Breast cancer

While many people associate genetics with breast cancer risk, it's important to note that only 5-10% of breast cancer cases have a clear genetic link. The remaining 90% of cases, often termed sporadic breast cancers, involve manageable risk factors.

Key risk factors for developing breast cancer include:

• Being female, as women are significantly more likely to develop breast cancer than men
• Advancing age, with most cases diagnosed after 50
• A history of specific breast conditions, such as lobular carcinoma in situ (LCIS) or atypical hyperplasia
• A personal history of breast cancer, as well as a history of cancer in one breast, which increases the risk of the other breast being affected
• A family history of breast or ovarian cancer, especially if a first-degree relative (mother, sister, or daughter) is affected
• Genetic mutations, particularly BRCA1 and BRCA2. For instance, a BRCA2 mutation can result in a lifetime risk of 26%-84%
• Dense breast tissue
• Early menstruation (before age 12) or late menopause (after 55)
• Never being pregnant or having a first child after 30
• Smoking and excessive alcohol consumption
• Obesity
• Hormone replacement therapy after menopause, especially estrogen combined with progestin
• A history of radiation therapy, particularly to the head, neck, or chest area

The most effective way to detect breast cancer early is through regular screening. Various screening methods can help identify potential signs of breast cancer:

Physical Breast Examination

Breast self-examination (BSE) is a screening method that can be performed at home by the individual. It typically takes 5-10 minutes and should be done monthly by women over the age of 15.

To perform BSE:

• Stand in front of a mirror with your arms at your sides and shoulders straight.
• Visually inspect your breasts for any noticeable changes such as dimpling, puckering, inverted nipples, or any alterations in size or shape.
• Raise your arms above your head and observe changes in your breast's appearance. Repeat the process by lifting each breast one at a time.
• Using the pads of your fingers (not the tips), gently press and move your fingers in small circles across the breast, starting from the collarbone, moving towards the center of the breast, and down to the underarms.
• Repeat the process lying down and again in the shower, as the soap and water will help your fingers glide easily over the skin.
• Finally, gently squeeze each nipple to check for any unusual discharge.

Clinical Breast Examination (CBE)

A clinical breast exam is conducted by a healthcare professional, such as a doctor or nurse. During this exam, the clinician will use their hands to feel for any lumps, abnormal firmness, or discharge. This exam is recommended every six months for women at high risk of breast cancer or those showing early signs of abnormalities. If an abnormality is detected during a BSE, a CBE should be scheduled to investigate further.

Blood Marker Tests

Blood tests for tumor markers help detect the presence of cancer in the body. These tests can also assess whether cancer cells have spread to other parts of the body or monitor the effectiveness of ongoing treatment. Additionally, they can help determine if cancer has returned after remission. Some commonly recommended blood markers include:

• CA 15.3
• CA 27.29 (specific to breast cancer)
• Carcinoembryonic Antigen (CEA)

Mammography

A mammogram is an X-ray image of the breast tissue. It is recommended that women begin annual mammograms after the age of 40 or as advised by their healthcare provider. For women with dense breast tissue, mammography alone may not be sufficient. In these cases, additional imaging such as ultrasound may be needed.

Magnetic Resonance Mammography

MRI uses magnets and radio waves to produce detailed images of the breast and can be more effective than mammograms or CBE for women at high risk, such as those with a BRCA gene mutation. MRI is often combined with mammography and CBE for comprehensive screening in high-risk groups. It is not recommended for women at average risk due to the possibility of false positives.

Additional Tests

If any abnormalities are detected during the screening process, further tests may be required for a more precise diagnosis. These may include:

• Excision biopsy: A portion of tissue is removed for examination to determine the type of cells involved in the cancer.
• Fine Needle Aspiration Cytology (FNAC): A needle is used to extract fluid from the breast tissue for analysis.
• CT Scan: This imaging test helps determine if the cancer has spread to other areas of the body.

