Breast Cancer

Breast cancer is the second most common cancer in women second only to lung cancer. In men it can occur in about 1% of men and carries a grim prognosis. These cancers originate from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas. There are many different types of breast cancer, with different stages (spread), aggressiveness, and genetic makeup; survival varies greatly depending on those factors.

Risk factors

  • Age- the risk increases with age till menopause and drops off gradually
  • Female sex
  • Family history of breast cancer, especially carriers of BRCA mutations
  • Previous history of breast cancer
  • Obesity and diet high in fat
  • Contraceptive pill increases the risk slightly
  • Early onset of menarche and late menopause – the risk is directly related to exposure of reproductive hormones especially oestrogen.
  • Nulliparity – child birth seems to have a protective effect on breast cancer
  • Lack of breast feeding – breast feeding seems to have a protective effect.
  • Alcohol intake.


Signs and symptoms

There could one or some of the following signs

  • Non- painful lump or area of irregularity in the breast is a classical sign and its imperative that women self examine their breasts at regular intervals.
  • Changes in the skin overlying the breast lump- there is often dimpling or indentation of the skin with the formation of wrinkles.
  • Inversion of nipple
  • Discharge from the nipple
  • A rash in the nipple area.
  • The breast may swell and become red and inflamed or the overlying skin may change and become like the skin of an orange. In some breast cancers this is due to a blockage of the drainage of lymph from the breast.
  • Patients sometimes present with a lump under the arm which is a sign that the cancer has spread to the lymph glands.
  • Loss of weight despite normal appetite
  • A low grade fever


Diagnosis

Diagnosis of breast cancer is usually by
  • Clinical examination by a trained medical practitioner
  • Mammography- x rays of the breast
  • Ultrasound
  • MRI of the breast especially in young women
  • Fine needle aspiration biopsy (FNAC) - where a needle is passed into the breast tissue to harvest cells which can be studied if they are cancerous.


Diagnosis is confirmed by biopsy which can be Core biopsy – where a section of the breast lump is removed

Classification and staging

Different methods of classification can be applied for breast cancer depending on the size of the tumour, spread of the cancer to the local lymph nodes, spread to other organs such as the liver, lungs, bones, brain etc, and the degree of cancerous nature of the tumour cells. The stage of the cancer is important to tailor treatment to the patient and in determining the prognosis or outlook of the disease.

Number staging system

Ductal carcinoma in situ (DCIS) is sometimes described as stage 0. It is almost always completely curable with treatment.

The following stages of breast cancer are known as invasive breast cancer

  • Stage 1.The tumour measures less than 2cm/1inch. The lymph nodes in the armpit are not affected and there are no signs that the cancer has spread elsewhere in the body.
  • Stage 2.The tumour measures between 2 and 5cm/1–2in, or the lymph nodes in the armpit are affected, or both. However, there are no signs that the cancer has spread further.
  • Stage 3.The tumour is larger than 5cm/2in and may be attached to surrounding structures such as the muscle or skin. The lymph nodes are usually affected, but there are no signs that the cancer has spread beyond the breast or the lymph glands in the armpit.
  • Stage 4.The tumour is of any size, but the lymph nodes are usually affected and the cancer has spread to other parts of the body. This is secondary or metastatic breast cancer.


Breast cancer that has come back after initial treatment is known as recurrent breast cancer.

TNM staging system

Another staging system known as the TNM system is commonly used. This can give more precise information about the extent of the cancer.

  • T describes the size of the tumour (cancer)
  • N describes whether the cancer has spread to the lymph nodes (sometimes called glands)
  • M describes whether the cancer has spread to another part of the body, such as the bone, liver or the lungs. This is known as metastatic or secondary cancer.


Grading

Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low-grade), grade 2 (moderate or intermediate grade) and grade 3 (high-grade).

  • Low-grade means that the cancer cells look very like the normal cells of the breast. They are usually slow growing and are less likely to spread.
  • In high-grade tumours the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.
  • Moderate-grade or grade 2 cancers fall between these two grades and have a level of activity somewhere in between.


The other factors important in determining the prognosis or outlook is the presence of hormone or HER receptors.

Hormone and HER2 receptors

Some breast cancer cells have receptors, which allow particular types of hormones or proteins to attach to the cancer cell. A sample of the breast tissue will usually be tested to see if it has these receptors. Whether particular receptors are present or not will affect the type of treatment that you will need.

Hormone receptors

Many breast cancers have receptors for the hormone oestrogen. When oestrogen attaches to these receptors, it causes the cancer cells to grow. If a breast cancer has a significant number of oestrogen receptors it is known as being oestrogen-receptor positive (ER+). If it doesn't it is known as oestrogen-receptor negative (ER-). By knowing the type of receptors present the cancerous cells can be targeted with anti- hormonal treatments.

Some breast cancers have progesterone receptors and are known as progesterone-receptor positive (PR-positive). Usually, cancers that are ER+ will also be PR+. Progesterone receptors are less important than oestrogen receptors in predicting the likely response to hormone treatment.

