Patients with breast cancer commonly present with:
- breast lump
- retracted nipple
- lymph node swelling in the axilla (armpits)
- ulcerated swelling on the breast
- redness & inflammation of the breast
- nipple discharge which can be blood or mucous
- incidental finding on screening by mammogram
95% of breast cancer occur sporadically while only 5% are due to genetic factors. The genes which are implicated in breast cancer are BRCA-1 and BRCA-2. Patients with BRCA genes have a 50% lifetime risk of breast cancer and a 30% risk of getting a breast cancer on the opposite breast. Women with BRCA-1 also have a 30% risk of getting ovarian cancer.
Other genetic syndromes associated with breast cancer are:
- Li Fraumeni syndrome which includes brain tumours, sarcomas and leukaemias
- Cowden syndrome which includes thyroid tumours and skin lesions
- Peutz-Jaghers syndrome which includes gastro-intestinal tract polyps, pigmentation of the lips and increased risk of gastro-intestinal cancers.
To confirm the diagnosis of breast cancer, 'Triple Assesment' is recommended. This includes:
- breast examination by the doctor
- tissue biopsy with Fine Needle Aspiration Cytology (FNAC) or Core Biopsy
- radiological investigations with a Mammogram or Ultrasound or MRI
Mammogram
Patients with strong family history of breast cancer should undergo genetic testing for BRCA-1 and BRCA-2 genes.
Once the diagnosis of breast cancer is confirmed, a patient is counselled on her diagnosis and the plan of management. The management will depend on the stage of the cancer, type of cancer (DCIS vs Invasive Ductal/Lobular Cancer) and patient's Estrogen/Progestrone Receptor (ER/PR) status.
For patients with non-metastatic (have not spread beyond the breast) cancer, the initial treatment is mastectomy (breast removing surgery) with removal of lymph nodes. The indications for mastectomy are:
- Invasive breast cancer more than 3cm
- multifocal DCIS
- patients with recurrent cancer after breast conserving surgery
- young patients who have a high risk of cancer recurrence (BRCA carriers)
- old patients who do not want to undergo further surgery
- male patients with breast cancer
Patients with DCIS (ductal carcinoma in situ) or Invasive breast cancer less than 3cm can undergo Breast Conserving Surgery (BCS) with post-operative radiotherapy. However, there is a 10% chance that further surgery might be required with BCS.
Removal of lymph node is needed for control of loco-regional disease and for more accurate staging of the disease. A few techniques commonly used are lymph node dissection or sampling or Sentinel Lymph Node Biopsy.
Post mastectomy, if the patient has got lymph node involvement or the tumour is bigger than 1.5cm, it is necessary for the patient to undergo chemotherapy which will further destroy the cancer cells in the body. The common regime used is a combination of 5-FluoroUracil, Epirubicin and Cyclophosphamide.
Patients who have ER/PR positive should be started on Tamoxifen tablets (20mg daily) which will reduce the level of estrogen in the body and reduce the risk of recurrence of the cancer. Post menopausal patients can be started on aromatase inhibitors such as anastrozole or letrozole which also reduces estrogen levels.
Patients who are HER-2 (human epidermal growth factor receptor-2) positive can be started on trastuzumab which is shown to improve disease free survival. However, this drug is contraindicated in women with heart failure.
Patients with locally advanced breast cancer (size more than 5cm or with involvement of chest wall or skin) should undergo pre-operative chemotherapy to reduce the size of the cancer. The regime is the same as the post-operative one or a taxane based (docetaxel) chemotherapy can also be used.
Post-mastectomy, patients who are keen for reconstruction of their breast should be referred to a Plastic Surgeon for reconstructive surgery. The breast can be reconstructed with the patients own muscles and skin (free or pedicled flap reconstruction) or with a prosthetic breast implant.
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