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Rajiv Gandhi Cancer Institute and Research Centre
New Delhi - 110085
Rajiv Gandhi Cancer Institute and Research Centre
New Delhi - 110085
Based on National Cancer Registry Programme (ICMR), report of (2001-03), about 25% of the total cancer cases among Indian women constitutes of Breast cancer. The crude incidence rate of Breast cancer at India level is about 85 per 100,000 women per year. It is estimated that about 85000 new cases of Breast cancer are occurring in India, every year. The mortality rate is around 7 per 100,000 cases per year.
Cancer of cervix followed by breast cancer are the commonest cancers among women in Barshi, Bangalore, Bhopal & Chennai. Breast cancer is the commonest in Delhi & Mumbai followed by cancer cervix. The rise in incidence is being documented mainly in the metros, it is reported that one in 22 women in India is likely to suffer from breast cancer during her lifetime, while in America one in eight women is a victim of this deadly cancer.
| Common Cancers in among Women in India |
|||||||
| Rank |
Bangalore |
Bhopal |
Chennai |
Delhi |
Mumbai |
Barshi |
|
| 1 |
Cervix |
Cervix |
Cervix |
Breast |
Breast |
Cervix |
|
| 30.8 |
24.9 |
41.9 |
29.0 |
27.1 |
27.7 |
||
| 2 |
Breast |
Breast |
Breast |
Cervix |
Cervix |
Breast |
|
| 21.4 |
22.2 |
22.4 |
29.0 |
19.5 |
8.0 | ||
Figures are age-standardized rates for the specific cancer sites. Figures for Bangalore, Chennai & Mumbai are for the years 1982-94. For other registries the figures are for the years 1988-94.
Breast cancer is a malignant tumor that develops from ductal and lobular cells of the breast. A malignant tumor is a group of cancer cells that have a tendency to invade surrounding tissues or spread (metastasize) to distant areas of the body.
There are several types of breast cancer, although some of them are quite rare. In some cases a single breast tumor can have a combination of these types or have a mixture of invasive and in situ cancer.
1. Carcinoma in Situ
This term is used for the early stage of cancer, cells remain confined to ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). They have not invaded into deeper tissues in the breast or spread to other organs in the body, and are sometimes referred to as non-invasive breast cancers.
2. Ductal Carcinoma in Situ
Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is the most common type of non-invasive breast cancer. DCIS means that the cancer cells are inside the ducts but have not spread through the walls of the ducts into the surrounding breast tissue.
About 1 in 5 new breast cancer cases will be DCIS.
Invasive (or infiltrating) ductal carcinoma (IDC)
This is the most common type of breast cancer. Invasive (or infiltrating) ductal carcinoma (IDC) starts in a milk passage (duct) of the breast, breaks through the wall of the duct, and grows into the surrounding tissue of the breast. Though at this point, it may be able to spread (metastasize) to other parts of the body through the lymphatic system and bloodstream. There are further many types of breast cancer based on the histopathology report.
Many factors may influence the development of breast cancer:
Age-It is less common in women 35 or younger, most cases occur in women 50 or older.
Family history-Risk is higher with a family history (especially mother, sister, daughter) of breast and/or ovarian cancer.
Hormones / childbirth-Occurrence of first menstrual period before age 12, menopause after age 55. No children or first child after age 30 or postmenopausal use of hormonal therapy(HRT). This is because of the increased duration of estrogen exposure.
Previous biopsy-If one had an abnormal breast biopsy(15-25% increased risk), benign breast diseases requiring biopsies.
Genetic alterations-Inherited susceptibility genes BRCA1 and BRCA2 account for about five to 10% of all breast cancer cases.
Oral contraceptive use, diet high in saturated fats, physical inactivity, alcohol (more than one alcoholic drink a day) also are under evaluation.
Lump or mass in breast is the most common presentation and is a vague swelling usually in the upper outer quadrant of the breast. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, irregular shaped lump that feels firmly attached within the breast is more likely to be cancer.
* Sudden increase in the size of lump present for long time usually a fibroadenoma.
* Enlarged lymph nodes in the armpit associated with swelling over arm or pain in axilla.
* Changes in breast size, shape, skin texture or color.
* Nipple retraction or discharge.
* Usually early breast cancer does not cause pain.
* Bony pains, significant weight loss and anorexia.
INVESTIGATIONS FOR DIAGNOSIS
These can be part of a screening examination, and are performed on healthy women with no symptoms on a regular basis especially if they have risk factors. This helps to catch cancer in its early stages, when it is much more likely to respond to treatment. Typical breast screening exams include a clinical breast examination and a mammogram.
Breast Cancer Diagnosis There are several procedures that can be used to diagnose breast cancer. Not every procedure will be done for each patient. The evaluation is based upon the patient’s examination and physician recommendations.
