Risk Assessment and Early Detection Key to Timely Treatment of Breast Cancer

Aditi Bhatt,  Consultant Surgical Oncology Fortis Hospital, India

Breast cancer is most common among women worldwide. Of late, it has been observed that the age group of women who fall prey to this disease has reduced to 30s and 40s. Women using contraceptive pills for 10 years or more are at an increased risk of getting breast cancer.

As the incidence of breast cancer sees a sharp increase, creating awareness about the disease and diagnosing it on time can make the difference between life and death for many women.

Among all the ailments that affect women, breast cancer seems to be the most dreaded, mostly because of the stigma attached to the disease and the apparent increase in the number of cases in recent times.

Breast cancer is the leading cancer among women worldwide and recent studies have revealed that the disease has replaced cervical cancer as the leading cause of cancer deaths among women in India. While cervical cancer still remains the number one cancer affecting women in the country, breast cancer is most common among urban Indian women accounting for 29 per cent of all female cancers.

According to recent research, breast cancer cases have increased manifold and most often patients present to the doctor in the later stages of the disease, decreasing the chances of their long term survival. Doctors feel that of late, there are a number of contributing factors about the disease that are unique to India:

1. Younger women are worst affected: Breast cancer is making its appearance among women who are still in their 30s and 40s.

2. Late diagnosis: Women are presenting to hospitals in the later stages of the disease lowering their chances of survival

3. Low awareness and screening among Indian women: Since there is a general lack of awareness about getting screened and checked for breast cancer, even among the high risk female population, the disease is not detected early.

Breast Cancer: Definition, Symptoms And Risk Factors

Breast cancer is a malignant growth in the cells of the breasts. It mostly affects women but some men can also get breast cancer.

Symptoms

• A lump or abnormal thickness inside the breast that feels different to the touch
• Blood or discharge from the nipple
• Sudden inverting of nipples
• Change in size or shape of the breast/dimples on the breast
• Dry or scaly nipples with peeling skin around it
• Redness of skin over the breast
• Pain

Risk Factors

• Being a woman: Since the disease is very rare in men, being a woman increases ones chances of getting breast cancer.
• Age: The risk of developing breast cancer increases with age.
• Menstrual and reproductive factors: Early onset of menarche and late onset of menopause, late pregnancy and women who have not breastfed are more at risk of developing breast cancer.
• Radiation exposure: An increased rate of breast cancer has been observed in women who are survivors of the atomic bomb explosions or those who have been treated with radiation for a particular disease.
• Contraceptive pills and hormone replacement therapy: Women using contraceptive pills for 10 years or more are at an increased risk of getting breast cancer. Similarly, women who use hormone replacement therapy (HRT) for prolonged periods are at risk.
• Alcohol: Women consuming alcohol are at a higher risk of getting breast cancer than those who do not.
• High-fat diet: Women who have diets high in animal fat or high-fat dairy foods.
• Obesity: Women who are overweight or obese are at a higher risk of getting breast cancer.
• History of breast cancer or other cancers: A woman who has already been treated for breast cancer is at a significant risk of being afflicted a second time.
• Family history: Breast cancer can affect one or more members of the same family because of a defective gene or because of being exposed to the same environmental or dietary factors. According to doctors, 5 to 10 percent of breast cancers are linked to gene mutations passed through generations of a family.
• Gene: A number of inherited mutated genes that can increase the likelihood of breast cancer have been identified. The most common are breast cancer gene1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which significantly increase the risk of both breast and ovarian cancer.  BRCA1 and BRCA2 are human genes that are linked to breast cancer. Genes control cell division and any abnormality (mutation) in the gene can lead to abnormal/ increased cell division which could lead to cancer. Specific inherited mutations in BRCA1 and BRCA2 increase the risk of female breast and ovarian cancers, and they have been associated with increased risks of several additional types of cancer.

Risk Assessment and Awareness of Breast Cancer

Oncologists reiterate the fact that creating awareness among women about the disease and assessing the risk a woman has of developing cancer can go long way in prevention and timely treatment, especially because, in India, majority of women seek medical attention at later stages when the options of treatment may be limited.

“Women may have lot of apprehensions and fears about getting breast cancer, if close family members have been diagnosed or if they find any abnormality in the breast. About 80 per cent of the breast lumps are non-cancerous and do not require surgery, therefore awareness in making women aware of which lumps are dangerous and which are not and also when they should opt for diagnostic tests such as mammography is a must,” says Aditi Bhatt, consultant surgical oncologist at Fortis Hospitals.

Based on various factors, a risk assessment of a woman can be done to check how susceptible she might be to the disease and if the risks are high, how it can be managed to ensure timely diagnosis and treatment, and long term survival.