HER2 receptors (Human Epidermal Growth Factor Receptor 2)

Some cancers have receptors for a protein known as HER2. Tumours that have high levels of these receptors are known as HER2-positive and may respond to treatment with drugs such as trastuzumab (Herceptin®).

Some breast cancers don't have receptors for oestrogen, progesterone or HER2. This type of breast cancer is known as triple negative breast cancer. After surgery, chemotherapy is the main treatment for triple negative breast cancer.

Treatment

The treatment of breast cancer is tailored for each woman depending on the type, stage, hormone receptors, etc.

The treatment will depend on many factors such as
  • The stage and grade of the cancer
  • Your age
  • Whether or not you have had the menopause
  • The size of the tumour
  • Whether the cancer cells have receptors for certain hormones like oestrogen or particular proteins (such as HER2).


Surgery

Surgical options for breast cancer can be broadly divided into breast conserving and non-breast conserving.

Breast conserving

  • Lumpectomy – the lump or the tumour is removed thus preserving the rest of the breast. Radiotherapy is usually applied to the breast that might destroy any remaining cancerous cells that were not removed initially.
  • Quadrectomy – this surgical technique involves removing more breast tissue along with the tumour. Depending on the size of the breast it might or might not be noticeable. Radiotherapy is usually recommended after Quadrectomy.


Non – breast conserving Mastectomy- This is an operation in which the whole breast is removed. It might be necessary if the breast lump is large in proportion to the rest of the breast tissue. There are several areas of cancer cells in different parts of the breast. The lump is just behind the nipple breast. There is a small invasive breast cancer but a widespread area of ductal carcinoma in situ. There are different types of mastectomy such as

  • Simple mastectomy- removal of only the breast tissue
  • Mastectomy with node biopsy – the involved breast is removed and the suspected lymph node in the breast is removed for examination for cancerous cells.
  • Modified radical mastectomy- breast and the suspected lymph nodes in the armpits are removed.
  • Radical mastectomy- the breast, the involved lymph nodes in the armpit along with the muscles underneath the chest is removed.


Radiotherapy

Radiotherapy is usually applied after surgery to destroy any cancerous cells that might be left behind. It's an outpatient procedure lasting about 5- 10 minutes. The course of radiotherapy is for about 3-6 weeks. Radiotherapy does not make one radioactive and its safe to expose other people to you.

Side effects of radiotherapy

  • reddening and soreness of the skin
  • feeling sick
  • tiredness


long term side effects

  • stiffness in the shoulder
  • swelling in the arm
  • numbness in hands, fingers (nerve roots affected by radiation)
  • cancers induced by radiation


Chemotherapy

Cytotoxic (cell destroying) drugs are used to kill cancerous cells. Chemotherapy can be used before surgery to reduce the size of the tumour and after surgery to destroy any remaining cancer cells. It can be administered either as tablets or intravenously (injecting into the vein). The commonly used drugs are

  • Fluorouracil (5FU) (5FU)
  • Docetaxel
  • Epirubicin
  • Cyclophosphamide
  • Capecitabine


The side effects are

  • nausea
  • vomiting
  • feeling tired
  • hair loss
  • prone for infections


Hormonal therapy

The cancer cells are stimulated by hormones such as oestrogen and progesterone secreted naturally in the body for their growth, so by reducing the levels of hormones or by blocking their effect on cancer cells, they have a beneficial effect in the treatment of breast cancers. Hormonal therapies are only effective in women whose cancer cells have receptors for oestrogen and/or progesterone on their surface. This is known as being oestrogen-receptor positive (ER+) or progesterone-receptor positive (PR+). They are often given after surgery, radiotherapy and chemotherapy for breast cancer to reduce the chance of the cancer coming back.

Hormonal therapies

There are many different types of hormonal therapy, and they work in slightly different ways. Hormonal therapies for breast cancer include the drug tamoxifen which is anti-oestrogen, drugs known as aromatase inhibitors which stop the body from producing oestrogen, and treatment to stop the ovaries from working (ovarian ablation).

There are many issues to consider when deciding which type of hormonal therapy is appropriate, such as

  • Age
  • Pre or post menopausal
  • The stage and grade of the cancer
  • Which other treatments are being used
  • Whether the cancer cells are HER2-positive.


Pre-menopausal

The following drugs are used

  • Tamoxifen which is an anti oestrogen agent
  • Goserelin a drug which is used to stop the ovaries from producing oestrogen (ovarian ablation). The ovaries can be stopped by radiotherapy or removed surgically. Radiotherapy and surgically removing the ovaries can cause a premature menopause loosing the ability to conceive. On the other hand by stopping the drug ovaries can resume their function. Tamoxifen is widely used.


Post-menopausal

The following drugs are used
  • tamoxifen
  • Anastrozole (aromatase inhibitor) which blocks the enzyme aromatase which is needed in the production of oestrogen.


Please consult the online doctor for bespoke, evidence based and confidential medical advice.