Friday, March 9, 2012

Breast Cancer | SKMH

Breast Cancer

Dr. Neelam Siddiqui
Consultant Medical Oncologist (Shaukat Khanum Memorial Cancer Hospital & Research Centre)

Breast Cancer poses a serious health risk for women throughout the world. More than one million women world wide are diagnosed with breast cancer every year. It is estimated that 1 in 9 Pakistani women will develop breast cancer at some stage of their life.  In developed countries there are national cancer registries where every newly diagnosed cancer patient is registered. This is very helpful to understand the epidemiology and causative factors of cancer. In Pakistan we do not have such a registry at national level. Several studies and reports suggest that among Asian population, Pakistani women have the highest risk of breast cancer (after non-Arab Israeli women).

Breast cancer is a disease which results from the interaction of different environmental and inherited risk factors. With the development of new technology by which DNA of cancer cells can be studied closely, our understanding of the biology and genetics of breast cancer has greatly improved. With this knowledge therapies for breast cancer are coming onto the market, which have given a new lease of life to these patients. Since the early 1990’s death rates from breast cancer have decreased by approximately 25% in the USA and Europe.  This has been possible mostly due to screening mammography and continuously improving treatment strategies utilizing chemotherapy, hormone therapy and more recently targeted therapy.

 While the prognosis of breast cancer has improved over the years, the exact cause of breast cancer still remains unknown.  However certain risk factors have been identified. The following factors are known to increase the chances of development of breast cancer.

Female gender and increasing age: As a woman grows older her risk of developing breast cancer increases. 

Hormonal factors: Early age of onset of menstruation and late menopause are associated with an increased risk of breast cancer. Women who do not have children or have their first child after the age of 30 are also at an increased risk. Prolonged hormone therapy is an additional risk factor.

Benign breast disease: Women who have had non-cancerous lumps in the breasts are also at higher risk of getting breast cancer compared to those women who have never had any breast problems.

Diet and Obesity: New studies indicate that obesity increases the chances of breast cancer and breast cancer related death.  Women who gain weight in adult life before menopause are at increased risk of developing breast cancer. It has been observed that high fat intake can increase the risk of breast cancer while high vegetable consumption may give protection against breast cancer development.

Family history: This plays an important role in breast cancer. Familial susceptibility to breast cancer accounts for approximately 25 % of all breast cancer cases. Among the breast cancer genes that have been identified, two are worth mentioning. These genes are called breast cancer 1 (BRCA1) and breast cancer 2 (BRCA 2) genes.  Alterations in these genes are associated with a significantly increased risk of breast and ovarian cancer. A woman who has two or more first degree relatives with breast or ovarian cancer (especially before the age of 50), may be carrying the BRCA1 or 2 gene.  These women could benefit from screening, risk assessment, genetic counseling, gene testing and appropriate medical interventions.

The outcome and prognosis of breast cancer is directly linked to the stage at which a woman is diagnosed with breast cancer.  It is difficult to prevent breast cancer, but one can try to detect it early. In this context, all women of reproductive age should conduct monthly breast self-examination while those over 40 should have an annual clinical breast examination and an annual mammogram. Development of a breast lump or skin and nipple changes are some common signs of breast cancer and warrant an urgent visit to the doctor.

During October all over the world breast cancer awareness campaigns are being conducted. In Pakistan we need to develop breast cancer prevention and screening strategies. There is a dire need for creation of more effective treatment which is easily available to all classes of society. Aspiration towards excellence should be the goal of every physician. We in the medical community need to step forward to fight against breast cancer by establishing  a national breast cancer control programme to reduce the risk of developing breast cancer. We should aim to detect breast cancer as early as possible and to offer the best treatment and support for our breast cancer patients.

Breast cancer signs and symptoms

Dr. Amina Khan
Consultant Surgical Oncologist
(Shaukat Khanum Memorial Cancer Hospital & Research Centre)

Breast cancer is the most common malignancy encountered by the woman of today. It is a disease process which is not restricted to any age; it spares no race color or creed. According to statistical estimates every 1 in 8 to 1 in 15 women will be diagnosed with breast cancer during their lifetime.