Radiological Investigations
1. Mammogram Diagnostic mammograms are x-ray pictures of the breast. It can often show a breast lump before it can be felt. They also can show a cluster of tiny specks of calcium called micro calcifications. Technique: Each breast is placed between two photographic plates and compressed, while an X-ray is taken of the breast tissue. Mammograms should be conducted every year beginning at age 40 and possibly earlier if a woman has certain risk factors such as inherited genetic mutations.
2. Magnetic Resonance Imaging (MRI): images of the breast are created with powerful magnets that interact with a computer.
3. Ultrasound: A special instrument placed against the skin transmits sound waves, which bounce off breast tissue and are used create an image on a monitor.
Histopathological Investigations
Fine Needle Aspiration (FNAC): A thin, hollow needle is inserted into the breast lump and cells are removed from the lump. While this test can help to determine if there is cancer present, it cannot determine if the cancer is invasive and additional biopsy may be needed if positive.
Biopsy: a small sample of the suspicious area of the breast is removed for examination under a microscope. Biopsies can be done in the following ways:
* Core Needle biopsy: A thicker needle is used to remove one or more small cylinder-shaped tissue samples from the tumor. This can give us additional information including ER, PR, and HER2Neu status.
* Surgical biopsy: an incision is made in the breast using a blade. In an excisional biopsy, the entire mass is removed. In an incisional biopsy, only a portion of the tumor is removed. Though if the lump is suspicious and radiological investigations, history and physical examination is indicating of a malignancy a wide local excision should be done.
Lymphatic Drainage Of Breast
Lymphatic system is responsible for collecting the lymph which is the fluid which leaks out of the blood vessels due to high pressure. The lymph nodes are olive-sized glands and are stations where the lymphatic vessels collect. The lymphatic system can also carry cancer cells from the tumor site to other areas of the body. In breast cancer patients, the most common nodes to be affected are located under the armpit.
Axillary lymph node dissection is done along with the surgery for the primary to remove these suspicious glands. A standard axillary dissection yields more than ten nodes.
Alternatively a sentinel lymph node biopsy, a radioactive tracer is injected into the area before surgery. Then, the surgeon injects a blue dye near the tumor site, which shows up in cancerous lymph nodes. The node with the highest amount of tracer or blue dye is the “sentinel” node. The surgeon removes all nodes with blue dye. This procedure can spare healthy lymph nodes, which results in fewer side-effects such as lymphedema and is being tested in randomized phase III trials before becoming a standard of care.
STAGING (Source: National Cancer Institute)
The staging system allows doctors to help identify the extent of breast cancer involvement. By knowing the extent of disease, doctors can then determine the best treatment for each patient.
Stage 0 (carcinoma in situ):cancer has not spread from the site of origin.
There are 2 types of breast carcinoma in situ:
Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.
Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.
Stage I
The tumor is 2 centimeters or smaller and has not spread outside the breast.
Stage IIA
No tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
The tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
The tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB
The tumor is larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA
No tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
The tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
The tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
The tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Stage IIIB
The tumor may be any size and cancer:
Has spread to the chest wall and/or the skin of the breast; and May have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
Stage IIIC
There may be no sign of cancer in the breast or the tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:
Has spread to lymph nodes above or below the collarbone; and May have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Stage IIIC: Breast cancer is found in: 10 or more axillary lymph nodes; or Lymph nodes above the collarbone; or
Axillary lymph nodes and in lymph nodes near the breastbone
Stage IV:
The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.
TREATMENT
Cancer treatment is either local therapy or systemic therapy:
Local therapy: Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
Systemic therapy: Chemotherapy, hormone therapy, and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.
Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next.
Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them. Your doctor can describe your treatment choices and the expected results. You may want to know how treatment may change your normal activities. You may want to know how you will look during and after treatment. You and your doctor can work together to develop a treatment plan that reflects your medical needs and personal values. At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns.
SURGERY
Modified Radical Mastectomy-
The entire breast is removed, along with any axillary lymph nodes. Breast reconstruction or implant surgery is performed during the same procedure, after the breast is removed.
Breast Conserving Surgery is an attempt to save as much healthy breast tissue as possible and removes the lump with a wide margin. Radiation therapy is always used with this kind of treatment.
The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:
The size, location, and stage of the tumor
The size of the woman's breast
Certain features of the cancer
How the woman feels about saving her breast
Whether she has any contraindication for radiation therapy like active collagen vascular disease or pregnancy.
