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Breast Cancer
Breast Cancer Breast cancer is the second most common reason for cancer deaths in women in the United States, following lung cancer. In 2016, an estimated 246,000 women were diagnosed of invasive breast cancer out of which 40,540 will be fatal. Breast cancer is not just unique to women; there have been cases where men were diagnosed of the same. To put into perspective, about 2,600 men from the US were diagnosed and four hundred and forty died of breast cancer in 2016. On the bright side however, the number of cases has fallen, thanks to early detection and improvement in medical treatments. The five year survival rate, which is the number of women that live on for five years or more expressed in percentages is eighty-nine per cent. However, if the cancer is only limited to the breast, then the five year survival rate is an uplifting ninety-nine per cent where about sixty-one per cent of the cases are diagnosed. This does not hold true if the cancer has spread to neighbouring lymph nodes or any distant organ or tissue in which case the five year survival rate is about eighty-five and twenty-six per cent respectively (1). Breast cancer is thus, a formidable foe and there’s a necessity to overcome it by increased public awareness coupled with timely diagnosis and treatment. ​ Causes: A cancer is a condition where the normal cells that usually comprise of a tissue or organ are replaced by abnormal cells: these abnormal cells arise due to mutations that may occur in the DNA of a normal cell causing it to function “abnormally”. One of the main functions that are compromised when a normal cell takes the form of abnormal one is the ability to die in terms of the lifespan of a normal cell. Instead it goes on spreading and mutating other cells, forming a growth called a tumour. These tumours can fall under two categories: benign (non-cancerous) and malignant (cancerous). Benign tumours nearly resemble normal cells and do not spread (also called metastasize) to other parts of the body, however malignant tumours if left unchecked may spread to other parts of the body uncontrollably. With regard to breast cancer, the malignant tumours arise in two places: in cells of the lobules which are the milk producing glands or at the passages between the lobules and the nipple. Rarely does the cancer originate from the stromal cells of the breast. These cancers also rarely stay put, restricted to the breast and tend to metastasize to neighbouring lymph nodes, tissue and organs. The lymph nodes provide an expressway for the cancer to spread to other parts of the body as they are all linked via the same. Finally, most cases of breast cancer, as discussed above are due to genetic mutations that take place in the normal cells during the course of its lifetime. However, about five to ten per cent of the cases are due to abnormalities inherited from the patient’s parents. ​ Symptoms: One of the main symptoms that is considered the biggest sign that you may have breast cancer is if you were to notice any lumps or areas on your breast with visibly thickened tissue. Though it is recommended you visit you doctor to have it analysed by him/her, it is to be mentioned that not all lumps denote breast cancer. A few other symptoms include: - Change in size or shape of either or both the breasts. - Discharge in the form of blood or other fluids from your nipples. - Swelling or a lump in either or both your arm pits. - Dimpling on the skin of your breasts - Rash on or around your nipple or - A change in appearance of your nipple. ​ Risk Factors: ​ The reason for the formation of abnormal cells and their subsequent tumours is in the works by medical professionals worldwide. However, they were able to list down a few risk factors that could lead to an individual being potentially diagnosed of breast cancer. ​Age: With a rise in age comes a rise in the risk of being diagnosed of breast cancer- women over the age of fifty comprise of eight out of ten of the total number of cases. Family History: Family members who have been diagnosed of either breast or ovarian cancer have been shown to increase the risk of an individual to be diagnosed. Previous Diagnosis of Breast Cancer: If diagnosed of breast cancer earlier, you run the risk of being diagnosed of it again. Previous Benign Breast Lump: As mentioned earlier, a benign breast tumour or lump is not cancerous. However, it could be an indication of a cancer that may arise in the future. Breast Density: A breast’s density is based on the amount of glandular tissue (tissue responsible for producing milk is present in the breast itself.) What this means for breast cancer is that there are now more glandular cells in the breast that may turn abnormal and thus cancerous. So a higher breast density has been correlated with a higher risk. Exposure to oestrogen: Oestrogen is the hormone produced by a female body that besides regulating menstrual periods facilitates breast growth. However, though the normal