Every woman’s risk is different and depends on a combination of factors, some of which are alterable. Age, race, gender, geographic location, family history, age of menarche and age of menopause are factors that are non modifiable. However women should try and avoid risk factors that are within their control; avoid late first birth of their child, have more than one baby, breast feed all children, avoid hormone replacement therapy, avoid smoking and alcohol use.

In contradiction to common misconceptions breast cancer generally carries a good prognosis and is treatable in most cases. The key to successful treatment is early detection and prompt medical attention. The international cancer community has devised guidelines to help in this regard – women are divided into 2 groups based on age - <40 and above 40 years.
* All women should learn proper breast self examination and perform it regularly once every month.
* All women need a baseline mammogram at the age of 40 years
* Follow up screening mammograms should be done annually after the baseline study
* Any new finding on breast self examination or mammography needs to be reported to a physician and investigated further

Important findings on self examination that need further evaluation include

* A new area of thickening in the breast or a new breast lump
* A lump in the axilla / arm pit area
* Nipple distortion
* Bloody nipple discharge
* Skin retraction or dimpling
* Fixation of skin to an underlying lump
* Skin redness
* Skin thickening especially around the nipple area
* Feeling of warmth over an area of skin which is already thickened and red
* Skin ulcer or blister that does not heal
* Skin rash over the breast especially around the nipple with lesions that do not heal
* Pain in the breast that travels to the arm pit and along the arm and neck

Treatment of Breast Cancer

Dr. Narjis Muzaffar
Diplomate American Board of Medical Oncology                            
Consultant Medical Oncologist, (Shaukat Khanum Memorial Cancer Hospital & Research Centre)

There are different types of treatments available for patients with breast cancer. In recent years, there has been on explosion of new life saving treatments for this cancer. Treatment includes surgery and radiation therapy which are localized treatments and chemotherapy and hormonal therapy which are systemic treatments. Both chemotherapy and hormonal therapy  go to many parts of the body, the purpose of which is to kill any cancer cell that may have spread  from the breast.
The most recent addition to breast cancer treatment is called  targeted therapy.
Clinical trials are also offered to patients which test new drugs. Patients are encouraged to take part in these clinical trials which will help not only in their treatment but also other women with breast cancer and will help future generations. No one treatment plan fits every woman diagnosed with breast cancer.  The choice of treatment is determined by many factors including age, menopausal  status, stage of the tumour, hormone receptor status and Her 2 Neu receptor status of the tumor.

Surgery is generally offered at the onset. The extent of surgery will be determined by many factors such as the size of the tumor and its location in the breast.  The patient’s surgeon will best guide her in making the right decision for the type of surgery. Surgery can be total removal of the breast, called mastectomy, or removal of the lump only, called lumpectomy.

Breast reconstruction is the rebuilding of the breast after mastectomy or lumpectomy.
This can be done at the time of the initial surgery or later.
Many women decide not to have reconstruction and opt for a prosthesis.

If the tumor is large or if the woman wants to conserve her breast chemotherapy or hormonal therapy can be offered before surgery which can shrink the tumor and  help the surgeon in getting clear margins after a mastectomy or help in breast conservation.

The type of chemotherapy used can vary from patient to patient. There are many highly effective treatment plans that can vary in duration, number of drugs used and dosage. Results of clinical trials done in thousands of women from all over the world help the medical oncologist on deciding for a specific treatment for each individual.

The side effects of chemotherapy can be managed through supportive care and lifestyle changes. Older women in otherwise good health can also benefit from chemotherapy in the same ways as younger women.

Hormonal therapy blocks the ability of the female hormones  estrogen and progesterone to stimulate the growth of cancer cells. These drugs will only work if the woman’s cancer cells show presence of these receptors.

Radiation therapy is limited to one area and is generally well tolerated. Side effects of radiation are also limited to the area being treated. It is a highly effective way of killing cancer cells in the breast or chest wall that may persist after surgery.

Targeted therapies for example the drug Herceptin, target specific characters of cancer cells such as proteins. These proteins allow cancer cells to grow in an abnormal way. These drugs are generally well tolerated.
At SKMCH&RC state of the art treatment is offered to patients with breast cancer.




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