Breast Cancer is one of the most distressing illnesses a woman can experience. A silent stalker whose origins and cure remains elusive despite research worldwide, the most effective tool to prevent it is healthy diets and lifestyles. Latest data indicates that 25% of all cancers in Sri Lanka are breast cancers. While better and readily available diagnostic facilities are now available, many women unfortunately get treatment only when the disease has already reached an advanced stage.
Consultant Oncologist,National Cancer Institute, Maharagama, Dr. Prasad Abeysinghe discusses how breast cancer can be nipped in its budding stage or prevented from developing in a woman from early age in this interview with the Sunday Observer.
Excerpts…
Q. October is breast cancer awareness month. Why is an entire month set aside for breast cancer awareness?
A. The Breast Cancer Awareness Month observed every October, aims at increasing attention and raising awareness on early detection, treatment and palliative care of this disease. This is because breast cancer is by far the most common cancer in women worldwide. Early detection of the disease remains the cornerstone of breast cancer control, and if detected early, there is a good chance of cure. Unfortunately, many breast cancers are diagnosed in late stages mainly due to lack of awareness and barriers to health services.
Q. According to latest data, 25% (¼) of all cancers in Sri Lanka are breast cancers with 3,000 to 3,500 new cases detected every year. Is this correct? Why?
A. Yes. It is the commonest cancer in Sri Lanka. We have seen an increasing incidence of breast cancer among Lankan women over the last two decades due to increase in life expectancy, urbanization and adoption of western lifestyles. Better and readily available diagnostic facilities and improved cancer registration may have partly contributed to this rise.
Q.Tell us what breast cancer is in simple language.
A. Breast cancer starts when cells in the breast begin to grow out of control. These cells then grow into surrounding tissues and spread to distant areas of the body.
Q. What causes it?
A. There are Breast Cancer risk factors you cannot change such as being a woman (men also can get breast cancer rarely), getting older, inheriting certain gene changes such as BRCA1 and BRCA2, having a family or personal history of breast cancer, having certain atypical benign breast conditions, starting menstrual periods early and going through menopause after age 55. There are Lifestyle-related Breast Cancer risk factors such as drinking alcohol, being overweight or obese, not being physically active, not having children, not breastfeeding, hormone therapy after menopause and breast implants
Q. Are there different types of breast cancers?
A. The type of breast cancer is determined by the specific cells in the breast that are affected. Most cancers start in the milk ducts or the milk-producing glands of the breast and are called adenocarcinomas. Among them are several sub types depending on the presence or absence of specific receptors on cell surface such as Oestrogen, Progesterone and HER2. Earliest form when breast cancers have not spread to surrounding tissue are called In situ Carcinomas. Other uncommon types are Angiosarcomas, Phyllodes tumour, Paget disease of the nipple and Lymphomas.
Q. How is breast cancer identified ?
A. Women should be familiar with how their breasts normally look and feel and report any changes to a doctor straight away. Women with symptoms such as swelling of all or part of a breast, skin irritation or dimpling, breast or nipple pain, nipple turning inward, redness, scaliness, or thickening of the nipple or breast skin, abnormal nipple discharge, a lump or swelling under the arm or around the collar bone should undergo imaging testing such as Mammograms and Breast Ultrasound followed by a fine needle biopsy or preferably core needle biopsy.
Q. Can scans help the Oncologist to identify which type of breast cancer she has?
A. Though scans can say how big a cancer is, only a core needle biopsy can determine the type of cancer.
Q. Is the size of the lump important in relation to treatment?
A. Size will determine whether a breast conserving approach is possible, whether only the tumour is removed with a margin, or whether the whole breast need to be removed along with the lymph gland in the armpit.
If it is too big to be removed by surgery, initial treatment with chemotherapy injections will be commenced to shrink the tumour.
Q. If a woman has a malignant lump on one breast, will it spread to the other breast as well?
A. If untreated the lump can spread through the skin to the opposite side. Women having a cancer on one side of the breast are more prone to have another one in the opposite breast.
Q. Can the same cells spread to other parts of the body through the lymph glands?
A. Breast cancer initially spreads to the surrounding breast tissue and lymph glands. They can also spread to other organs such as bones, liver, lung and brain if left untreated.
