Breast Cancer

Yumnam Samita Devi *

1: Introduction to cancer : Cancer is a disease caused by the abnormal growth of the cells. It is generally presented in the form of Lump. This cells has the potential to grow uncontrollably and invade the nearby structure , organs and nodes. Sometimes its character is very difficult to identify in the beginning of the disease and generally manifested when the disease becomes more aggressive. Many at time patient gets wrong treatment due to poor differentiation.

Types of tumor : 1. Benign tumor – Non Cancerous and 2. Malignant tumor – Cancerous

2: Signs and symptoms of cancer :

2.1: Seven warning signs of cancer : Since the manifestation of the cancer symptoms are generally late, we can always alert ourself with the knowledge of C-A-U-T-I-O-N – seven warning signs of cancer.
C – Change in bowel and bladder pattern;
A – A sore that does not heal;
U – Unusual bleeding or discharge;
T – Thickening or lump in breast or elsewhere;
I – Indigestion;
O – Obvious change in size, color, shape or thickness of a wart, mole or mouth sore and
N – Nagging cough or hoarseness of voice.

2.2: Other signs and symptoms that may be associated with cancer or may not be, but should not be neglected :

1. Blood in cough;
2. Blood in sputum;
3. Blood in urine;
4. Blood in stool;
5. Lump in breast;
6. Unexplained weight loss;
7. Loss of Appetite;
8. Unexplained fatigue/ tiredness;
9. Persistent headache;
10. Nausea and vomiting for no specific reason;
11. Low grade fever constantly or intermittently;
12. Heavy night sweats;
13. Problems in urination;
14. – Fowl smell vaginal discharge;
15. Back pain constantly or intermittently prolong menstruation period;
16. Unexplained body pain or ache more than 4 weeks;
17. Changes in skin – new mole that increases in size 7mm, irregular shape, itching, crust and bleeding (may be normal, but can also be melanoma)

3: What is Breast Cancer ?

Breast Cancer is an uncontrolled growth of the breast cells, which may be due to normal mutations or abnormal changes of the cells, as a result a lump or a tumor is formed in the breast. The tumor may be Benign or Malignant. Benign tumor are non-cancerous, and may not require treatment, but require follow up and observation. Malignant tumor are cancerous and need immediate treatment.

4: Signs and symptoms of Breast Cancer :

1. Painless lump in breast;
2. Lump in Axilla;
3. Breast pain;
4. Skin changes (Ulceration, redness, nodules, Peau d’Orange skin) and
5. Nipple (Discharge, inverted, Eczema and retraction)

5: Screening, investigation and diagnosis and monitoring test :

5.1: Screening protocols : Test done to rule out any lump or changes in breast which can be a matter of suspected cancer
Puberty to 30’s – Breast Self Examination optional, Clinical breast exam every three years, as part of general physical and no mammogram
40 to 49 – Breast self exam optional, Clinical breast exam annually as part of general physically and Mammogram every year for patient with family history of breast and ovarian cancer)
50 to 74 – Breast self exam optional, Clinical breast exam annually, as part of general physical and Mammogram every year)
75 and above – Regular screening as long as an individual is in good health
Women of all ages – Breast self exam recommended, Clinical breast exam every 6-12 months, as part of general physical, Talk to your doctor for an individualized program.
You may benefit from starting screening earlier and using other screening tools, such as Ultrasonography, Mammogram and MRI

5.2: Investigation and diagnosis :

a) Breast Self Examinations (BSE);
b) Clinical Breast Examinations (CBE);
c) Ultrasonography (USG);
d) Mammography;
e) Fine Needle Aspiration (FNAC);
f) Core Biopsy;
g) Blood Test and
h) MRI and CT scan.

a) Breast Self Examinations (BSE) : BSE is one of the most effective way to catch the breast lump is an early stage. Individual should stand in front of a mirror and see both the breast and looks for visual signs of 1. Dimpling, 2. Swelling, 3. Redness and 4. Discharge.

Feel the breasts with the finger pads – The process covers the entire breast, including the “arm Pit” of each breast. Women that are not breastfeeding gently squeeze each nipple and check for any discharge.
1. Vertical strip pattern: Involves moving the fingers up and down over the breast.
2. Pie-wedge pattern: Starts at the nipple and moves outward.
3. Circular pattern : Involves moving the fingers in concentric circles from the nipple outward.

Ideal time of doing BSE: 1) Just after the end of menstruation because the breasts are likely to be less swollen.
2) Postmenopausal or have irregular cycles might do a self-exam once a month regardless of their menstrual cycle.

