What is breast cancer?
Breast cancer is not a single disease; there are several different types of breast cancer that can grow at different rates and have different characteristics which will determine management of the disease.
Facts and figures about breast cancer
It is the most cancer common in the UK, with a significantly higher incidence in women. The male to female ratio is 1:143. Female breast cancer is strongly related to age, an average of over 80% being diagnosed in the 50+ years age group. However, it is the most common cancer in women under 40 years.
Risk factors include:
- The use of oestrogen-progesterone oral contraceptives.
- Family history of breast cancer.
- BRCA1 and BRCA2 gene mutation carriers.
- Obesity in post-menopausal women.
- Previous primary breast cancer.
Routine mammography screening is now offered to all women between the ages of 50 and 70 in the UK at three year intervals. This has increased early detection and an independent review concluded that 1,300 deaths/year are prevented due to the UK breast screening programme. In some areas the age group has been increased to include all women between the ages of 47 and 73. Approximately 80% of patients diagnosed with early stage breast cancer are now considered to be cured.
Symptoms of breast cancer
Symptoms may include:
- Breast lump.
- Lump or swelling in the axilla.
- Change in the shape or size of the breast.
- Change in appearance or feel of the skin on the breast.
- Rash on or around the nipple.
- Discharge from the nipple.
- Inverted nipple.
Breast cancer diagnosis
Investigations may include:
- Physical examination.
- Ultrasound scan and/or mammogram.
- Needle core biopsy or fine needle aspiration to remove small sample of cells for analysis.
- Blood tests.
- Chest X-ray.
- Bone scan.
- CT scan.
- MRI scan.
Breast cancer treatment
Depends on several factors:
- The type and grade of breast cancer.
- The size of the tumour.
- The stage of the cancer.
- Patient’s age and if pre or post-menopausal.
- Receptor status-this will identify if cells are hormone sensitive and if hormone suppression treatment is appropriate.
- General health.
Treatment may often include a combination of methods, including surgery, chemotherapy, radiotherapy, hormone and targeted therapy.
Surgery will normally be used to remove the tumour from the breast if possible. In most cases this will be a wide local excision (lumpectomy), rather than removing the whole breast. However, in some case, particularly if there are several tumours (multifocal) in the breast, removal of the whole breast (mastectomy) may be recommended. After mastectomy, patients may be offered breast reconstruction.
Chemotherapy may be prescribed before surgery with the intention of shrinking the tumour, but more commonly is given after surgery and possibly in conjunction with radiotherapy to reduce the risk of the disease spreading or recurring. Also, it may be offered if the disease has recurred. Chemotherapy is known to reduce the risk of recurrence and spread especially in younger patients and those found to have node positive tumours.
Radiotherapy may be offered post-surgery or in conjunction with chemotherapy.
Most commonly it is given after surgery to eradicate any remaining cancer cells in the breast tissue and/or local lymph nodes to reduce the risk of recurrence. In a small number of cases it may be used if a patient refuses or is unfit for surgery. Also, it can be used in locally advanced cases to relieve distressing symptoms such as ulceration and pain.
Radiotherapy can be effective in the treatment of metastatic disease, relieving symptoms such as pain from bone secondaries. Standard radiotherapy can lead to lung fibrosis and other late side effects such as cardiac damage in patients with left breast tumours.
However, the implementation in some radiotherapy centres of intensity modulated radiotherapy (IMRT) particularly in combination with image guided radiotherapy (IGRT) enables more precise targeting of the cancer site to minimise possible damage to surrounding healthy tissues. In the case of left sided breast tumours, where suitable, techniques such as deep inspiration breath hold (DIBH) can be used to help lift the breast away from the heart during treatment.
Hormone therapy may be used in conjunction with other treatments. It is effective for most tumours that test positive for oestrogen or progesterone receptors. The female hormone oestrogen can stimulate some of the breast cancers to grow and there is a variety of drugs that suppress this. Hormone therapy in these cases is effective in reducing the risk of recurrence, shrinking tumours, improving cancer-related symptoms and treating metastatic breast cancer.
There are some drugs (Herceptin is the most publicised of these drugs) that block the growth and spread of the disease by disrupting the growth of the cancer cells.