Overview

Breast Cancer is one of the most common cancers in women and the one with the second highest occurrence in India. The average incidence rate in India varies from 22-28 per 1,00,000 women per year in urban areas to 6 per 1, 00,000 per year in rural areas. Most cases occur in women over 50. In developed countries around one in eight women develop breast cancer at some stage in their life.

Breast Cancer develops from a cancerous cell present at the lining of a milk duct or milk gland (lobule) in one of the breasts. This phenomenon is commonly known as lobular breast cancer. It is important to note that any cancer cell that forms in the breasts also qualifies as malignant breast cancer. On noticing any lump or change, women should regularly conduct self-examination of the breast as well as consult the doctor. This will help facilitate any early stage breast cancer treatment. If breast cancer is diagnosed at the first stage it would naturally increase the possibility of a cure.

TYPES OF BREAST CANCER:

Breast cancer is broadly divided into the following kinds:

• Non- invasive and Carcinoma in SITU
  • Some people are diagnosed when the cancerous cells are still within a duct/lobule. These are known as 'carcinoma in situ' as no cancer cells have grown out from the 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 tumour 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 the local blood or lymphatic vessels and those where they have not.
  • Another type of invasive breast cancer would be inflammatory breast cancer which can make the skin look red and warm also. There are treatments available for such rare conditions as well.

Having said this, Men are also susceptible to breast cancer and require treatment. The most common type of cancers is carcinomas, adenocarcinoma and sarcoma.

Here DCIS (Ductal Carcinoma in Situ), LCIS (Lobular Carcinoma in Situ) and Paget disease of the nipple constitute the Stage 0 and Stage 1 of breast cancer treatment.

Carcinoma & Adenocarcinoma:

A cancer is classified as Carcinoma especially when the tumours begin through the epithelial cells that bind organs and tissue in the body.

In the case of Adenocarcinoma, the tumour begins in the milk ducts or the lobules (milk producing glands). Once the duct becomes affected they are classified as Ductal Breast Cancer.

• There are different treatments available in both cases depending on the magnitude and nature of the cancer.

Although Breast Cancer is quite common in women, there are possibilities of it occurring in men as well. Typically male breast cancer forms in the breast tissue of men with a high probability among older men. Usually men have a higher chance of cure if diagnosed at an early stage. Options to treat breast cancer in men include chemotherapy, radiation therapy and/or surgery.

Symptoms

Generally, lumps in the breasts warrant a medical opinion/treat by breast medical oncology specialists. Most breast lumps aren't cancerous. The most common signs of breast cancer that can be considered to be common symptoms in women are:

• A painless lump or thickening in the breast
• A spontaneous clear or bloody discharge from the nipple often associated with a breast lump
• Retraction or indentation of nipple
• A change in the size or contours of the breast
• Redness or pitting of the skin over the breast
• Mass below the arms
• 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 fibro adenomas which are benign.
• However you should always see a breast cancer treatment doctor if a lump develops as the breast lump may be cancerous.

Other symptoms, which may be noticed in the affected breast, include:

• Changes in the size or shape of a breast
• Dimpling or thickening of the skin on a part of a breast
• The nipple becomes inverted or retracted
• Rarely, a discharge from a nipple occurs (which may be blood-stained)
• A rare type of breast cancer causes a rash around the nipple which can look similar to a small patch of eczema
• Rare pain in the breast

The first place that breast cancer usually spreads to is the lymph nodes (glands) in the armpit. Cancer that spreads to the lymph nodes and is observed to be invasive is a part of stage 2 breast cancer (i.e. metastatic) and requires treatment for metastasis. If this occurs one may develop a swelling or lump in an armpit. Also if cancer spreads to other parts of the body then various other symptoms can develop. This phenomenon is classified as ‘stage 4 breast cancer’ or metastatic cancer which requires treatment soon. Another important point to note is in certain instances when the tumour is cancerous it is termed as ‘malignant neoplasm’.

Causes

• Early age at menarche, late age at menopause and first childbirth at late stage
• Shorter duration of breastfeeding
• Family history of breast cancer increases the risk. If a woman has a mother who has suffered from breast cancer, her risk increases about 3-fold while having a sister with cancer, the risk increases 2-3 fold
• Obesity

A cancerous tumour starts from one abnormal cell and multiples 'out of control'. The exact reason why a cell becomes cancerous is unclear.

