Breast Cancer, Mammogram, Her2 Positive, Mastectomy – Dr. Samanta

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Breast cancer overview

  • When some cells of the breast begin to grow abnormally, breast cancer develops. These cells divide at a faster rate than healthy cells and continue to grow, producing an abnormal or irregular lump or mass. Cancer cells in your breast may spread (metastasize) to your lymph nodes in the underarms or other places of your body.
  • In the United States, around 255,000 women are diagnosed with breast cancer each year, and about 42,000 are dying from the disease. 
  • There are more than 3.1 million breast cancer survivors in the United States, according to the American Cancer Society (ACS). A woman’s likelihood of dying from breast cancer is about 1 in 38. (2.6 percent ).
  • In the UK, Breast cancer is the most common type of cancer in women. 
  • Breast cancer can affect men as well, but it is uncommon.1 out of every 100 breast cancer cases identified in the United States are found in a man.
  • Breast cancer is most commonly detected in women over the age of 50, although it can also affect younger people.
  • Breast cancer affects about 1 in every 8 women at some point in their lives. If it’s detected early enough, there is a good chance of recovery. For this reason, women must check their breasts for changes regularly.

Causes of breast cancer

About 5% to 10% of breast tumors are connected to familial gene mutations passed down through generations. Several inherited mutant genes have been identified that potentially raise the risk of breast cancer such as Breast cancer genes 1 (BRCA1) and 2 (BRCA2), both of which also increase the risk of ovarian cancer.

Several risk factors have been identified that may increase your risk of breast cancer. However, it is unclear why some people with risk factors never get cancer while others with no risk factors get cancer. Breast cancer is most likely caused by a complex interaction between your genetic makeup and your environment.

Risk factors of breast cancer

    1. Gender– more prevalent in women.
    2. Age- The chance of getting breast cancer increases as a woman gets older. Over 80% of all female breast cancers occur among women aged 50+ years. 
    3. Genetic factors– Women who carry the BRCA1 and BRCA2 genes have a considerably higher risk of developing breast cancer.
    4. Family history– Breast cancer risk is higher among women whose close blood relatives have breast cancer.
    5. Personal history– Women with a previous history of breast cancer have a greater chance of getting new cancer in the other breast or another part of the same breast.
    6. Having no children or having them later in life.
  • Not breastfeeding
    1. Using birth control pills
    2. First menstruation before 12 years of age or menopause after 55 years
    3. Drinking alcohol (more than one drink a day)
    4. Smoking may increase the risk of breast cancer
    5. Lack of exercise, being obese or overweight after menopause
  • Radiation exposure

 

Types of breast cancer

  1. Non-invasive breast cancer (carcinoma in situ): which means cancer has not spread into the breast tissue surrounding the ducts. It is often detected by mammograms and rarely shows any lump in the breast. 
  1. Invasive carcinoma: the cancer cells have spread into the surrounding breast tissue through the duct lining. This is the most common type of breast cancer.

Other less common types-

  1. Inflammatory breast carcinoma
  2. Paget’s disease of the breast
  3. Medullary breast carcinoma
  4. Mucinous breast carcinoma
  5. Tubular breast carcinoma
  6. Papillary breast carcinoma

Symptoms of breast cancer

  1. Lump in the breast  which is hard with irregular borders
  2. Dimpling, puckering of the breast skin (like an orange peel)
  3. Pulling in of the nipple (nipple inverted)
  4. Bloody Nipple discharge
  5. Any unusual change in the size or the shape of the breast
  6. Lump or swelling in the underarm
breast Cancer, Mammogram, Her2 Positive, Mastectomy

Diagnosis of breast cancer

Triple assessment

  1. Clinical breast examination– Your doctor will feel for lumps or other abnormalities in both of your breasts and the lymph nodes in your armpit.
  2. Imaging-
    1. Ultrasonography of both breasts and axilla – for younger patients below 40 years with dense breast tissue.
    2. Mammogram of both breasts- Diagnostic mammogram is a special type of low-powered x-ray technique. It gives detailed images of the internal structure of the breast and is indicated for women aged above 40 years with less dense breast tissue. 
    3. MRI of both breasts: Breast MRI, in addition to mammography, is a screening option for those women who are at a very high risk of developing breast cancer or who have a history of breast cancer.
  1. Breast biopsy and histopathology to confirm the diagnosis. Tissues obtained during the biopsy are examined to determine: Malignant or Benign, Invasive or Non – invasive.                                                                                            

Others:  CT scan, Bone scan, X-ray chest may be needed to check whether cancer has spread to other parts of the body.

