Breast Cancer

The breasts are made up of glandular tissues comprising mammary gland tissues, fat and connective tissues. During pregnancy, mammary glands will produce and excrete milk for babies.

However, when cells in the mammary gland divide and proliferate in an uncontrolled way, they may eventually develop into tumours which may be benign or malignant. Breast cancer is a malignant tumour developed in the breast.

High risk factors of breast cancer include:

• Gender: although some men may also suffer from the disease, nearly all breast cancers are found in women.

• Age: in general, the risk of breast cancer increases with age.

• Family history and genetics: a woman is more likely to have breast cancer if her mother, sister or direct relative had suffered from the disease. According to clinical studies, around 5-10% breast cancers may be related to genetic changes.

• Menstrual cycle: women having first menses before 12 or menopause after 55 may have higher risk

• Diet: prolonged intake of diet with high animal fat

• Lifestyle: smoking, drinking and lack of exercise will increase the risk

• • Childbirth: women with no kid or having their first child after 35

• Drugs: prolonged intake of contraceptives or having hormonal replacement therapy for more than 5 years
  

• Personal history of cancer: history of certain malignancy like Hodgkin’s Disease, lung cancer, bowel cancer, or history of cancer in childhood

Most breast cancers are first spotted by the patients themselves. Since the cure rate is much higher in early breast cancers, women should stay aware and self-examine their breasts monthly:

 Healthy life styles will help to lower the breast cancer risk.

• Regular exercise
• Eat more fresh vegetables and fruits and stay away from food with high fat
• No alcohol or smoking

The role of mass breast screening in Asian population remains controversial. Up to present, there is no convincing evidence to recommend routine check-ups to all women. However, women with higher risk (e.g. strong family history of breast cancer) should consult their doctors for advice.

The exact cause of breast cancer remains unclear. Breast cancer mainly develops in mammary duct cells or lobular cells. Possible causes include familial and genetic cause, use of contraceptives or female hormone replacement therapy, radiation (X-ray) to breast region, high dietary fat, smoking, alcohol, or lack in exercise.

	If your have the following symptoms, you may get breast cancer:

• Breast
• lump of any size*
• changes in shape or size
• dimpling on skin
• vein congestion or orange-peel appearance on skin
• Nipple
• blood-stained discharge
• retraction (sinks into the breast)
  
• Armpit
• swollen lymph nodes

* Bloated or lumpy breasts are normal physiological reactions caused by cyclic hormonal changes, which are common among women before menstrual cycles. There is no need to worry about it. If you are in doubt about the existence of lumps, please consult your doctor to check if they are benign or malignant. Many of these lumps are benign cysts (fluid-filled sacs or pockets in tissues) or fibroma (non-cancerous tumours composed of fibrous tissue) which are harmless to human body.

After taking the medical history and physical examination, the doctor will arrange the following check-ups for suspicious cases:

a) Mammogram: to detect and confirm the location of breast tumours

b) Biopsy: tissues of the lump are taken out through a fine needle for further microscopic examination to determine the nature of cells in the lump.

Some other tests will also be arranged if necessary:

a) Ultrasound: ultrasound scan is used to supplement the mammogram in determining the location, size and nature of breast lumps

b) Hormonal Receptor and HER2 tests -: these may help to determine whether a patient should receive hormonal treatment or targeted therapy

c) Blood tests: to evaluate general body conditions and functions of the liver and the kidneys

d) Chest x-ray

e) Computed Tomography (CT) scan and bone scan; or PET scan: especially for patients with high risk of tumour spreading to other organs.

	Once the diagnosis has been confirmed, one or more of the following treatments will be recommended to patients:

Surgery

There are two main types of surgery:

1) Breast conservation therapy
The surgeon removes only the breast tumour and its surrounding tissues; patients should require radiotherapy afterwards to reduce the risk of recurrence. This approach is most suitable for smaller lumps located away from the nipple and there is less undesirable effect on the cosmesis.

2) Mastectomy (removal of whole breast)
When the breast tumours are too large or found in different parts of breasts, the whole breast has to be removed surgically.

In either procedure, the lymph nodes in the armpit of the affected side has to be sampled or removed for further microscopic examination. Nowadays suitable patients would be offered sentinel lymph node biopsy. If no tumour cells are detected in the sentinel lymph node, patients could be spared the operation of axillary dissection. This will reduce the chance of post-operative lymphoedema of the upper limb.

For patients undergoing mastectomy, the patient may choose to have breast prosthesis or breast reconstructive surgery. The reconstructive surgery generally uses the fat from the belly or specially made saline implant to restore the contour and shape of breasts. It is recommended to seek further advice from experienced surgeons and nurse specialists before and after breast surgery.

Radiotherapy

For more aggressive tumors or potential residual tumor cells around the surgical wound (e.g. in breast conservation therapy), radiotherapy (treatment using high energy X-ray beams) may also be needed as an adjuvant treatment to reduce the risk of recurrence. A whole course of radiotherapy usually takes 5 to 6 weeks. Nowadays hypofractionated treatment of 3 to 4 weeks has also been proved to be equally effective.

Chemotherapy

Adjuvant chemotherapy is often given after surgery for patients with intermediate to high risk of recurrence. Anti-cancer cytotoxic drugs will be used to kill the residual cancer cells, thus helping to reduce the risk of recurrence. A complete course of chemotherapy usually takes 3-6 months. For patients with advanced breast cancer, chemotherapy can also be used in the palliative setting.

Hormonal treatment
Estrogen will stimulate the growth of breast cancer cells. Therefore doctors may prescribe drugs to block the effect of female hormones to stop the growth of breast cancer cells. However, this approach is only effective in tumors with positive hormonal receptors. The treatment usually consists of oral tablets being taken for up to 10 years.

Targeted therapy

For HER2-positive breast cancers, targeted therapy drugs will further improve the effectiveness of adjuvant chemotherapy. The course will last for 1 year.

Breast cancer may turn out to be fatal if it spreads to other parts of the body, such as lungs, liver, and brain, etc. Treatments may also lead to side effects or complications, including:

• Wound infection after surgery.

• Patients with their armpit lymph nodes removed may suffer from arm swelling, soreness, discomfort and stiffness around shoulders.

• Mastectomy patients with their chest wall muscles removed may have slight limitation in movement of their arms.

• Radiotherapy may cause reddening and soreness of the skin, discomfort and swelling of breast, or tiredness. These symptoms may last a few weeks after radiotherapy.

• During chemotherapy, patients are more vulnerable to bacterial infections due to the weakened body defence system. The treatment will also cause short-term hair loss, vomiting and tiredness, etc.

• Targeted therapy usually has mild side effects, but may affect cardiac function in uncommon situation.
  

Although treatments may induce some side effects with variable degree of severity, modern treatment has been improved to reduce the associated discomfort and side-effects. Nursing care, medications as well as support from relatives and friends can help to relieve discomfort caused by treatments.

Patients need to be attentive to various aspects before and after surgery and during recovery. Knowing more about breast cancer and being considerate will help them to face the disease in a positive way.

Regular clinic visits: patients will need to be followed up regularly to see whether they develop any signs of symptoms of relapse or treatment complications. In general, the risk of relapse will decrease with longer disease-free period.

Avoid lifting heavy objects with the affected arm. This will also decrease the risk of arm swelling after surgery.

Simple exercise: with instructions from doctors and physiotherapists, patients should have simple arm exercise for upper limbs training so as to maintain the mobility of shoulder joints and reduce the risk of arm swelling.