Knowing Breast cancer
Why is breast cancer important?
Breast cancer is the most common non-skin cancer malignancy among Australian women. It is estimated that one in eight women in Australia will have breast cancer by 80 years of age. Early detection provides the best chance of curing breast cancer. Understanding the risk of breast cancer, instituting appropriate method and frequency of screening based on individual risk, and promptly assessing any new breast symptoms are keys in the early detection of breast cancers.
Breast cancer risk and risk management
Being a woman and the age of the person are the most important risk factors for breast cancer. There are a number of other factors that can add to this risk. None of them can be implicated as the sole cause of breast cancer in any individual patient. It is often a complex interaction of these risk factors that determine the composite risk of an individual. While many of the risk factors are non-modifiable, some, for example, lifestyle, factors can be modified to reduce the total risk. A detailed discussion of risk factors can be found here. One’s risk may be estimated using one of the many online risk assessment tools available. Understanding one’s risk, taking appropriate steps to reduce this risk, and choosing appropriate strategy for breast screening can be the best positive steps one can take towards breast health.
Breast cancer awareness and breast self-examination
Many women think that they do not know or cannot do a breast self-examination. Please refer to the cancer councils’ advice on this topic. Any woman can familiarise the normal presentation of their breast by regularly observing their breast. This will help one to determine any change in their breast earlier than they will otherwise do.
Breast screening is the process of assessing the presence of breast cancer when one has no symptoms of the disease. In Australia, breast screening is performed using the special X-rays for the breast called mammograms. Breast screening programme targets all women aged between 50 and 74 years. Breast screening helps to detect cancers before they manifest with symptoms. As such, breast screening-detected cancers tend to be smaller and offer better chance of surviving the cancer. Screening-detected cancers are more often amenable to breast-conserving surgery. Screening of healthy women under the age of 50 and over 75 years is optional.
Breast symptoms and assessment (triple test)
Breast symptoms cause anxiety in women of all ages. Common breast symptoms include breast lump, breast pain, unusual discharge from the nipple and deformities, skin changes, and asymmetries of the breast or nipple. Any of these symptoms can be an indicator of cancerous or precancerous changes. Any new breast symptoms should be discussed with the general practitioner. Breast symptoms can be reliably assessed by following the principles of ‘triple assessment’. Triple assessment involves careful clinical examination, appropriate radiological assessment, and appropriate histopathological assessment. An underlying breast cancer can be accurately established in majority (96% to 98%) of cases by following the principles of triple assessment. It is often advised that one consult the specialist before having a breast biopsy since breast biopsy can mislead a subsequent clinical assessment.
Breast cancer diagnosis
Breast cancer is commonly diagnosed through breast screening, when breast cancer causes symptoms like mass or breast changes or incidentally while investigating an unrelated symptom. Mammogram and ultrasound scan help to diagnose and assess the extent of the disease in the breast. MRI may be needed in some cases. All breast cancers will need biopsy to help formulating the treatment. Most of the breast cancers in Australia are diagnosed at early stage and are amenable to curative treatment. Some cases of breast cancer may need further scans to ascertain the extent of spread of the disease.
Breast cancer management.
Breast cancer treatment is multidisciplinary and involves close interaction of the breast surgeon, the radiation and the medical oncologist, the plastic surgeon, the physiotherapist, and the breast care nurse. Surgery, radiotherapy, and systemic therapy are the components of breast cancer treatment.
Surgical treatment is the mainstay of treatment for breast cancer. Surgery will involve surgery to excise the cancer from the breast and surgery of the axilla (armpit).
Surgery of the breast
Surgery to excise the cancer from the breast can be performed either as breast-conserving surgery or mastectomy. In breast-conserving surgery, the surgeon aims to excise the cancer with a rim of normal tissue (wide excision) preserving the rest of the breast. Using plastic surgical techniques to excise the cancer and reshape the breast, oncoplastic surgeons can now excise even large tumours with satisfactory cosmetic outcomes in suitable cases. In cases that are not suitable for breast-conserving surgery, mastectomy (removal of the entire breast) may become necessary. In established specialist breast cancer care, majority of mastectomy can be followed by appropriate reconstruction.
Surgery of the axilla
Surgery of the axilla is necessary because it is vital to know if the cancer has spread to the lymph node in the axilla or not. Most of the early-stage breast cancers will not have spread to the lymph node at the time of diagnosis, and hence, a biopsy of the lymph node (sentinel lymph node biopsy) performed at the time of breast surgery is all that is necessary. However, in cases where cancer has spread to the lymph node, excision of a defined set of lymph nodes from the axilla may become necessary (axillary dissection).
Radiotherapy is integral part of the breast cancer treatment, especially so if treated by breast-conserving surgery. Radiotherapy aims to destroy cancer cells in the radiated area. Radiotherapy of the breast or chest wall, the armpit area, and/or the neck are done depending on the extent and aggressiveness of the cancer. Radiotherapy is performed over 3 to 5 weeks. Radiotherapy is usually well tolerated; however, some adverse reactions are possible. Radiation oncology specialist will be in charge of radiation treatment, will guide patient through this treatment and treat any side effects that may occur.
Significant advances have been made in the options available for systemic treatment of breast cancers. While surgery and radiotherapy aim to treat cancer in the breast and lymph node area, systemic treatment aims to treat cancer cells in the whole body. By this form of treatment, we aim to reduce the risk of recurrence of cancer. Systemic treatment options include endocrine therapy, which is often given as tablets for 5 to 10 years, or chemotherapy, which is often given over 3 to 6 months. A specific form of systemic treatment is available for a special type of tumour presenting with HER2 receptors. This treatment is usually given over a period of 1 year. Systemic therapy is administered under the care of a medical oncologist.
Majority of breast cancers are treated by surgery first followed by systemic therapy and radiotherapy. In selected cases, systemic therapy is given first before the surgery. This is called neoadjuvant therapy which needs close interaction between the surgeon, the radiation oncologist and the medical oncologist. Neoadjuvant therapy offers a number of advantages, one of which is the increased chance of breast-conserving surgery.
Breast cancer surveillance.
Following the completion of initial breast cancer treatment, a period of close observation is instituted. This is called breast cancer surveillance. During this period, regular clinical examinations and yearly mammogram and ultrasound scan of the breast will be performed. Any new symptoms or concerns will be appropriately addressed.