Breast Cancer

Breast tissue is the predominant characteristic of the female figure and the nourishment tool for motherly nature. The breast goes through cyclic changes during the reproductive life of women that involves a play of many hormones. The increased proliferative rate of breast tissue under the influence of hormones makes it vulnerable to develop cancer. Early diagnosis and prompt treatment reduces the complications and increases the survival rate of women with breast cancer. 

Incidence and Prevalence

Breast cancer is the most commonly occurring cancer in women and the second most common cancer all over. Every 1 in 8 women will develop cancer over the course of her lifetime. Every year almost 2 million cases of breast cancer have found and the incidence of breast cancer is increasing worldwide. It is common both in men and women, but it is far more common in women. Non-Hispanic white women have the highest incidence of developing breast cancer. 

Risk factors

Age:

The risk of breast cancer increases as increasing age. It is rare before the age of 20 years but the incidence increases rapidly after age 30, peaking at 70 to 80 years and then declining thereafter.

Family history:

About 15-20% of women with breast cancer have an affected first-degree relative like a mother, sister or daughter, but they do not carry identified breast cancer gene mutation. Still, most of the people diagnosed with breast cancer have no family history of this disease.

Gender:

Women are more likely to develop breast cancer than men. Only 0.5%of men develop breast cancer.

Hormones:

Women who are more exposed to estrogen and progesterone have increases the risk. 

Menstrual cycle:

Early menarche (beginning of periods before 12 years of age) increases the risk of breast cancer.

Late menopause (ending of periods) also increases the risk of breast cancer. 

Pregnancy:

First pregnancy after the age of 30 years increases the risk significantly. Women who had never been pregnant are also at risk than those who get pregnant. A full-term pregnancy before the age of 20 halves the risk of breast cancer.

Breastfeeding:

Women who never breastfeed their children are also at risk of developing breast cancer. The longer women breastfeed, the greater the reduction in risk. In developing countries, the incidence of having breast cancer is lower due to frequent and longer nursing of infants.

Oral contraceptives:

Increase the use of oral contraceptive pills increases the risk.

Hormonal replacement therapy:

Women who take hormone replacement therapy for a longer period of time containing estrogen and progesterone together may also develop breast cancer.

Diet:

Moderate or heavy intake of alcohol increases the risk.

Radiations:

If you ever have received radiation to your chest as a child or an adult, whether for cancer therapy or due to nuclear accidents, the risk of breast cancer is increased. 

Genetics: 

Approximately 5% to 10% of breast cancers occur in persons with germline mutations in tumor suppressor genes. Mutation in a very well known family BRCA-1 and BRCA-2 is very common for breast cancers.  

Breast density:

Women with very dense breasts have a four to six-fold higher risk of breast cancer compared to women with the lowest density.

Obesity:

Obese women may or may not at the risk of developing breast cancer. Obese women under the age of 40 are at lower risk as a result of anovulatory cycles and low progesterone levels. In contrast, obese women after menopause are at increased risk of breast cancer, which is attributed to the synthesis of estrogen in fat depots.

Sign & Symptoms

The sign and symptoms of breast cancer vary in different women with different types and stages of the disease. In the majority of cases, breast cancer presents as: 

●      Lump or mass in the breast appreciable at self-examination. 

●      General or localized swelling of the breast.

●      Itching or irritation of the nipple or surrounding breast tissue.

●      Skin Changes such as redness or other visible differences in either of the breast.

●      Pain can sometimes be present if there’s nerve involvement.

●      Abnormal nipple discharge or other changes in the nipple appearance.

●      Pitting of breast skin along with redness can give the breast tissue an orange-like shape (peau d'orange appearance) and is a sign of more complex metastatic disease

●      Presence of tiny masses (lymph nodes) in the axilla can also be a presenting feature in metastatic breast cancer.

Diagnosis

Any patient present with a breast lump or other symptoms that are giving suspicion of breast cancer should be assessed by performing a triple assessment. Triple assessment is a combination of three things.

1.   Clinical assessment

History and complete physical examination of both breasts and lymph nodes in the armpit or any lump or swelling is the first step in the diagnosis of breast cancer. 

2.   Radiological assessment

Mammography is an X-ray of the breasts and it is used for screening as well as diagnostic purposes. Mammography is not indicated before age 35, as breast tissues are denser in younger women. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram for further evaluation.

Ultrasound is a useful tool when it is difficult to interpret the findings of the mammogram. It is also particularly useful in young females before the age of 35 years and those with dense breasts.

Magnetic Resonance Imaging (MRI) is a useful screening tool in high-risk women (with a family history). It is the best imaging modality in women with implants.

3.   Histological analysis

Histological examination of the breast tissue remains the gold-standard for the diagnosis of breast cancer. A small sample of the breast tissue is obtained and is examined under the microscope to see the malignant cells. Immunohistochemistry is an expensive test performed on the biopsy specimen to know the receptor type of breast cancer that can help the oncologists in deciding the treatment regimen. Biopsy of breast tissue can be obtained with either of the following surgical methods:

●      Fine Needle Aspiration (FNA) involves the insertion of a needle probe into the breast tissue, especially at the site of lump, with or without local anesthesia. The slides are prepared with aspirated cells and seen under the microscope.

●      True Cut Biopsy uses a thick blade-like needle that dissects and captures the tissue and sample is preserved and sent for pathological evaluation

●      Excisional Biopsy is a surgical procedure performed in Operation Theater under local or general anesthesia. A large lump of the breast is excised by the surgeon and the tissue is sent for histopathology for confirmation of diagnosis as well as the staging of cancer. Excisional biopsy is both diagnostic as well as a therapeutic procedure in some of the cases.

Treatment

The treatment of breast cancer depends upon the type and stage of the disease, receptor status, presence of metastatic deposits, local complications, and general tolerance of the patient to cytotoxic medications. Generally, breast cancer treatment involves three modalities

●     Chemotherapy

Chemotherapy is the administration of cytotoxic medications that destroy or kill the rapidly growing cells. Since cancer cells have a high proliferative rate, they’re most likely to be killed with this aggressive treatment. Since chemotherapeutic drugs affect all the cells in the body, there are quite a lot of side-effects associated with this treatment, yet the benefits surpass the risks. 

●     Radiotherapy

Radiotherapy is the exposure of breast tissue to ionizing radiations that damage the cellular makeup of cells. Cancer cells are rapidly dividing cells and have no time and mechanism of repairing themselves. Thus, radiotherapy stops the progression of the disease and is also efficacious against microscopic metastatic deposits. 

●     Surgery

The surgical excision of the root cause of cancer is the most conservative yet preferable option in localized disease. Surgery involves partial or complete removal of the breast tissue with or without lymph node excision. Artificial breast implants are now widely available that makes the surgical option a preferred choice of treatment.