Engage in Regular Physical Activity

Lack of physical activity is linked to an increased risk of breast cancer. Women who are physically active have a 10%-20% lower risk compared to inactive women. Exercise helps regulate inflammation, hormones, and energy balance. Even simple activities like walking can be beneficial. Aim for moderate-intensity exercise for at least 30 minutes a day, four times a week.

Quit Smoking

Long-term smoking significantly raises the risk of breast cancer. Additionally, exposure to secondhand smoke, particularly for premenopausal women, also increases the risk.

Limit Alcohol Consumption

Excessive alcohol intake can increase the risk of breast cancer. It is best to restrict alcohol to social events or avoid it entirely.

Maintain a Healthy Weight

Obesity is a major risk factor for breast cancer. Postmenopausal women who are overweight or obese have a much higher risk of developing breast cancer, with a risk 1.5 times higher for overweight women and twice as high for obese women. This is likely due to higher estrogen levels produced by fat tissue. Maintaining a healthy weight through regular exercise and a balanced diet is essential.

Perform Monthly Breast Self-Exams

Regular self-examination of the breasts can help detect any changes early. Check your breasts in the mirror with your shoulders straight and arms on your hips for any abnormal changes like dimpling or inversion of the nipple. Use the pads of your fingers to feel your breasts in a circular motion. Doing this while the skin is wet in the shower makes it easier to feel any irregularities.

Schedule Yearly Clinical Examinations

After the age of 35, it is advisable to undergo a clinical breast examination annually by a qualified breast specialist. For women with a family history of breast cancer, annual exams should begin at age 25.

Get Regular Mammograms/Ultrasounds

Mammograms are essential for screening women over the age of 40, especially for those with no symptoms. For women under 40, an ultrasound is recommended to check for changes in the breast tissue.

Take Extra Care if You Have a Family History

If there is a family history of breast cancer, consult with an oncologist to assess your risk. For women over 40, mammography is recommended, while younger women may benefit from an ultrasound. Early detection of any lumps or abnormalities can increase the likelihood of successful treatment and recovery.

Specialists to Consult

If you find a lump in your breast or notice nipple discharge, it's crucial to seek medical advice. For women with a family history of breast cancer, annual mammograms are recommended.

Treatment for breast cancer often involves a multidisciplinary team of specialists, including:

• Oncologists
• Oncosurgeons
• Radiation oncologists

This team works alongside other healthcare professionals such as radiologists, pathologists, nutritionists, counselors, and general physicians to create a tailored treatment plan. For women over the age of 65, a geriatric oncologist may also be part of the team to address age-related health concerns.

Breast cancer can present in various forms. Some tumors are small but grow quickly, while others may be larger and grow more slowly. Because of this, treatment plans must be tailored to each patient's specific condition. Key factors considered when determining the appropriate treatment include:

• The tumor's location in the breast
• Tumor size
• Whether the cancer has spread to other areas
• The type of cancer
• The stage/grade of the cancer
• The patient’s menopausal status
• The patient’s age
• The presence of genetic mutations
• The presence of hormone receptors or proteins on the cancer cells
• The patient's overall health and fitness

Breast cancer treatment often involves one or more of the following approaches:

1. Chemotherapy

Chemotherapy uses medications to shrink or destroy cancer cells. These medications can be given in pill form or by injection (intravenously). Typically, chemotherapy involves the intravenous administration of drugs, either through a central line (a long tube inserted into a large vein in the chest) or a cannula (a small tube inserted into a vein in the arm).

Chemotherapy is most effective when multiple drugs are used together. It can be given either before surgery (neoadjuvant) to shrink the tumor or after surgery (adjuvant) to lower the chances of cancer returning. After surgery, chemotherapy is often recommended if:

• Cancer cells are found in the lymph nodes under the arm
• The tumor is large
• The cancer cells are of a high grade (grade 3 or higher)
• Hormonal therapy is ineffective due to a lack of hormone receptors on the cancer cells

How many cycles?

