BCA Articles

Breast Cancer Signs, Symptoms and Treatment

Dr. Neelam Siddiqui
FRCP (G)
Consultant Medical Oncologist
Shaukat Khanum Memorial Cancer Hospital and Research Centre

Breast cancer may be a devastating disease but it is potentially curable. Although in majority of cases with breast cancer, it is difficult to tell what exactly triggered the beginning of cancer, certain factors have been identified which can make a woman more prone to develop breast cancer than others.

The following risk factors may increase the risk of breast cancer:

Age: The older we grow the higher the chances of developing breast cancer.

Exposure to estrogen: Estrogen is a hormone which is normally produced in females and takes part in reproductive function.  Women who are overexposed to estrogen due to early periods, late menopause or late childbirth, may be at a relatively increased risk of breast cancer. Post menopausal women who take hormone replacement therapy have also been shown to have an increased chance of breast cancer. Once a woman stops taking hormone replacement therapy, her risk of developing breast cancer decreases.

Obesity: Women who gain weight especially with increased waist girth, around the age of menopause, have been shown to have increased chance of breast cancer and breast cancer related death.

Inherited risk: Some women inherit changes in breast cancer genes which are called BRCA 1 and BRAC 2 genes. These women are at a much higher risk of developing breast cancer, which may be at a young age.

Radiotherapy to chest wall and alchohol are some other factors in the list.

How to prevent breast cancer?

Once we know how cancer starts, what makes it grow and spread, we may be able to prevent it. As is obvious from the above list, there are certain factors which we cannot change, e.g. age and family inheritance, however we should try to look for protective factors which could help decrease the risk of developing breast cancer.

Exercise: Most Pakistani women, especially those coming from the cities, have sedentary life styles. It is possibly because of multiple cultural, social, economic factors.  However, in order to try to improve our health, we need to understand that exercise at least half an hour to one hour every day would help prevent not only breast cancer but also many other diseases. I would urge all women to keep themselves active thorough out the day. Simple steps as walking fast, climbing stairs rather than taking a lift, not sitting after meals can keep them healthy.

Breast-feeding has been shown to be helpful in keeping the estrogen levels low.

Avoid taking over the counter hormone tablets. If you have to take these tablets, you must discuss with your doctor first.

How does breast cancer present? This is a question we hear frequently. The first symptom of breast cancer for many women is a lump in their breast. However 9 out of 10 breast lumps (90%) are not cancer. If you spot a lump, see your doctor straight away.

Changes that could be due to breast cancer are:

  • A lump or thickening in an area of the breast
  • A change in the size or shape of a breast
  • Dimpling of the skin or the skin over the breast becomes like orange peel
  • A change in the shape of nipple, particularly if it turns in, sinks into the breast or becomes irregular in shape
  • A blood-stained discharge from the nipple
  • An eczema like rash or ulcer over the breast
  • A swelling or lump in armpit

These signs don’t necessarily mean you have cancer but if you notice any such changes, you should get a checkup.

Once you see the doctor, after examination your doctor may decide to do mammogram or ultrasound of the breast. If needed, further tests like a biopsy or needle test of the lump are arranged. In case a diagnosis of breast cancer is made, the patient is referred to a cancer specialist. Although breast cancer is much more common in females, it can sometime develop in men too. Therefore, all the signs mentioned above, apply to male breast as well.

Treatment of breast cancer: Over the last two decades, we have come a long way in understanding the different aspects of breast cancer. This has been made possible due to research conducted on thousands of women suffering from breast cancer around the world. We now know that breast cancer is a disease which has different molecular types which have specific biology, behaviour and response to therapy. It is this understanding that is helping us tailor treatment for each patient with breast cancer according to the subtype of disease that she has.

Depending on the stage at presentation, several treatment modalities are used for breast cancer patient. I will briefly explain the new trends in treatment of breast cancer:

  1. Surgery: Surgery plays an important role during therapy for patients presenting with localised disease. Traditionally, surgeons used to do mastectomy, which is a removal of the entire breast and chest wall tissue. However, these days if a woman is diagnosed with an early stage disease, it is very likely that she will not have mastectomy. Instead breast conservation is done frequently in these cases, meaning that only a portion of the breast which has the tumour and little bit of normal tissue around is excised. This operation has very good cosmetic results and also does not compromise the survival. Likewise surgery of the axilla is also now much more conservative and most women undergo only sentinel lymph node biopsy where only 2-3 lymph nodes under the armpit are removed.
  2. Radiotherapy:  Some patients require radiotherapy to the chest wall. It is usually given after a patient has had surgery and chemotherapy. Radiotherapy is also a very effective modality for pain control in patient with bone metastases and in cases with local recurrence.
  3. Chemotherapy: We now know that breast cancer is a systemic disease. By the time a patient presents with a lump in the breast, the cancer cells are likely to have travelled to other parts of the body. While surgery and radiotherapy provide local control, chemotherapy takes care of tumour cells wherever they are in the body. Therefore, in most cases, either before or after surgery the patients are given chemotherapy.  Chemotherapy is not an easy treatment and does have side effects but most of these effects are temporary and manageable with supportive remedies.
  4. Hormone therapy: Patients who have hormone receptor positive tumour are given hormone therapy for at least five years or more.
  5. Targeted therapy: In 25 to 30 per cent of breast cancer patients, the tumour is reported to be HER-2 positive. These patients benefit for anti-HER-2 antibody.
  6. New therapies: Several trials are looking at improving outcome for patients with breast cancer. As the results of these trials are announced, we try to incorporate these results in our patient care.

