intricacies of medicine and especially cancer". My decision is final and binding replies the doctor signals his assistant to send in the next patient.
You come out of the oncologist's office dazed and more confused and telephone one of your relatives about the appointment that you just had with the oncologist. He narrates a story to you and guides you to another oncologist who is supposed to be very good. When you visit him, he leaves you more confused about the management because what he tells does not tally with the previous oncologist's version. You don't know what to do and whom to approach with your dilemma. You decide to surf the internet to gather some information but that does not help either because the search engine returns results in millions in a fraction of a second. You don't know which information to assimilate. Finally you choose to toss a coin and select an oncologist and you do your best to stick on to him and follow his instructions though sometimes you have your own doubts.
This is not the way cancer should be treated. There are guidelines for everything starting from prevention to diagnosis and management. All these have been devised after years' of clinical research. Keeping these guidelines in the back of your mind while treating a patient or guiding him promises to deliver the best possible as per evidence based medicine.
Keeping this in mind I envisaged a site of my own which will help these cancer patients by guiding them properly and by being a friend in their days of need. I am not a rich doctor and therefore could not afford to build a fancy dedicated site of my own. I have decided to start small with a blog site therefore and provide my services through it only. Some years down the line I wish to upgrade this endeavor of mine to be upgraded to something like a "Wikioncologica" which will serve the mankind. If anybody reading this blog has any questions or comments, I would be more than happy to answer them either at my blog or by e mail.

Autobiography

Hello friends of the cyberspace. I am Partha and this is my first official blog post. I loved biology during my school days and dreamt of becoming a doctor. I cherished that feeling all throughout my higher secondary days and ultimately qualified to join my alma mater - R G Kar Medical College, Kolkata in 1983. Like any new comer to the medical school, slogged Anatomy, mastered the technique of drawing a simple muscle curve with the twitch of the index finger and never understood the complex biochemical structures during the days of my first professional. Second professional was more easy going - bunked classes for reasons best known to me, overslept in the hostel, got interested in college politics and tried to make up for the bunked classes by arranging for extra classes before the exams were due as a part of my duty as the class representative. I felt like a hero! I fell in love with Internal Medicine during my final professional, tried to be a master of murmurs but in vain, never went to the ophthalmology OT but managed to pass out of Medical School. Compulsory Rotatory Internship and Housemanship in Internal Medicine and Cardiology was fun. After a brief stint with the West Bengal Health Services for about an year, I joined PGIMER, Chandigarh for my postgraduate training in oncology. I shifted base to AIIMS thereafter for my Diplomate of National Board and to gather larger experience. I did some basic and clinical research along with active patient management during my days in AIIMS. I decided to move out of AIIMS and joined Max Healthcare as a consultant oncologist in 2003. Now I am on the verge of joining as the Chief of South East Asia operations of Healthcare Global Enterprises from March 2010 onwards. It has not been a smooth sailing throughout but with God's grace and your blessings I have been able to make it this far. I seek all your best wishes and blessings to succeed in my new venture.