Chemotherapy typically follows a specific cycle schedule determined by the doctor, which can range from weekly to every few weeks. In many cases, chemotherapy is an outpatient procedure, allowing the patient to return home the same day. In some instances, the patient may need to stay in the hospital overnight or longer.

Common chemotherapy drugs include:

• Cyclophosphamide
• Vinblastine
• Vinorelbine
• Fluorouracil
• Capecitabine
• Gemcitabine

Side effects of chemotherapy may include fever, loss of appetite, weight loss, extreme fatigue, increased risk of infections, easy bruising or bleeding, digestive issues, and hair loss.

2. Radiation Therapy

Radiation therapy uses high-energy rays (like X-rays) to destroy cancer cells. It is often combined with other treatments such as chemotherapy and surgery. The radiotherapy team will determine the appropriate radiation dose, where to target it, and how much radiation the surrounding tissues should receive.

Types of radiation therapy include:

• External-beam radiation therapy: Radiation is delivered from a machine outside the body.
• Intraoperative radiation therapy: Radiation is delivered during surgery using a probe.
• Brachytherapy: Radioactive material is placed directly into the tumor.

External-beam radiation is the most common method, used for treating the entire breast or specific parts of it.

What happens during radiotherapy?

The patient will lie on a special board, often with a mold over the breast. The radiographers will align the machine with the patient's body based on marks on the skin or mold. The patient must remain still during the procedure, and sometimes they may be asked to hold their breath briefly. Multiple images will be taken before the treatment to ensure proper positioning.

Radiation therapy can lead to side effects such as fatigue, breast swelling, skin redness or discoloration, pain or burning at the site of radiation, and in rare cases, pneumonitis (lung inflammation).

How many cycles?

Radiation therapy typically involves daily treatments, 5 days a week, for 3 to 6 weeks. Each treatment is referred to as a "fraction."

Radiation therapy is recommended in the following cases:

• When the tumor is too large to be removed surgically
• To treat metastatic breast cancer (cancer that has spread to other areas of the body)
• After breast-conserving surgery (lumpectomy) to reduce the risk of recurrence in the same breast or nearby lymph nodes
• After mastectomy, if cancer is found in nearby lymph nodes, or if the tumor is over 5 cm, has spread to nearby skin, or muscles

3. Hormonal Therapy

Hormonal therapy works by either reducing or blocking the production of hormones that fuel the growth of cancer cells. It is often used as a supplementary treatment after surgery to reduce the likelihood of cancer returning. Most hormonal treatments aim to either lower estrogen levels or prevent estrogen from acting on the breast tissue, which helps control the disease.

Who should use it?

Hormonal therapy is most effective when the breast cancer cells have estrogen receptors (ER). Approximately 70% of breast cancers are estrogen receptor-positive (ER-positive), meaning these cancers rely on estrogen for growth.

The type of hormonal therapy prescribed will depend on the patient's menopausal status, the risk of cancer recurrence, and the potential side effects of the medication.

How is it taken?

Hormonal therapy medications are available as pills or injections. Drugs like tamoxifen or aromatase inhibitors such as anastrozole are typically prescribed for a duration of 5 years or longer, depending on the patient's situation. Fulvestrant is given as a monthly injection.

Common drugs in this category include:

• Tamoxifen: A selective estrogen receptor modulator (SERM) that blocks estrogen receptors.
• Fulvestrant: An anti-estrogen that blocks and destroys estrogen receptors.
• Letrozole: An aromatase inhibitor that reduces estrogen levels by blocking its production.
• Megestrol: A progesterone-like drug that lowers progesterone levels in the body.

The side effects of hormonal therapy can vary depending on the specific drug, but common issues include hot flashes, sweating, irregular periods, reduced libido, vaginal dryness or discharge, nausea, joint pain, mood changes, and fatigue.

