Breast Cancer

Breast cancer is the commonest cancer in women all over the world. The incidence is highest in women around the age of 40 - 60 years but it may also occur at any age. The lifetime risk of developing a breast cancer in a woman is 11%.

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.

Breast Lumps

Breast lumps are a common complaint among women. It constitutes about 60% of referrals to the breast specialist clinic. However, the good news is that up to 90% of breast lumps are non-cancerous. The common causes for breast lumps are: fibroadenomas, cysts, fibrocystic disease, lipomas, haematomas, abscesses and breast cancer.

Fibroadenomas are common in young women. It usually occurs in adolescence and up to early 30s. It is a benign (non-cancerous) condition and does not turn malignant (cancerous). A small fibroadenoma can be observed and treated conservatively while a palpable one can be surgically excised. The surgery is a minor one and takes less than 1 hour. It is usually done as a day case (no need for admission to hospital).

A breast cyst is a collection of fluid within the breast lobules. It usually occurs in premenopausal women. Clinically, smooth discrete lumps will be palpable. It is diagnosed by ultrasonography. The treatment of breast cyst is with simple aspiration of the cyst in the clinic.

Fibrocystic disease is the commonest cause of breast lumps. It consists of a spectrum of cysts, lobules and fibrous changes within the breast. Treatment is the same as for a fibroadenoma.

Lipomas are benign tumours which originate from fat cells. It presents as a soft, lobulated lump. Lipomas can also grow at other parts of our body as long as there are fat cells. The treatment of lipoma is surgical excision.

A haematoma is a collection of clotted blood. This is usually preceded by a history of trauma or occurs after a biopsy is taken from the breast.

An abscess is a localised collection of pus. This occurs more commonly in women who are diabetic or who are immunocompromised. It can also occur in an infected haematoma. A breast abscess can also form from an infection in the nipple. This condition usually occurs during breastfeeding (lactational mastitis). The treatment for breast abscess is antibiotics and aspiration of the abscess. If that does not work, a surgical drainage of the abscess would be necessary.

Breast cancers commonly occur in women aged 40 and above. The lifetime risk for a women to get breast cancer is 11%. Patients usually present with a breast lump, breast ulceration or incidentally detected on screening.

All patients with breast lumps should go through a triple assessment. This consists of:
- consultation and clinical examination by a doctor,
- radiological investigations (mammogram for women >40 years old and ultrasound for women <40),
- biopsy of the lump either with a Fine-Needle Aspiration Cytology (FNAC) or a core biopsy or with a surgical excision biopsy.

FNAC and core biopsies can be done in the clinic. A FNAC is a simple procedure where a needle is inserted into the breast lump and its cells are aspirated and sent for microscopic examination. The results will show if the lump is benign or malignant (cancerous).

A core biopsy is carried out with a bigger needle. It is called so because a core of tissue from the breast lump is taken out using the needle. This procedure is done in the clinic but local anaesthesia is usually given. There is a risk of bruising after the procedure. Core biopsies provide a piece (core) of tissue for histopathological examination. It can help determine if a lump is benign or malignant. It is also able to tell if the lump is an invasive cancer or early confined (in-situ) cancer. Hormonal receptor status of the lump can also be identified which will help in post-operative treatment of breast cancer.