DOCTOR-SPEAK—Breast Cancer, Dr Wesley M Jose
MNAMS, FIACM, PGDIM
Associate Professor Medical Oncology & Hematology
Amrita Institute of Medical Sciences, KOCHI
Is Breast cancer hereditary? If in a family one lady has Breast cancer, what are the chances of her siblings or daughters to have it? Is it preventable?
Hereditary cancers are those which can propagate from one generation to the next. Breast cancer is one of the proven hereditary cancers but all breast cancers are NOT hereditary in nature. This means that every patient who is diagnosed to have breast cancer does not have a relative or family member with breast cancer. Such breast cancer with no background family history or evidence of heredity is known as sporadic breast cancer. Sporadic breast cancer could occur to anyone of us including males. The hereditary breast cancers account for just 5–10 percent of the entire breast cancer population which means approximately 90 per cent breast tumors are sporadic in nature. The hereditary breast cancers occur due to abnormalities in our genes (also called mutation) which are present in the DNA which we inherit from our parents. A very common gene mutation responsible for breast cancer is called BRCA mutation. There are many such mutations that we are aware of and many are still being discovered. In a family with an established mutation, there is always a higher risk of developing breast or ovary cancer. This is preventable to some extent by preventive surgeries. Please read the story of Hollywood actress Angelina Jolie to get an understanding of what preventive surgery means (https://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?_r=1&). For further information on hereditary breast cancer please visit https://scienceblog.cancerresearchuk.org/2013/05/14.
What are the symptoms of Breast Cancer? How is Breast cancer diagnosed? Is screening of general population advised, if yes, at what age?
One of the most common symptoms of breast cancers is a lump in the breast. But we need to understand that most breast lumps are not cancer. They could be fluid-filled cysts or a fibroadenoma (non cancerous fibrous and glandular tissue). Other common symptoms include a change in the size or shape of the breast, dimpling of the skin or thickening in the breast tissue, an inverted nipple that’s turned in, a rash on the nipple, discharge from the nipple, lump in the armpit and pain or discomfort in the breast that doesn’t go away.
Breast cancer is easy to diagnose and definitely NOT expensive. It can be done at almost all the hospitals and in most cities. Government also runs cancer detection centers in many cities where the services are provided at very affordable costs. The most important tool to screen and diagnose breast cancer is a mammogram which is a simple x-ray of the breast. This x-ray mammogram is supplemented with an ultrasound of the breast to improve the detection of the breast tumor. A sonomammogram provides 95% sensitivity in picking up an abnormality in the breast. Occasionally, a sonomammogram is inadequate to make a diagnosis, in which case, a radiologist would recommend an MRI of the breast for clearer understanding.
You can read more about breast MRI at https://www.mayoclinic.org/tests-procedures/breast-mri/about/pac-20384809. A qualified radiologist can look at the sonomammogram or MRI Breast and categorize it by a system called BIRADS (Breast Imaging Reporting and Data System) into six categories. If your sonomammogram is reported as BIRADS 4 or BIRADS 5, it means that there is something highly suspicious in the breast and needs to be further evaluated. All breast abnormalities that are reported as BIRADS 4 or 5 will need a biopsy (removing a small piece of tumor for testing) which is done by inserting a biopsy needle into the tumor under local anesthesia (making it painless). The biopsy is a day care procedure done by either the radiologist or a surgeon and does not need admission to the hospital and there are no major complication related to breast biopsy. The biopsy results are available in a matter of 3–5 days.
Women who are between 50 and 74 years of age and have no family history of cancer should get a mammogram once every two years. Those women who are between 40 and 49 years of age if presumed to be at higher risk of breast cancer should talk to their doctor about when to start and how often to get a mammogram.
Can Breast cancer occur in males too?
Breast Cancer occurs in males too. Male breast cancers accounts for less than 1 percent of all breast cancers. It can occur at any age but it is more common in those older than 60-years. It is rare to have males who are less than 35 years of age to have breast cancer. The risk of male breast cancer is higher if the gentleman is obese, or on estrogenic drugs, or if he has a family history of breast cancer, has liver cirrhosis, or diseased/removed testis. Males who have a genetic condition called Klinefelter syndrome (https://www.nhs.uk/conditions/klinefelters-syndrome) are also at a higher risk of breast cancer. The diagnosis and treatment however is same as for female breast cancer.
What, in your opinion, is the best treatment approach for a patient diagnosed with Breast cancer? What is the total expenditure involved?
The treatment of breast cancer is complex. It depends on the patient’s age, the status of her menstrual cycles, the size of the tumor in the breast, number of lymph nodes positive for tumor deposit, extent of spread in the body, the hormone status of the tumor and presence or absence of a protein called Her2neu. Since it is dependent on so many factors, the treatment for two patients of breast cancer may not be identical. The treatment of breast cancer always includes a surgery to remove the cancerous growth. Based on the characteristics of cancer the patient may require a combination of chemotherapy, 1 year of anti her2neu therapy (only if her2neu positive), radiation treatment, long-term hormone therapy which may be up to 10 years. This additional treatment after surgery is called adjuvant treatment. The treatment cost varies depending of the patient’s disease features and the center where the treatment is taken.
Is Breast cancer completely curable? Does stem cell or gene therapy have any role here? If yes, where can it be done and what is the cost involved?
Breast cancer is a curable disease provided it is diagnosed in early stages. As the stage at diagnosis becomes higher, the risk of recurrence increases. Hence it is of utmost importance to ensure that a disease is diagnosed at the earliest. In early breast cancer which is operated and completely removed there is no role for stem cell or gene therapy.
Can breast reconstruction be done in patients who have undergone surgery?
The answer is YES. Breast reconstruction can be done in patients who have undergone a partial or complete breast removal. This is called oncoplasty. Complete removal of breast is no more mandatory for anyone except in rare circumstances since the outcomes of partial and complete breast removal surgery is the same. Patients should inform the operating surgeon during the surgical consultation of their desire to have a breast reconstruction so that the same can be planned in the same sitting. However for those who wish to have a reconstruction done later there are options which should be discussed with an oncology or plastic surgeon who will be able to provide a realistic picture of cosmetic outcomes.
Can you suggest some support groups (online or offline), NGOs or government agencies in your city/India that offer support to individuals with Breast cancer.
Every city has a group which offers support to individuals going through breast cancer care. Canserve (Kochi, Kerala), The Pink Initiative (Mumbai), Breast Cancer Support group of India are some of the agencies offering support.
Are you aware of any Breast cancer clinical research trials currently going on in our country?
There are various clinical trials for breast cancer from time to time. The best place to search for ongoing clinical trials in India is Clinical Trials Registry India at http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.
What is the one advice that you would like to give to the patients suffering from Breast cancer?
Know your breast. Detect a lump early and seek professional help quickly as time is of essence. Stay Motivated. You live only once and with cancer there is never a second chance.
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