Breast cancer: symptoms and treatments of breast cancer.

INTRODUCTION

Breast cancer commonly afflicts women above the age of 50 years and is a disease seen in
1 out of 7 women is western countries. It is showing a rising incidence in India, mainly in cities
like Bombay and Delhi. Breast cancer is the second most common cancer in Indian females,
cancer of cervix being number one (described in unit 3 of this block). Early menarche, lesser
pregnancies or nulliparity and urbanised lifestyle are known actiological factors. The risk is
high if mother and sister are affected by breast cancer.

Clinical Features

The most prevalent symptom is a woman experiencing painless lymph in her breast. However, by the time this is felt, the lump has grown to be 2-3 cm in size. There may be axillary swelling (enlarged lymph node) or nipple retraction/discharge. Dimpling or retraction of the skin above the lump site can be observed. When breast cancer is advanced (as is common in India), there is a large mass in the breast with skin fungus, fixity of the mass to the skin/underlying chest wall, multiple lymph nodes in the axilla/supraclavicular area, inflammation of the entire breast, bone pain (due to metastasis), and liver/lung/other organ metastatic spread.

In summary, the clinical findings are as follows:

(1) Breast lump.

(2) Nipple discharge/retraction.

(3) Breast inflammation.

(4) Axillary swelling.

(5) Symptoms related to metastasis spreads to bone, liver/lung, and other organ sites.
When breast cancer is suspected, a doctor should carefully analyze and record all of these signs in a woman.

Investigations

The research for breast cancer is separated into two parts:

(a) Breast cancer screening.

(b) Breast cancer diagnostic test.


a) Screening: Breast cancer screening is frequent in Western countries. Some of these techniques may be useful in India. Women should be urged to follow the following rules:

  1. Breast self-examination (BSE) in standing and lying down postures, at least once a month, for women over the age of 25.
  2. A physical examination (PE) of the breasts by an experienced doctor between the ages of 20 and 40, at least every three years.
  3. A woman over the age of 50 should have screening mammography at least three times before the age of 60.
  4. Woman who has mother, sister or other relative diagnosed with breast cancer should
    routinely undertake BSE and PE.

b) Diagnostic Tests:

Breast cancer diagnostic tests are carefully performed in order to determine the extent of the disease and establish treatment solutions. The following tests are required:

1) Physical examination by a doctor as described in clinical features.

2) Fine needle aspiration cytology of a mass in the breast/axilla.

3) Breast biopsy (if FNAC is inconclusive).

4) Chest X-ray and abdominal ultrasound.

c) Optional Tests


1) Mammography of both breasts.
2) Radio-isotope Bone Scan.
3) Molecular markers and oncogenes.

Staging of Breast Cancer

The pathology diagnosis and stage are used to make a treatment decision. The UICC/AJC cancer staging system (1997) based on TNM classifications is the most extensively utilized.
This is detailed further below:
TNM breast cancer staging system in 1997

I) Primary Tumour (T)

Definition: The clinical and pathologic classifications of the main tumor are the same.
TX The primary tumor cannot be evaluated.
T0 There is no evidence of a primary tumor.
In situ carcinoma: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor (Paget’s disease with a tumor is classified based on tumor size).


T1 Tumor with a maximum size of 2.0 cm or less


TIa 0.5 cm or less TIb greater than 0.5 cm but less than 1.0 cm


TIc greater than 1.0 cm but less than 2.0 cm


T2 Tumor >2.0 cm in maximum diameter but less than 5.0 cm


T3 Tumor with a maximum diameter of more than 5.0 cm

Any size T4 tumor with direct extension to the chest wall or skin
T4a Chest wall extension

T4b Edema (including peau d’ orange) or ulceration of breast skin or satellite skin nodules localized to the same breast.


T4c T4a, T4b, and T4d Inflammatory carcinoma (breast skin induration with an erysipeloid margin, usually without an underlying palpable tumor).

II) Regional Lymph Nodes (N)

NX Regional nodes cannot be evaluated (e.g., they were previously removed or no information about them is available).
NO There are no metastases.
N1 Metastases in ipsilateral moveable axillary lymph node(s)
N2 Metastases in ipsilateral axillary lymph node(s) that are attached to one another or to other structures
N3 ipsilateral internal mammary lymph node(s) metastasis

III) Distant Metastasis (M)

MX Cannot be assessed
MO None
M1 Distant metastasis present (includes metastasis to Histopathologic grade (G)

Treatment and Results

EBC: Breast conserving treatment (BCT) is recommended in women with a tumor size of less than 4 cm and no palpable axillary node. BCT surgery consists of a lumpectomy followed by radiation therapy to the whole breast, with or without irradiation to the ipsilateral axilla.
Patients with a bigger lump, axillary nodes, or who refuse BCT should have a conventional mastectomy followed by adjuvant postoperative radiation. Chemotherapy is recommended for patients with tumors larger than 1cm in size and/or node positivity. CMF (cyclophosphamide, methotrexate, 50fluorouracil) or FAC (5-fluorouracil, adriamycin, cyclophosphamide) are common first-line regimens. Tamoxifen, a monsteroidal anti-oestrogen, is currently suggested as adjuvant hormone therapy for estrogen-receptor status positive women and postmenopausal women. The 5-year survival for stage I is 80% and it is above 60% for
stage II, with properly selected treatments.

LABC: Surgery, chemotherapy, radiation therapy, and other modalities are used in multimodal therapy. It is now the standard of care in LABC, and is frequently used in conjunction with tamoxifen. In India, over half of all breast cancer patients are in this stage. Obviously, such multimodal practice will be beneficial. Be pricey and will require extensive treatment course. The patient’s cooperation is required. Patients who are resectable are first treated with modified radical mastemy, then adjuvant chemotherapy and postoperative locoregional radiation (LRRT). LRRT is required to improve locoregional control as well as overall survival. Patients who are considered advanced and inoperable at the outset will get induction chemotherapy–typically 2-3 cycles of FAC regimen. After induction chemotherapy, around 50-70% of patients are operable. Following surgery, the patient receives post-operative LRRT, followed by further chemotherapy and hormone therapy. A close follow-up, at least every three months, is required because more than half of treated patients are likely to have locoregional recurrence or distant metastases. The total 5-year survival rate for LABC is 35-50%.

MBC: Individualized treatment for metastatic cancer is available. Metastasis frequently affects the supraclavicular nodes, bones, liver, lungs, and CNS. When a patient has a locoregional tumor burden (breast lump less than 7 cm, few axillary lymphnodes) and one or two metastatic sites, the prognosis is good, with a 2-year survival rate. Otherwise, the average survival time for patients with widespread disease is less than a year. In general, the treatment will include surgery such as a toilet mastectomy. Palliative radiation therapy is administered to the breast tumor and lymph node locations. If the patient’s overall health allows, chemo and hormone therapy are added. Chemo-hormone therapy is anticipated to improve the quality of life in 15-20% of these individuals. However, cautious decision-making is required to ensure that the patient does not experience adverse chemotherapy-related toxicities.

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