Q. What advice would you give to prevent the cells from spreading?
A. We recommend two yearly mammograms on the unaffected breast for breast cancer survivors.
Q. In some cases using advanced technology, oncologists are now able to prevent the onset of cancer by destroying pre-cancerous cells discovered in a woman’s breast during a routine mammogram. Tell us more about this technology which offers new hope to women who are afraid they could inherit cancer from closely related victims.
A. If a mutation in the BRCA1 or BRCA2 gene is found in a woman which put her at very high risk of breast cancer, a prophylactic surgery can be offered to remove one or both breasts to lower the chances of getting breast cancer. Patients in earliest forms of in situ cancers are also offered similar surgical or radiotherapy options. Other experimental treatments such as cryotherapy cannot be recommended
Q. Are there different stages in the progress of breast cancer? What are they?
A. There are four stages. Stage one is being confined to a small area of breast and Stage four being spread to other areas of the body. Stage two and three are in between these two extremes.
Q. Treatment wise, what are the options?
A. Some treatments are local - usually surgery and radiotherapy, and treat the tumour without affecting the rest of the body. Chemotherapy drugs used to treat breast cancer are considered systemic therapies because they can reach cancer cells almost anywhere in the body.
They can be given by mouth or put directly into the bloodstream. The sequence of these treatments is carefully discussed among surgeons and oncologists. Some locally advanced breast cancers as well as breast cancers with no specific receptors on cell surface (Triple negative) will be treated with systemic therapies to shrink them down before surgery.
Q. Does treatment depend on the stage of the cancer, patient’s health status and age?
A. Yes, Treatment for stages I to III breast cancer usually includes surgery and radiation therapy, often along with chemo or other drug therapies either before or after surgery. Treatment for stage IV breast cancer is usually a systemic (drug) therapy.
The more the breast cancer has spread, the more treatment you would likely need. But other factors could also be important, such as: If the cancer cells contain Oestrogen, Progesterone receptors or HER2, the overall health and personal preferences, whether gone through menopause or not, how fast the cancer is growing, etc.
Q. Radiation or chemotherapy – what is the difference?
A. Radiotherapy is a local treatment whereas chemotherapy can reach anywhere in the body.
Q. How do surgeons decide on which type is best for the patient?
A. Surgeons decide the extent of surgery depending on the size, site of the tumour, patient’s health and preference.
They need to find out whether the cancer has spread to the lymph nodes under the arm (sentinel lymph node biopsy). Lymph nodes will be removed if they are affected.
Q. Does she have to be on medication thereafter? If so for how long?
A. Women with breast cancers containing Oestrogen, Progesterone receptors will receive oral anti oestrogen medications for up to 10 years.
Q. Can a breast cancer patient return to her normal life?
A. The aim of our treatment is to achieve a holistic cure i.e. physical, functional and psychosocial. By avoiding excessive mutilating surgery, by using chemotherapy in an appropriate manner, by rehabilitating the functional deficiencies and with proper psychological counselling, most women return to normal life.
Q. According to studies ideally a breast cancer survivor should keep her weight down which would vary according to her height. What is the recommended weight according to height? Is there a chart ( BMI index) ?
A. BMI is calculated by dividing your weight in Kgs by the square of your height in metres. Ideally, it should be kept below 25kg/m2
Q. As you mentioned breast cancer is one of the most preventable cancers. Give us some simple exercises women can do to detect early symptoms.
A. Stand in front of a mirror arms by the sides, arms pressed on the waist, arms lifted above the head and inspect the breasts for changes in shape, skin dimpling and colour changes, nipple changes and lumps. Palpate the breast using the flat surface of the three middle fingers on opposite side in a circular manner applying gradual pressure for any lumps. Then examine the armpit and look for nipple discharges by squeezing.
Any abnormality detected should be immediately reported to a doctor. However, it is important to note that all the changes in the breast are not cancerous.
We recommend that all women above 20 years do a monthly breast self-examination preferably one week after the start of menstruation or a fixed date every month if post-menopausal.