BREAST CANCER

Breast cancer starts when cells in the breast start to grow out of control. These cells usually form a tumor that can often be felt as a compact mass of a substance. Breast cancer is the most common cause of cancer-related deaths in women and occurs most frequently in postmenopausal women over the age of 50. Breast cancer mostly occurs in women but however it can also occur in men but it is very rare. Breast cancer can also run in families.

If you feel a lump in your breast, see your doctor or nurse right away. Breast lumps can be caused by conditions that are not cancer. But it is a good idea to have any lumps checked out.

In women, breast cancer is the most common type of cancer occurring globally including in Pakistan. Reportedly, Pakistan is the country with highest incidence rate of breast cancer in Asia. Common age bracket of diagnosis with breast cancer in Pakistan is between 31 years to 60 years. In Pakistan at some stage of the life, 1 in 8 women would develop breast cancer.

Whereas, globally in 2018 the incidence rate of breast cancer is 2,088,849 per 100,000 with 5-year prevalence rate of 6,875,099 and deaths occurring due to breast cancer was 626,679.

Following are the risk factors that might increase the chance of developing breast cancer.

Gender: Women have greater chance of getting breast cancer. In men breast cancer occurrence is very rare.

Age: Most breast cancer in found in women of age 55 or above.

Inherited genes: Almost 5% to 10% of Breast cancer cases are due to inherited genes. They may be resulted directly from genes defect passed on from parents.

Family history: A woman who have close blood relatives with breast cancer have a higher risk of developing breast cancer.

Personal history of breast cancer: A woman with cancer in one breast has a greater chance of getting another breast cancer.

Ethnicity: Overall, white women are slightly more likely to get breast cancer than African-American women.

Dense breast tissues: Dense breast tissue means there is more gland tissue and less fatty tissue. Women with denser breast tissue have a higher risk of breast cancer.
Menstrual periods: Women who began having periods early (before age 12) or who went through menopause (stopped having periods) after the age of 55 have a slightly increased risk of breast cancer.

Alcohol use: Use of Alcohol is directly linked with development of breast cancer, with the increase in amount of alcohol use the risk of breast cancer also increases. Excessive alcohol use is also known to increase the risk of other cancers.

Obesity and overweight: Being overweight or obese after menopause (or because of weight gain that took place as an adult) is linked to a higher risk of breast cancer.
Using hormone therapy after menopause: Taking estrogen and progesterone after menopause (sometimes called combined hormone therapy) increases the risk of getting breast cancer. This risk seems to go back to normal over time once the hormones are stopped.

Physically inactive: Studies have found that regular physical activity reduces the risk of developing breast cancer, especially in women post menopause.

Not having children: Women who have not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant many times or pregnant when younger reduces breast cancer risk.

Not breastfeeding: Studies have found that breastfeeding may slightly lower the risk of developing breast cancer, especially if it is continued for 1½ to 2 years.

Birth control: Studies have found that women who are using birth control pills or an injectable form of birth control have a slightly greater risk of breast cancer than women who have never used them. This risk seems to go back to normal over time once the pills are stopped.

Breast implants: Some types of breast implants can be linked to a rare type of cancer. Silicone breast implants can cause scar tissue to form in the breast cancer.

Radiation exposure: If you received radiation treatments to your chest as a child or young adult, your risk of breast cancer is increased.

Following are the signs & symptoms that might indicate the development of breast cancer.

• Swelling in some parts of all parts of the breast.
• Change in breast size or shape
• Skin dimpling or skin changes (e.g. thickening, swelling, or redness)
• Recent nipple inversion or skin change or other nipple abnormalities (e.g. ulceration, retraction, or spontaneous bloody discharge)
• Nipple discharge (other than milk), particularly if blood stained
• Breast pain or pain in nipple

Early detection and treatment of breast cancer is key to avoid death from the cancer. Breast cancer that is found in early stage is small in size and is not spread to the other areas and is easy to successfully treat.

Following are the guidelines for women who are at average risk for developing breast cancer.

• Women between 40 and 44 have the option to start screening with a mammogram every year.
• Women 45 to 54 should get mammograms every year.
• Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.