RISK FACTORS     

Even when breast cancer can develop for no apparent reason, there are certain 'risk factors’ that increase the chances of developing it. These are:

• Ageing: The risk of developing breast cancer roughly doubles every 10 years.
• Location: The rate of breast cancer varies between countries, possibly due to environmental factors.
• Family history: One may be at risk if he/she has close relatives who have or have had breast cancer.
• Childlessness: Being childless or having the first child after thirty puts a woman at risk.
• Early Menarche: Menarche at too early an age or stage may increase the risk.
• Late Menopause: Developing menopause after the age of 55 may also put a woman at risk.
• HRT (Hormone Replacement Therapy): Taking Hormone Replacement Therapy for several years increases risk of breast cancer.
• Dense breast tissue: A highly dense tissue can increase the risk too.
• History: Having fought some benign breast diseases in the past can also be a risk factor.

Lifestyle factors: Lifestyle issues like lack of exercise, obesity after menopause and excess alcohol can also add to the chances of getting breast cancer.

Diagnosis

The first test after physical evaluation may include an X-ray of the breast known as mammography. This could be followed by breast cancer biopsy and other imaging tests.

INITIAL ASSESSMENT:

If you develop a lump or a symptom which may be breast cancer, a doctor will usually examine your breasts and armpits to look for any lump or other changes.

• You will normally be referred to a specialist.
• Sometimes a biopsy of an obvious lump is pre-arranged but other tests may need to be done first, such as:
  • Digital mammogram: This is a special X-ray of the breast tissue which can detect changes in the density of breast tissue indicating tumours which gives a sign of possible breast cancer.
  • Ultrasound scan of the breasts
  • MRI scan of the breasts: 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 a small sample of the tissue that is removed from a part of the body. The sample is then 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 withdraw some cells commonly known as FNAC procedure (Fine Needle Aspiration Cytology). Sometimes a mammogram or ultrasound scan guides the doctor in precisely locating the spot for needle insertion. 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 (STAGING)         

The aim of staging is to find out:

• The extent of growth of the tumor ie., if the cancer has spread to local lymph nodes in the armpit or other areas of the body.

• The grade of the cells and the receptor status of the cancer. This information helps doctors to know the best breast cancer surgery or non-surgery options that are available. In case of a surgery, the role of a breast oncology surgeon becomes crucial in treating the cancer.

Treatment

Treatment for Breast Cancer:

Breast Cancer treatment includes operation, radiation therapy, and chemotherapy depending on the stage of the disease. Early stage detection can lead to curing of breast cancer. Treatment options which can be considered include Surgery, Chemotherapy, Radiotherapy and Hormone Treatment.  

The treatment depends on:

• The tumor:
  • Its size and shape (whether it has spread)
  • The grade of the cancer cells
  • Hormone responsive tumors
• The patient:
  • Age
  • Reaching menopause
  • General health and personal preferences for treatment

SURGERY FOR BREAST CANCER:

The different types of surgeries which may be considered are:

• Breast – Organ preservation surgery is often suggested if the tumour is not too big
• 'Lumpectomy' (or wide local excision) is a type of surgery where just the tumour and some surrounding tissues of the breast are removed for effective breast cancer treatment. It is usually followed up with radiotherapy or in other words lumpectomy radiation along with surgery which is usually done to kill any cancer cells that may have been left in the breast tissue.

• Removal of the affected breast
  • This may be necessary if there is a large tumour or a tumour in the middle of the breast. During aggressive breast cancer treatment there is a possibility of surgical removal of the breast known as mastectomy.
  • It is often possible to have breast reconstruction surgery to create a new breast after the removal of the breast as part of cancer treatment. This can be done at the same time of the surgery, or it can also be done at a later time where a reconstructive surgery has to be scheduled separately.
• After the surgery is completed, it is also usually normal to remove one or more lymph nodes in the armpit which is where the breast cancer usually first spreads to. The lymph nodes which are removed are examined to see if they contain any cancerous cell, which helps to accurately stage the disease and 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 contain any cancer at all. If they are clear then the remaining lymph nodes in the armpit need not be removed.

RADIOTHERAPY FOR BREAST CANCER:

Radiotherapy (or) breast radiation therapy is a treatment which uses high energy beams of radiation focused on the cancerous tissue to kill the cancerous cells or stop them from multiplying. For breast cancer, radiotherapy is mainly used in conjunction to surgery. With advancement of technology newer techniques in radiotherapy are used to reduce the damage to the healthy tissues and also reduce the duration of treatment.