RADIATION THERAPY
Radiation therapy uses high-energy beams to destroy cancer cells. It is a painless form of treatment. There are two types of radiation treatment for breast cancer:
External beam radiation: the beams are aimed at the tumor from outside the body. Patients undergo radiation five days a week for a certain number of weeks usually 5 to 6 weeks. Usually the chest wall is treated for mastectomy patients and the intact breast for the breast conserving surgery patients. The technique used is mainly two tangentials with beam modifying devices and use of bolus for the mastectomy patients. The choice of treatment of lymph node regions depends on many factors.
Internal radiation: small plastic tubes or catheters are implanted in the breast in operation theatre at the tumor site using special applicators. X rays or CT scan is done and the planning is done on computers using sophisticated software and then radioisotopes like Iridium is used to deliver the desired dose of radiation limited to the target volume.
Precautions with radiation therapy- You should wear loose-fitting cotton clothes during this time and avoid wearing bras as it will rub against irradiated skin and cause soreness.. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. The area gradually heals once treatment is over. However, there may be a lasting change in the color of your skin.
You are likely to feel tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but one should try to stay active and in a positive state of mind.
CHEMOTHERAPY
Chemotherapy is the use of drugs, either alone or in combination, to kill cancer cells. In breast cancer, chemotherapy is most often used either before or after surgery, or as a primary treatment for cancer that has spread outside the breast at the time of diagnosis.
Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:
Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.
Your doctor can suggest ways to control many of these side effects.
Some drugs used for breast cancer can cause tingling or numbness in the hands or feet.
Some anticancer drugs can damage the ovaries. The ovaries may stop making hormones and one may have symptoms of menopause. These symptoms include hot flashes and vaginal dryness.
HORMONE THERAPY
Hormone therapy is used to prevent female hormones (estrogen, progesterone and estradiol) from fueling the growth of breast tumors in some patients. Hormone therapy can involve taking drugs, either by mouth or through an IV. Tamoxifen is an example of a hormone therapy drug. Surgery to remove the ovaries in women who have not yet reached menopause is another type of hormone therapy. Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they need. These hormones are estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of tumor, you may have hormone therapy
This treatment uses drugs or surgery:
Drugs: Your doctor may suggest a drug that can block the natural hormone. One such drug is tamoxifen, which blocks estrogen. Another category of useful drugs are aromatase inhibitor including anastrozole, letrozole etc but are useful only in postmenopausal female. The testing of serum FSH, Estradiol levels may be required before starting the hormonal treatment.
Surgery: If you have not gone through menopause, you may have surgery to remove your ovaries. The ovaries are the main source of the body's estrogen. A woman who has gone through menopause does not need surgery. (The ovaries produce less estrogen after menopause.)
The side effects of hormone therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormone treatment. In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge. Other side effects are irregular menstrual periods, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Not all women who take tamoxifen have side effects.
Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins. Blood clots form most often in the legs and in the lungs. Women have a slight increase in their risk of stroke.
Tamoxifen can cause cancer of the uterus and therapy should be monitored with regular pelvic ultrasounds measuring the endometrial thickness. You should tell your doctor about any unusual vaginal bleeding between exams.
BIOLOGIC THERAPY Biologic therapy is a drug treatment that helps the body’s immune system fight cancer. Herceptin® is a type of biologic therapy that targets cells which produce excessive amounts of a protein called HER2. This protein is present in some breast cancer patients and can be tested by Immunohistochemistry, the confirmation can be done with a FISH test.
Some women have chemotherapy before surgery. This is neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.
After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.
FOLLOW UP
This comprises of a clinical breast examination and general physical examination for every two to three months during first year, every 4 monthly during next two years, 6 monthly in third and fourth years followed by yearly check up. Investigations such as chest X ray, USG abdomen, blood investigations, mammogram can be done on yearly intervals or a on advise of the physician.
Side effects can appear later such as swelling of the ipsilateral arm and is known as lymphedema and can develop right after surgery or months to years later. One should practice regular arm, shoulder exercises as directed by your physician to prevent this.
You will need to protect your arm and hand on the treated side for the rest of your life: By avoiding tight clothing or jewelry on your affected arm, carrying your purse or luggage with the other arm.
* Useing an electric razor to avoid cuts when shaving under your arm
* Have shots, blood tests, and blood pressure measurements done on the other arm
* Wear gloves to protect your hands when gardening and when using strong detergents
* Have careful manicures and avoid cutting your cuticles
* Avoid burns or sunburns to your affected arm and hand
* You should ask your doctor how to handle any cuts, insect bites, sunburn, or other injuries to your arm or hand. Also, you should contact the doctor if your arm or hand is injured, swells, or becomes red and warm.
If lymphedema occurs, the doctor may suggest raising your arm above your heart whenever you can. An elastic sleeve should be worn to improve lymph circulation. Medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm may also help. You may be referred to a physical therapist or another specialist.