Steps of BSE :
Step 1: Stand in front of mirror with hands down looking at your breast.
Step 2: Now, raise your arms and look for the same changes.
Step 3: Stand in front of mirror with your shoulders straight and your arms on your hips

In Step 1, 2 & 3 Here’s what you should look for:
1. Breasts that are their usual size, shape, and color, 2. Breasts that are evenly shaped without visible distortion or swelling and 3. Dimpling, puckering, or bulging of the skin.
Step 4: Put one hands above head and examine your breast by the opposite hand.
Step 5: Squeeze your nipple and see for any discharge.
Step 6: Finally, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast.
Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter.

b) Clinical Breast Examinations( CBE) : It is done by health care providers who are well trained in this field (may be doctor or a nurse). This is one of the method of early detection of Breast Lump or cancer.
c) Ultrasonography Breast (USG) : USG is one of the method to identify breast lump or tumor. It is advisable in woman younger than 35 years who have dense breast tissue.
Mammography may give false in result due to thick and dense breast tissue and if there are full of milk glands .
This tool can be used for both the purpose 1. Screening and 2. Diagnostic.

Indications : 1. Age below 35 yrs.
2. Pregnant Mother.
3. Breast Feeding
4. Suspected rupture of Implants
d) Mammography : It is an X-Ray of Breast. Mammogram combine with USG gives better understanding of the disease.
This tool can be used for both the purpose 3. Screening and 4. Diagnostic.

e) Fine Needle Aspiration ( FNA) : FNAC is one of the biopsy technique. The health care provider use a small gauze needle to pierce the mass and withdraw the fluid and send for study.
This procedure is inferior in comparison with core biopsy. However in certain cases this works well, depending on the type of the tumor. e.g palpable tumor mostly cystic in content. A negative FNA does not rule out a Breast Cancer.

f) Core Biopsy : Core biopsy is much more definitive study in comparison with FNA. In this procedure the area is anesthetized with local anesthesia and a large gauze needle inserted into a spring loaded device the physician or the train nurse pulls the trigger on the device that directs the needle into the mass . One or multiple core can be obtained by repeating the procedure.

g) Blood Test : As per advice by doctor base on the presenting condition of the individual and associated disease
h) MRI and CT scan : Advice as per condition of the individual. Has a role in staging patient with proven.
These are very expensive diagnostic too just to rule out the breast cancer.
But helpful in staging of a new diagnosis case. Also useful in early detection of unknown cancer in breast.
Diagnosis of Breast Cancer rarely done in patient with metastasis disease to find a small focus of primary carcinoma in the breast

6: Staging of Breast Cancer :

Staging is the process of finding out how widely the cancer is spread when detected for the first time.
Staging is an important factor for choosing the right treatment and also to determine the prognosis. There are different stages of the Breast Cancer. Staging of Breast Cancer depends on the following criteria- Tumor, Lymph Node and spread to distant regions (metastasis).
1. Size of the Tumor, 2. Involvement of the Lymph Nodes and 3. Status of the spread of the disease so calls Metastasis.

7: Treatment and monitoring test, complications :

7.1 Treatment :
1. Surgery – for a Localized disease,
2. Chemotherapy – in all stages of the disease,
3. Radiotherapy – to control the local disease after surgery as well as to palliate painful disease,
4. Endocrine Therapy – when indicated and
5. Palliative- when the disease has spread and patient need to be comforted and relieved from pain.

7.2 Monitoring test : Monitoring test depends on the presenting condition of the patient at the time of follow up.
Following test may advise – 1. USG, 2. Mammogram, 3. CT, 4. MRI, 5. Bone Scan and 6. Blood Test.

7.3 Complications of the treatment : There are Short term and long term complications some of the common complications are 1. Pain, 2. Reduce movement of hand (generally shoulder joint), 3. Seroma Formation ( collection of fluids in Surgical site) and 4. Swelling of hand (Lymphedema)

8: High Risk Group For Breast Cancer :

1. Woman age between 30 to 70 years,
2. Early Menstruation,
3. Late or no pregnancy,
4. Menopause after 55 yr,
5. Dense Breast,
6. Personal history of Breast Cancer,
7. Family history of Breast Cancer,
8. Family Infrastructure,
9. Breast disease,
10. Physically inactive
11. Obesity,
12. Oral Contraceptives Pills,
13. Alcohol & Smoking,
14. Dietary Pattern and
15. Stress.