Staging of breast cancer

Staging is done to know how extensive breast cancer is by determining the size of the tumor, if it has migrated to lymph nodes or if it has gone to distant parts of the body. Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all tests are completed. Knowing the stage aids the doctor in determining the best course of therapy and can aid in predicting a patient’s prognosis, or the possibility of recovery.

 

Staging of breast cancer is done by using the TNM classification

Stage 0: localized to breast tissue only; non-invasive carcinoma or carcinoma in situ 

Stages I and II: early stage

Stage III: advanced stage; tumor > 2 cm size and spread to underarm lymph nodes or spread to lymph nodes near breastbone or other tissue near breast 

Stage IV: spread to other parts of the body

Treatment for breast cancer

Your treatment plan will be determined by the type of breast cancer you have. Your doctor will discuss with you the various treatment options.

 

  1. Surgery  
    1. Surgery to breast
      1. Mastectomy– All breast tissue including the nipple is removed.
        1. Radical Mastectomy, 
        2. Modified Radical Mastectomy 
        3. Simple/Total Mastectomy
      2. Breast-conserving surgery (BCS)– Surgically removing the tumor and a small margin of healthy tissue around it. After having breast-conserving surgery, you will most likely be given radiotherapy to kill any cancer cells that remain. 

Breast reconstruction surgery can be done to create a new breast that resembles your other breast as closely as feasible. Reconstruction can be done simultaneously with a mastectomy (immediate reconstruction) or done later (delayed reconstruction).

It can be done with a breast implant or with tissue taken from another region of your body to generate a new breast.

 

  1. Surgery to axilla-
    1. Axillary lymph node dissection: about 10 to 40  lymph nodes are removed at the same time as the mastectomy or breast-conserving surgery.  
    2. Sentinel lymph node biopsy: is used to determine if cancer has spread to the lymph nodes under the arm without removing many of them. A blue dye/radioactive substance is injected to identify the sentinel lymph nodes which drain lymph from the tumor in the breast. They are then removed after identification.

Complications of surgery:

  • short-term pain or discomfort in the affected area
  • Weakness of arm muscles
  • Swelling in the arm (lymphedema)
  • Radiation therapy- 
  • High energy rays (such as x-rays) or particles are used to kill cancer cells. 
  • The type of breast cancer will determine the type of radiation therapy to be used.
  • Complications of radiotherapy: skin irritation, skin becomes red and swollen like a sunburn, fatigue, etc.
  1. Biological therapy (for HER2 positive breast cancer) –  
  • Drugs that target HER2 such as Trastuzumab, Pertuzumab, etc. 
  • HER2: a protein that increases cancer growth.  
  • Complications of targeted therapy: nausea, vomiting, diarrhea, fatigue, mouth sores, and rashes.
  1. Hormone therapy –
  • Hormone therapy is used for breast cancers that are sensitive to hormones such as estrogen or progesterone. 
  • These types of cancer are often referred to as estrogen receptor (ER) positive and progesterone receptor (PR) positive breast cancers. 
  • Estrogen and progesterone promote cancer growth.
  • Drugs used to block estrogen such as Tamoxifen 
  • Drugs used to change hormone levels:  Aromatase inhibitors (AIs): stop fat tissue from making estrogen after menopause Luteinizing hormone-releasing hormone (LHRH) analogs: shuts down the ovaries.
  • Complications of hormone therapy: hot flashes, vaginal discharge, dryness and irritation, irregular periods, decreased sex drive, and mood changes.
  1. Chemotherapy- 
  • Treatment of cancer with one or more cytotoxic anti-neoplastic drugs that act by killing cells that divide rapidly
  • It can be either curative or palliative 
  • It is often used in combination with radiation therapy or surgery 
  • Complications of chemotherapy: nausea, vomiting, fatigue, nerve damage, sore mouth, diarrhea, constipation and decreased blood counts.