4. Targeted Therapy

Targeted therapy involves drugs designed to target specific genes, proteins, or other elements in the cancer cells that drive their growth and survival. Unlike chemotherapy, which affects both cancerous and healthy cells, targeted therapy works more precisely, minimizing damage to healthy tissue. Your doctor may perform tests to identify the specific targets of your cancer before starting this treatment.

Hormonal therapies were among the first targeted therapies approved for breast cancer. More recently, HER2-targeted therapies have been approved for treating HER2-positive breast cancer. HER2 is a gene involved in the development of certain breast cancers.

When is targeted therapy recommended?

• Before surgery, to reduce the size of the tumor
• After surgery, to lower the risk of recurrence
• For metastatic breast cancer (when cancer has spread to other parts of the body)
• If cancer recurs

Examples of targeted therapy drugs include:

• Trastuzumab: Approved for non-metastatic HER2-positive breast cancer.
• Pertuzumab: Used with trastuzumab and chemotherapy for HER2-positive breast cancer.
• Pertuzumab, trastuzumab, and hyaluronidase-zzxf: Approved for early-stage HER2-positive breast cancer.
• Neratinib: Used for higher-risk HER2-positive, early-stage breast cancer.
• Alpelisib: Prescribed for hormone receptor-positive, HER2-negative metastatic breast cancer, in combination with fulvestrant.

The side effects of targeted therapy can depend on the specific drug, dosage, the patient’s overall health, and any additional medications used alongside it. Common side effects include nausea, shortness of breath, allergic reactions, fatigue, diarrhea or constipation, body aches, hot flashes, muscle spasms, soreness, and loss of appetite.

5. Immunotherapy

Immunotherapy is a treatment that boosts the immune system’s ability to fight cancer cells. This method uses substances, either naturally produced by the body or synthesized in the form of medications, to:

• Slow down or stop the growth of cancer cells
• Prevent cancer from spreading to other parts of the body
• Help the body’s immune system identify and destroy cancer cells

Approved immunotherapy drugs for treating breast cancer include:

• Pembrolizumab
• Atezolizumab
• Pertuzumab

How does it work?

T-cells are immune cells in the body that identify and fight infections. These cells examine proteins on the surface of cells. If these proteins signal that the cell is healthy, the T-cells leave it alone. However, if the proteins indicate that the cell is abnormal or cancerous, T-cells will target and destroy the cell. Immune checkpoints are specialized proteins that protect healthy cells. Immunotherapy drugs focus on these checkpoints to help the immune system detect and attack cancerous cells.

Immunotherapy is a relatively new approach and has not been studied as extensively as treatments like surgery, chemotherapy, radiation, or hormonal therapy. However, research shows that targeting specific proteins with these medications could also lead to the immune system attacking healthy cells, potentially affecting vital organs such as the lungs, liver, pancreas, kidneys, and intestines.

6. Surgery

Several surgical treatments are commonly used for breast cancer, including:

1. Mastectomy

Mastectomy involves the complete removal of the breast, unlike lumpectomy, which only removes the tumor. The decision to opt for a mastectomy or lumpectomy depends on the type and stage of the cancer. A mastectomy may be recommended if:

• The tumor is large, especially in a small breast
• The tumor is located centrally in the breast
• There are multiple cancerous areas in the breast
• There is a large area of ductal carcinoma in situ (DCIS)
• The patient has previously undergone breast radiation

The type of mastectomy surgery may vary based on the size and location of the tumor, and whether breast reconstruction is planned. In a simple mastectomy, a scar typically extends across the chest and into the armpit. Breast reconstruction can be performed either immediately following the mastectomy or at a later time.

In some cases, women at high risk of breast cancer may choose to undergo prophylactic mastectomy, a preventive surgery to remove the breast tissue and reduce the risk of developing cancer.

2. Breast-Conserving Surgery (Lumpectomy)

Also known as lumpectomy, this procedure involves the removal of the tumor and a small margin of surrounding healthy tissue. While it is technically a partial mastectomy, it preserves most of the breast.