“In our country women with average risk under30 years of age are generally not recommended to undergo mammography. But those with family history or personal hisptory, a genetic mutation known to increase risk of breast cancer (such as BRCA), and women who had radiation therapy to the chest before the age of 30 are at higher risk. Those at average risk should do breast self-examination every month and clinical breast examination once a year. For any abnormality an ultrasound of the breast is useful. Women aged 40 to 50 years should have the choice to start annual breast cancer screening with mammograms if they wish to do so. Those above 50 should continue yearly screening as long as they are in good health,” adds Dr Bhatt.

Women with high risk can get a mammogram every year. This includes women who have a lifetime risk of breast cancer of about 20 per cent to 25 per cent or greater, according to risk assessment tools that are based mainly on family history; have a known BRCA1 or BRCA2 gene mutation; have a close relative (mother, sister, child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves; had radiation therapy to the chest or have certain rare genetic disorders such as Li-Fraumeni Syndrome, Cowden Syndrome, or Bannayan-Riley- Ruvalcaba Syndrome, which increases their risk of breast cancer.

Screening for Breast Cancer

Cancer screening is looking for cancer before a person has any symptoms. Screening tests can help find cancer at an early stage, before symptoms appear, which may make it easier to treat or cure. By the time symptoms appear, the cancer may have grown and spread, which makes it harder to treat or cure.

Diagnostic Tests Used for Breast Cancer Screening

Mammogram: A mammogram is an X-ray of the breast. This is the best way to find breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms. Having regular mammograms can lower the risk of death from breast cancer. Clinical breast exam: A clinical breast exam is an examination of the breasts done by a doctor or nurse. It can be done by the gynaecologist or general practitioner at the time of consultation for other reasons.

Breast self-examination: Being familiar with how ones breasts look and feel can help one notice symptoms such as lumps, pain, or changes in size that may be of concern. These could include changes found during a breast self-exam. Any changes noticed should be reported to the doctor.

Breast MRI: A breast MRI uses magnets and radio waves to take pictures of the breast. This is used along with mammograms to screen women who are at high risk of getting breast cancer.

Genetic Counselling and Testing and for Breast Cancer

Genetic counselling is recommended before and after any genetic test for an inherited cancer syndrome. This counselling should be performed by a health care professional who is experienced in cancer genetics. Genetic counselling usually covers many aspects of the testing process, including: A hereditary cancer risk assessment based on an individual’s personal and family medical history, medical implications of a positive or a negative test result, the psychological risks and benefits of genetic test results, the risk of passing a mutation to children and explanation of the specific test(s) that might be used.

“A thorough history is taken to determine if the person could be harbouring a genetic mutation. The test itself is done on a blood sample that is drawn from the individual who is to be tested. A positive test result indicates that a person has inherited a known harmful mutation in BRCA1 or BRCA2 and, therefore, has an increased risk of developing certain cancers. However, not all persons harbouring the mutation develop cancer and
some of them may never develop any cancer in their lifetime,” explains Dr Bhatt.

Getting a genetic test done resolves uncertainty regarding future cancer risk and may allow people to make informed decisions about their future, including taking steps to reduce their cancer risk.

Reducing the Risk

Some women might choose to take preventive measures if they are found to have a higher risk of developing cancer. These include Prophylactic (risk-reducing) surgery that  involves removing as much of the breast tissue as possible; and chemoprevention: this is the use of drugs, vitamins, or other agents to try to reduce the risk of, or delay the recurrence of, cancer.

Treatment

A group of specialists comprising of a surgical oncologist, medical oncologist, radiation oncologist, radiologist and pathologist with review the patient’s reports once all the diagnostic tests have been done. They will also look at factors like the age of the patient, personal and family history, as well as other illnesses that may affect the choice of treatment and draw up a treatment plan that is best suited for the patient. The treatment choice depends on the stage of the tumour and the pathological classification as well.

Breast Cancer Requires One or a Combination of the Following Treatments:

Surgery: This involves removal of the tumour with the surrounding normal breast tissue and glands from the armpit. In some cases the whole breast may have to be removed.

Radiotherapy: Radiation therapy is the use of electromagnetic waves to destroy tumour cells. It is generally used in combination with surgery to treat the remaining breast and/or glands in the armpit and around the collar bone. In patients with stage 4 cancer, it may be used to treat cancer spread to other areas, e.g. bone, brain.

Chemotherapy: It is drug therapy to kill the cancer cells. It is given in the form of injections or tablets.

Hormone therapy: This comprises drugs that alter the hormone levels in the body.

-- Issue 36 --

Author Bio

Aditi Bhatt

Aditi Bhatt is a consultant surgical oncologist. She has an experienced over 10 years and has been working at renowned cancer centers in the country and abroad and has performed around 1,000 major cancer related surgeries.

Aditi is a specialist in the management of peritoneal cancers (stage 4 cancers which have spread in the abdominal cavity like pseudomyxoma peritonei, colorectal cancer, ovarian cancer, endometrial cancer, and mesothelioma). She has wide experience and has performed extensive surgeries related to her specialisation.

She is the first surgeon in Bangalore and South India to perform HIPEC (hyperthermic intraperitoneal chemotherapy) for these cancers.

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