Different types of diagnostic techniques are:

Breast exam: Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.

Mammograms: A mammogram is an x-ray of the breast that looks for changes that may be signs of breast cancer.

Breast ultrasound: Breast Ultrasound is used to examine some of the types of breast changes.

Breast MRI scans: Breast MRI scan is used to check the size of the cancer, check for tumors in second breast and if any other tumor in the breast.

Breast biopsy: In biopsy cells are removed from specific area and sample is taken to check if cancer cells are present. There are different kinds of breast biopsies. Some use a needle, and some use an incision (cut in the skin).
Staging breast cancer

Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Your cancer’s stage helps determine your prognosis and the best treatment options.

Complete information about your cancer’s stage may not be available until after you undergo breast cancer surgery.

Tests and procedures used to stage breast cancer may include:

• Blood tests, such as a complete blood count
• Mammogram of the other breast to look for signs of cancer
• Breast MRI
• Bone scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances and taking into account new symptoms you may be experiencing.

Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Breast cancer staging also takes into account your cancer’s grade; the presence of tumor markers, such as receptors for estrogen, progesterone and HER2; and proliferation factors.

Below are some treatment options that might differ from individual to individual:

Surgery: There are two main types of surgery to remove breast cancer.

• Breast conserving surgery: Such a surgery in which only the part of the breast containing the cancer is removed.

• Mastectomy: Such surgery in which the entire breast is removed.

Breast cancer radiation: In Radiation therapy high-energy rays (such as x-rays) or particles that destroy cancer cells are used to treat the cancer.
Systemic treatments

Chemotherapy: Chemotherapy is the term doctors use to describe a group of medicines that kill cancer cells. Some women take these medicines before surgery to shrink the cancer and make it easier to remove. Some women take these medicines after surgery to keep cancer from growing, spreading, or coming back.

Hormone Therapy: Some forms of breast cancer grow in response to hormones. Your doctor might give you treatments to block hormones or to prevent your body from making certain kinds of hormones.

Targeted therapy drugs: Targeted drug treatments attack specific abnormalities within cancer cells. As an example, several targeted therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal growth factor receptor 2 (HER2). The protein helps breast cancer cells grow and survive. By targeting cells that make too much HER2, the drugs can damage cancer cells while sparing healthy cells.

Targeted therapy drugs that focus on other abnormalities within cancer cells are available. And targeted therapy is an active area of cancer research.
Your cancer cells may be tested to see whether you might benefit from targeted therapy drugs. Some medications are used after surgery to reduce the risk that the cancer will return. Others are used in cases of advanced breast cancer to slow the growth of the tumor.

It is not sure that these measures can prevent breast cancer but however they might help to lower risk of developing breast cancer. Following are some measures that might help you to lower the risk of developing breast cancer.

• Optimum body weight: Weight gain and overweight are both risk factors for developing breast cancer. It is advised to maintain optimum body weight through proper diet and exercise to stay healthy.
• Physically active: Less physical activities are associated with risk for developing breast cancer. However, many studies supported the fact that moderate to intense physical activities can reduce the risk of developing breast cancer. It may include brisk walk, yoga, weight lifting etc.
• Avoid alcohol: Alcohol consumption is directly linked with risk of developing breast cancer and other cancers also. It is advised to limit or avoid alcohol use.

Other factors: Breast feeding for several months and avoid use of hormone therapy after menopause may also help you to avoid risk of developing breast cancer.

• Soomro, R., et al., Age and stage of breast cancer in Pakistan: An experience at a tertiary care center. JPMA. The Journal of the Pakistan Medical Association, 2018. 68(11): p. 1682-1685.
• Gulzar, F., Identifying the Barriers of Delayed Presentation in Pakistani Breast Cancer Patients Undergoing Care at Tertiary Hospital: Access to care. 2018, American Society of Clinical Oncology.
• Bray, F., et al., Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 2018. 68(6): p. 394-424.
• https://www.mayoclinic.org/diseases-conditions/breast-cancer/diagnosis-treatment/drc-20352475