Prior to surgery, the surgeon or nurse may mark the area where the incision will be made. After the tumor is excised, the entire breast may be treated with radiation therapy. The surgery typically lasts between 15 to 40 minutes.

After the procedure, patients are advised to rest at home, follow instructions for medication, care for the surgical site, perform exercises to maintain arm mobility, and report any signs of infection to the doctor. Follow-up appointments are essential to monitor for any recurrence of cancer.

3. Breast Reconstruction Surgery

Breast reconstruction is considered by women who have undergone a mastectomy or lumpectomy. This surgical procedure aims to rebuild the breast. There are two main techniques:

• Implant reconstruction: A breast implant, filled with saline or silicone gel, is inserted to restore the shape of the breast.
• Autologous or "flap" reconstruction: Tissue from another part of the body, such as the abdomen, thigh, or back, is used to recreate the breast.

In addition to reconstruction, some women opt for a breast prosthesis, which comes in various shapes, sizes, and materials like silicone gel, foam, or fiberfill. Common options include lightweight models (foam or polyfill) and silicone prostheses, which offer a more realistic appearance and feel.

Note:The outlook for breast cancer depends on several factors, including:

• The stage of cancer (tumor size and lymph node involvement)
• The presence of certain proteins, such as estrogen and progesterone receptors (ER and PR) and HER2
• Whether the woman is premenopausal or postmenopausal

Regular screenings, including mammograms, are crucial for early detection of breast cancer.

If breast cancer is left untreated over time, it can become life-threatening. In cases of metastatic breast cancer, the cancer can spread to other parts of the body, particularly the lungs, a condition known as lung metastasis. Often, this does not show symptoms and may only be detected through a chest CT scan.

That’s why it’s crucial to consult a doctor if you notice any symptoms of breast cancer. Early diagnosis significantly improves the chances of successful treatment. Thanks to advancements in breast cancer treatments, there is now greater hope for those affected. The good news is that if caught early, breast cancer can often be cured.

As women age, certain natural changes occur in the breast, but it’s essential not to overlook these changes, as they could signal the presence of underlying breast cancer. This is why women over 25 years old or those with a family history of breast cancer are advised to perform regular self-breast examinations. Early detection through such exams can reveal changes that might otherwise go unnoticed.

In addition to following your prescribed treatment plan, such as chemotherapy and radiation, here are some key lifestyle tips to consider:

• Consume foods rich in antioxidants to help your body combat free radicals.
• Avoid processed and fatty foods.
• Maintain a healthy weight, as obesity is a known risk factor for breast cancer.
• Engage in daily physical activity to stay strong and energized.
• Manage stress levels to reduce its impact on your health.
• Strengthen your immune system to help protect against various illnesses.
• Quit smoking and limit alcohol consumption, as both increase the risk of breast cancer.

The impact of breast cancer on daily life varies based on the stage of the disease and the treatment received. How a woman manages her diagnosis and treatment will differ from person to person, but there are several forms of support that can help.

• Lean on your friends and family for support—they can be your biggest source of strength.
• Connect with others facing similar challenges and prioritize time for yourself. Engage in activities that promote physical and emotional well-being.
• Fatigue and weakness are common during treatment, but gentle exercise can help alleviate symptoms and improve your energy levels. Avoid overexertion when your body feels drained.
• The physical changes from breast cancer treatment, such as changes in breast shape or surgical scars, can affect self-esteem. Joining support groups and engaging in uplifting activities can help improve your mental outlook.
• You may find it beneficial to talk to a counselor or therapist who can offer professional advice and help address any post-treatment concerns. Having a clear understanding of your condition and treatment can provide reassurance and confidence.

Recovery and Follow-Up After Treatment

For many women who undergo breast cancer surgery, returning to normal life may take time. During recovery, it’s important to avoid heavy lifting or strenuous household tasks. Regular follow-up appointments are essential after treatment. These should include routine blood tests and mammograms to monitor for any recurrence of the disease.