cells are usually the ones that are facilitated by oestrogen, it can also help the growth of cancer cells, since the base cell continues to be a normal cell. So if your body is exposed to more oestrogen, your likelihood of developing cancer is high. This high exposure can be related to starting periods in an early age, which means that your body was exposed to oestrogen earlier than most, thus increasing your risk. Obesity: If you’ve experienced menopause and are all obese, your body would tend to produce more oestrogen, thus increasing your risk. Alcohol: Research has developed a positive relation with the risk of being diagnosed with the risk of being diagnosed with breast cancer and alcohol consumption: more the amount of alcohol consumed, higher the risk. Radiation: A slight increase in risk of breast cancer if you have received any form of radiation therapy or CT scans, especially in the chest area. Hormone Replacement Therapy (HRT): This is a treatment procedure sought after by menopausal women to relieve the symptoms caused by it - it involves replenishing low hormone levels in the body, particularly oestrogen and progesterone. We have seen that oestrogen is known to facilitate cancer cell growth in the breast and thus people who have been under HRT run a higher risk. Contraceptive Pill: Research has shown that the use of contraceptive pills has increased the risk of breast cancer. ​ Diagnosis: Early diagnosis is crucial and has played a significant role in helping to bring down the death rates due to breast cancer that had a rising trend till the 1990s after which the advent of cheaper and efficient screening methodologies and public awareness helped turn things around. A few of the tests your doctor may recommend are: Breast Examination: As mentioned earlier, one of the biggest signs that you may have breast cancer is in the form of lumps on scars you may have on the breast region. Physical examination can be performed by the patient herself and can be brought to light to her doctor, if she finds any abnormalities. Any further tests depend on this initial step. Mammogram: Is an x-ray based screening test focused on the breasts and aimed at finding any abnormalities that may persist in that region. ​ Breast Ultrasound: Where a mammogram excels at finding lumps closer to the surface of the breast, a breast ultrasound can help image tumours that may exist deeper within and also provide a clearer picture of the status quo. Biopsy of the breast: A sure shot method of detecting breast cancer, this involves taking a sample of the tissue present and analysing for cancerous cells. It also helps to provide an idea about the extent and stage of the cancer. MRI: Makes use of magnetic and radio waves to image the breast region and help look for tumours and other abnormalities pointing towards cancer. ​ Stages: Post the various tests, doctors will try to stage your cancer: give it a definite quantity to allow for comparison and cross reference and also allow the doctors to develop a clear idea so as to treat it with the right medical procedures. The staging terminology most commonly used is the TNM system, where T stands for tumour, N for nodes and M for metastasis. These represent the three pillars based on which a person’s cancer is staged: T defines the size and the location of the tumour, N lets the doctor know if it has spread to neighbouring lymph nodes and M notifies if the tumour/cancer has spread to a distant part of the body. These three parameters are ranked from 0 to 4 (except M, which is ranked from 0 to 1). To give you an idea, the representation from T and its meaning is given below: TX: Primary tumour cannot be evaluated. T0: No evidence of tumour. T1: If the widest area of the tumour is less than 20 mm. T2: Widest area of the tumour is between 20 mm and 50 mm. T3: Widest area of the tumour is more than 50 mm. T4: Tumour has grown into the chest wall, skin or both. Having staged your cancer, your doctor will now discuss the possible treatment options available to you. Note that these options are case specific, meaning what treatments may work for someone else may not work for you. It is thus crucial you talk to your doctor regarding the same. However, the type of treatment can be generally bifurcated into two broad categories: local and systemic treatments. Local treatments usually work with cancers limited to the breast and tend to leave the rest of the body unaffected whereas systemic treatments are capable of treating cancer cells anywhere in the body. The two are discussed below: ​ Local Treatments: Surgical Treatment: The main goal of a surgery with respect to breast cancer is to remove the region of the breast affected by cancer. There are two ways of going on about this: a breast-conserving surgery and a mastectomy. In a breast conserving surgery, the cancer along with a part of the healthy tissue is removed. This option is best in cases where the tumour is small and has not spread to the remaining healthy region of the breast. It is further bifurcated