CHEMOTHERAPY FOR BREAST CANCER:

Chemotherapy otherwise known as ‘chemo treatment’ is a procedure to treat breast cancer where anti-cancer drugs are used against cancer cells to stop them from multiplying. ‘Adjuvant Chemotherapy’ comes into play when chemotherapy is used after surgery. Chemo is sometimes given before surgery to shrink a tumour in case it has grown to an abnormal size (ie., advanced stage breast cancer) so that the surgery may have a better chance of success and to perform a smaller operation known as 'neoadjuvant chemotherapy'. 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. Also in terms of breast cancer treatment among older patients, chemotherapy is also considered a potential mode of treatment.

HORMONAL THERAPY FOR BREAST CANCER:

Some types of breast cancer are affected by the female hormone oestrogen and progesterone. These hormones stimulate the cancer cells to divide and multiply. 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. Hormonal therapy provides better response amongst patients who are ER/PR positive than those who are ER/PR negative during the breast cancer treatment.

Another type of cancer where Hormonal therapy becomes important as a treatment is triple negative breast cancer which is termed to be invasive.

Genetics & Breast Cancer:

Breast Cancer is been one of the most common types of cancer when it comes to women. Although there are multiple environmental and genetic factors that come into play in identifying the cause, there are some interesting headways being made in the field of genetics.

Mutations of tumor suppressing genes (responsible for repair of DNA) namely BRCA1 & BRCA2 can denote cancer. It is important to know that BRCA mutations account for 5-10% of all breast cancers.

Out of the total patients affected by Breast Cancer, BRCA1 accounts for 50-80% and BRCA2 ranges at 40-70%.  Often during BRCA testing, a biological specimen (blood or saliva) is taken to determine if the patient or family members are carriers of any germline mutation in a cancer susceptible gene.

In case the test is positive, the patient can be subject to genetic counseling, routine surveillance, enhanced screening, prophylactic surgery, drug therapy of chemo-prevention, evaluation of family member's risk, single mutation confirmation testing and early detection of pathogenic tests.

• Germline Mutation Tests:

The ‘Oncquer Germline mutation test' analyzes multiple cancer genes and complex cancer syndromes. Apart from the concise reports including comprehensive interpretation and recommendations, an integrated diagnostic work up is conducted by a team of genetic counselors for extended care & support for the patient and their family members.

• Oncquer Test (Somatic Mutation Test):

The Somatic Mutation test profiles genotype to detect somatic alterations in hot spot regions of 48 cancer specific genes. The test comes with a complete informatics interpretation with possible therapeutic, clinical or prognostic implications at a turn-around time of 3-4 Weeks. Pre and Post Genetic counseling is also an integral part of the test.

• Genetics for Effective Treatment of Cancer

Taking the genetics route helps predict prognosis response thereby making cancer treatment and management more personalized, effective & accessible. The feature of conducting 'massively parallel deep sequencing of genes' helps in mapping the multi-gene mutation profile and ultimately helps in understanding the processes that drive an individual's cancer. This will help in creating patient-tailored action, evidence-based therapy and/or treatment plan in cancer. An interesting point to note is that determining genomic markers (for response to chemotherapy) may dramatically improve response rates impacting the risk-benefit ratio for patients which not only will be more cost effective but also will add value in terms of changing therapy regimen and stratifying responders vs non responders.

• Centre for Genomics and Translation Research

The CGTR is a state-of-art genomics centre offering comprehensive genomics-based cancer diagnostic services with the aim of establishing a new standard of cancer care. The centre features:

a) Genomic tests designed to predict the risk of developing cancer and complex cancer syndromes
b) Expert team of oncologists and multidisciplinary team approach of screening, monitoring and surveillance
c) Trained Genetic Counselors with Pre and Post-test genetic counseling services.

For more details visit www.strandls.com

However it would be important that the patients monitor and have constant checks done with their treatment doctors post treatment in order to detect breast cancer recurrence at an early stage.

HCG provides comprehensive and personalised breast cancer treatment across centers in India located at:

Ahmedabad, Bangalore, Chennai, Cuttack, Hubli, Jaipur, Gulbarga, Kenya, Kolkata, Mangalore, Mumbai, Nagpur, Nashik, Ongole, Ranchi, Shimoga, Tanzania, Vijayawada, Vishakhapatnam (Vizag)

Specialists

• 

  Prof Dr Raj Nagarkar

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• 

  Dr. Aditya Adhav

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