Overall, the ten-year survival rate for all types of breast cancer has improved significantly by 25 to 30 per cent present over the last two decades. This improvement is because of better understanding of the disease, earlier disease detection and improvement in treatment of breast cancer.

Breast Cancer: The Reality We Must Face

Dr. Huma Majeed Khan

FRCS
Consultant Breast Surgeon
Shaukat Khanum Memorial Cancer Hospital and Research Centre

Though life at any stage is important and meaningful but a woman’s life is most productive and important from the age 30-55 years. Whether it’s her work career or her role as a home maker or raising a family, this time is vital for everyone around her.

The tragedy of breast cancer is that it affects this particular age group as one of the most important diseases and cause of death all over the world.

Pakistani women have the highest risk in this region of the world to develop breast cancer and for some still unknown reasons are even affected at an earlier age than the western women. This is our reality and we have to do every thing possible to overcome this disease and its consequences at the state level, as doctors and health providers and as women who are at risk.

Reducing Risk:

  • Regular exercise and maintaining ideal body weight is extremely important as it can cause not only risk reduction but also helps women who already have breast cancer fight the disease better and keep it at bay.
  • Good bone health with adequate daily calcium intake is very important and is not only good for bone health but helps in direct and indirect ways in breast cancer as well. Despite of plenty of sunshine, most Pakistani women are deficient in Vitamin D, which is essential in the absorption of calcium in the body and putting it in the bones. Besides this, there is a relationship of breast and many other cancers with a deficiency of this vitamin.
  • Smoking and alcohol consumption also increases the risk and avoiding these is helpful for many health reasons.
  • Women should avoid long term use of female hormones whether these are in the form of oral contraceptive pills, hormone replacement therapy or fertility treatment.  Especially women with a family history of breast or ovarian cancer should be more cautious and doctors should always assess the risk of a woman to develop breast cancer before prescribing these.
  • Intermarriages especially in near relatives or for generations, can pass good and bad genes in the children and breast cancer risk can also multiply in certain families.
  • Having the first child before the age of thirty and breast feeding is also helpful.
  • Genetic testing in younger women with breast cancer can tell us about her chances of having another breast cancer later in life. In families where 2 or more near relatives are effected especially if the age is less than 50 of at least one, BRCA1 and BRCA2 is recommended in the developed world and we hope to achieve the same if possible.

Women at risk:

  • All women are at risk but with age this risk also increases. A life time chance of developing breast cancer can be as high as 1 in 9 if all women live up to the age of 80 years.
  • BRCA1 and BRCA2 careers, this means that these women with the genetic predisposition have a much higher rate of developing breast and/or ovarian cancer throughout their lives.
  • The risk of developing breast cancer increases if there is a family history of the disease in your first degree relatives even in the absence of BRCA genes. This risk is higher if two or more first degree relatives are affected.
  • Overweight women who do not exercise, women who smoke or drink alcohol and women with poor bone health also have an increased risk.
  • Using hormonal therapy especially for a prolonged period is harmful too, especially with a positive family history. This is very important as a lot of young women undergo prolonged fertility treatment (medical treatment to have babies) in our society
  • Certain breast diseases can increase the risk of cancer and the doctors should be aware about them and guide their patients accordingly.

So how can we win?

We can reduce our risk to a minimal by doing or not doing the things listed above. But unfortunately even with all this, cancer will develop in certain women

Here we rely on early detection that means that we pick the cancer early enough, the chances of a complete cure are higher.

Women with any abnormality felt in their breasts should contact their doctor as soon as possible.

What is abnormal?

Anything new whether it’s a lump or hardening or a nipple discharge or a skin or nipple change should be checked by a doctor.

We must realize that most breast cancers are not painful especially in the early stages and a woman should not avoid seeing her doctor just because it does not hurt. In Pakistan, it is one of the most important factors and a lot of patients delay getting medical advice because they did not have any pain.

Early detection:

  • All girls from the age of 20 should examine their breasts once a month for a new lump or any change. They should do it just after their monthly menstrual period and women who do not have a period should pick a date of a month like the first of every month to do so.
  • From age 40 till she is physically active, every woman should have a mammogram and a physical exam by a doctor at least every two years. If the risk is high then it must be done every year.
  • In my opinion, in Pakistan an ultrasound scan at least every year from the age of 40 can be useful, as in good hands it can pick most cancers and is available throughout the country where mammography services are lacking.
  • Women with a strong family history should always get screening done and it should be as early as five years younger than the relative affected. For example if the sister had cancer, she should see a doctor for advice and check at the age of 35 years.
  • Women with 2 or more relatives with breast /ovarian cancer and younger women with breast cancer should discuss genetic testing with their doctor as it can give them future preventive options to reduce their risk.

Reducing risk and early detection can save almost 75-80 percent of women in the prime of their life from this deadly disease.