into two: lumpectomy- which involves removing the cancer region along with the healthy tissue and quadrantectomy, which is the removal of one-fourth of the breast tissue. Unlike lumpectomy, it is not a preferred treatment method as it tends to leave the breast out of shape and disfigured a complication that may require plastic surgery to rectify. Any remaining cancer cells are treated with radiotherapy. On the other hand of the spectrum, mastectomy involves the complete removal of the breast tissue of the affected breast. This is usually preferred when the cancer takes up a large portion of the breast or there is more than one tumour in the breast. Usually, the topic of breast reconstruction may come up, to retain the aesthetic nature of the breast: a procedure that may be performed during a mastectomy. Finally, in most cases, a mastectomy should be restrained to only the affected breast and not both, unless both of them are affected or there is a genetic risk of being diagnosed of breast cancer thanks to a family history of the same (7). Most of the side effects are temporary with a slight pain or tenderness in the area that has been treated or a weak arm, if lymph nodes have been removed along with the breast tissue. Radiation Therapy: This procedure involves the use of high intensity x rays to kill cancer cells that may exist in the breast region. Though there are instances where radiation therapy is used as the main medium of treatment for breast cancer, it is usually used to cure the remnant cancer cells after a surgery to remove a tumour. There are two ways this procedure may be carried out: from an external source (called external beam therapy) and from an internal source (called brachytherapy). In an external beam therapy, x-rays are introduced to the body from an external source (machine), at different frequencies, aimed at killing the cancer cells present, over the course of five to six weeks. This usually leaves with a few short term side effects like fatigue, swelling and heaviness in the breast area and maybe skin changes in the treated area. However, it has a few long term symptoms that are far more prevalent: - Radiation eliminates the choice of breast reconstruction in the future as it could lead to complications. - May lead to breast feeding issues. - May lead to shrinkage of the breasts. - May cause lymphedema- swelling in the chest or arm and may cause pain. - May lead to weakening of the ribs. - Chances are parts of the lung or heart may be exposed to the radiation which may cause complications later on. However, thanks to modern machines and technology, such instances are rare these days. Brachytherapy: It involves using radioactive seeds or pellets placed inside the breast tissue to kill cancer cells that may be present. Used especially in cases with women who have performed breast conservation surgery (BCS), there are two main ways the procedure is carried out: (a) interstitial brachytherapy: involves placing the seeds in and around the area of the cancer and (b) intracavitary brachytherapy: the seeds are placed in the space formed after BCS. Side effects may include redness, bruising, breast pain, infection, breaking down of the fat tissue in the breast and in rare case, weakness and damage to the ribs. Systemic Treatments: Chemotherapy: Involves the use of drugs that are designed to kill cancer cells in the body why may be taken intravenously or via mouth. The drug then travels via the blood and reaches various parts of the body affected by cancer. With respect to breast cancer there are three instances where chemotherapy is used: (a) after surgery- to kill any cancer cells that were left behind, (b) before surgery- in order to reduce the size of the tumour so as to allow for easy removal of the tumour during surgery, (c)Advanced breast cancer- may be used to treat cancers that have metastasized to other parts of the body and require a chemotherapy’s properties of being able to work on cancers in different parts of the body. However side effects of chemotherapy include and are not limited to: hair loss, nail changes, mouth sores, and loss of appetite, nausea, vomiting and diarrhoea. It is also known to weaken the immune system of the body leading to easy bruising and bleeding, prone to infections and fatigue. Hormone Therapy: We have seen how hormones like oestrogen tend to facilitate the growth of cancer cells in the breasts. Hormone therapy takes this idea and tries to counter it by inhibiting the receptors of the cancer cells to receive signals from oestrogen or reducing the levels of oestrogen in the body via drugs taken in by the patient. The side effects that correspond to treatments of this nature are based on the kind of drug you take and may include fatigue, hot flashes, vaginal dryness and discharge and mood swings. Targeted Therapy: A new entrant in the scene of breast cancer therapy and other cancers, it involves using drugs that target certain functions of the cancer cells so as to inhibit them from growing and spreading any further.