How to prevent breast cancer

Making lifestyle changes can help lower your risk of breast cancer such as-

  • Regular exercise to maintain a healthy weight
  • Avoid hormone replacement therapy or birth control pills
  • Avoid alcohol consumption (limit to no more than one drink per day).
  • Stop smoking
  • Breastfeeding your child
  • Having a baby before the age of 30 years
  • Limit hormone therapy after menopause

What to do if you have a high risk of developing breast cancer?

If you have a positive family history for breast cancer or positive genetic mutation for breast cancer, you can discuss options to reduce risk with your doctor such as:

  1. Chemoprevention
  2. Preventive surgery-  Women who are at a high risk of developing breast cancer may decide to have their healthy breasts removed surgically (prophylactic mastectomy). They can also have their healthy ovaries removed (prophylactic oophorectomy) to lower their risk of breast and ovarian cancer.

Screening for breast cancer

  1. Clinical Breast Exam (CBE)
  2. Women in their 20s and 30s should have a clinical breast exam if their doctor thinks they need it. 
  3. After age 40, women should have a breast exam every year.
  4. Breast – Self Exam (BSE)
  5. 7-10 days after the menstrual period starts every month to look for any changes in breast tissue.
  6. Ultrasonography
  7. Mammography: annual mammogram after the age of 40 years (earlier if you have a family history of breast cancer) according to the American Cancer Society. 
  8. Breast FNAC or biopsy from any suspected lump.

Breast Self Examination

Breast self-examination is looking for lumps or changes in your breasts. Many women discover breast problems on their own, often accidentally. When your menstrual period begins, the optimum time to examine your breasts is usually one week later, when they are the least swollen and painful.

Begin by lying on your back and placing your hand behind your head. Use the pads of your three middle fingers—not your fingertips of the opposite hand in an up-and-down pattern or a spiral pattern.

Next, stand in front of a mirror with your arms by your side and look at your breasts directly in the mirror for any skin changes, such as dimpling, puckering, or skin that looks like an orange peel. Then do the same as above with your arms raised above your head.

Prognosis and survival rates of breast cancer

  • Increased awareness and significant funding for breast cancer research have aided in the advancement of breast cancer diagnosis and treatment. 
  • Early detection and treatment are possible due to a better knowledge of the disease which has contributed to an improvement in breast cancer survival rates and a steady decline in the number of deaths linked with the disease.

 

According to the American Cancer Society, the 5-year survival rate are as follows-

Breast cancer localized to only breast 99%

Breast cancer spread to regional lymph nodes (axilla) 86%

Breast cancer spread farther in their body 27%

 

Make an appointment with your doctor if you notice an unusual lump or area in your breast, or if you have any other signs of breast cancer. If detected early enough, then early-stage breast cancer can often be treated and cured. The longer breast cancer is left untreated, the more difficult it becomes to treat.

Breast cancer FAQs

Is there a vaccine available against breast cancer?

NO, currently no vaccine is discovered for the prevention of breast cancer!

Can breast cancer recur after treatment?

You have a 3% to 15% probability of a breast cancer recurrence within 10 years. The risk of recurrence of breast cancer is highest in the first 2-3 years after treatment. The likelihood of recurrence steadily diminishes over time. However, the disease may reappear many years later, either locally or in distant organs across the body. 

The cancer recurrence rate is higher in patients with a family history of cancer with a BRCA1 or BRCA2 gene mutation. New malignancies, such as ovarian cancer, may also be more likely to be discovered. The likelihood of cancer recurrence is determined by a variety of factors, including the type of cancer and how it was treated. By receiving radiation therapy thereafter, you can reduce your risk of breast cancer recurrence.

Will you be able to have a baby after breast cancer surgery?

Treatments like chemotherapy affect the functioning of the ovaries, reducing the amount or quality of eggs. You may want to evaluate your choices for preserving fertility before commencing treatment and share your questions and concerns with your oncologist.

Will your breast look or feel differently after surgery?

Your breast may resemble the one you had before the operation after breast-conserving surgery. But it may appear different or smaller if the tumor was larger. There will be a scar at the site of the operation. 

After a mastectomy, breast reconstruction may be done to help restore the appearance and feel of the breast.

Is it possible to breastfeed a baby if a mother had a history of breast cancer?

Yes, you can breastfeed your child after breast cancer treatment has been completed. However, it is not recommended to breastfeed while receiving treatments like chemotherapy or oral treatments like tamoxifen due to the risk of excretion into breast milk. It is essential to speak to a doctor about breastfeeding before and during the treatment process.

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