Breast cancer

Symptoms Of Breast Cancer

Although breast cancer may not show symptoms in the early stage, there are certain changes that happen in the breast as you age. Knowing about these changes in the breast can help in the early detection and treatment of cancer.

Here are some of the common signs and symptoms of breast cancer every woman needs to be aware of:

• Presence of a lump in the breasts that feels different from the rest of the breast tissue

• Changes in the size, shape, or appearance of the breast

• Inverted, painful, or enlarged nipple

• Any discharge or bleeding from the nipple

• Skin dimpling or appearance of folds on breast skin

• Pain around the breast/s

• Swollen lymph nodes (in underarms and around the collarbone) may indicate that the cancer has spread.

Watch the video to know more about the symptoms and stages of breast cancer explained by our expert Dr. Priya Tiwari (in Hindi).

Risk Factors For Breast Cancer

Most people believe that genes put you at risk of breast cancer and it cannot be prevented. But in reality, only 5-10% of the cases of breast cancer have genetic predisposition. In the remaining 90% which are known to be sporadic breast cancers, the identified risk factors can be managed. 

The factors that increase the risk of breast cancer include:

1. Being woman as they are much more likely to develop breast cancer than men.

2. Old age as the risk increases with age. Most breast cancers are diagnosed after the age of 50.

3. A personal history of breast conditions like lobular carcinoma in situ (LCIS) or atypical hyperplasia of the breast.

4. A personal history of breast cancer. Also a history of cancer in one breast, increases the risk of developing cancer in the other breast.

5. A family history of breast cancer or ovarian cancer. The risk for breast cancer increases if your mother, sister, or daughter or any family members have had breast or ovarian cancer. Also having a first degree male relative with breast cancer elevates the risk.

6. Presence of certain harmful mutations of genes [BReast CAncer genes 1 and 2 (BRCA1 and BRCA2)]. For example, BRCA2 mutation in women carries a lifetime risk of approximately 26% to 84%.

7.  Having dense breasts.

8.  Early menarche (before 12 years) or delayed menopause (after 55 years).

9.  Never being pregnant or having the first child after 30 years of age.

10.  Smoking and excessive alcohol consumption.

11.  Obesity. 

12.  Hormone therapy after menopause (estrogen with progestin).

13.  A personal history of radiation therapy especially to the head, neck or chest.

Diagnosis Of Breast Cancer

The best way to know about breast cancer is through early screening. The different types of breast cancer screening tests include:

1. Physical examination of the breast

Breast self-examination (BSE), as the name suggests, is a breast cancer screening test that can be done by oneself and at home. It usually takes 5-10 minutes and should be done every month by all women above 15 years of age.

• Stand topless in front of a mirror with your hands on your sides and shoulders straight.

• Look at your breasts in the mirror for any visual changes in the breasts such as dimpling, inverted nipple, puckering, and changes in the size, shape or symmetry.

• Lift your hands and place the palms on the back of the head to look for changes in the breast. Repeat this by lifting one breast at a time.

• Feel your breasts by using the pads of your fingers (not the tips). Apply pressure and move your fingers over the breasts in a circular motion just like massaging the area. As you do this, make your way to the collarbone, center of the breastbone and near the armpits.

• Inspect your breasts when lying down and again in the shower. The use of water and soap while taking a shower makes it easier for your fingers to glide over the skin and make it easy to feel the breasts.

• Repeat the procedure by placing one hand over the back of the head and massaging the breast with the other hand. Lastly, gently squeeze the nipple to check for any discharge.

2. Clinical breast examination (CBE)

A clinical breast exam is done by a doctor or a nurse. During this exam, the clinician uses his/her hands to feel any lumps, hardness, nipple discharge or any other changes in the breast. It should be done once in six months in women who are at a high risk of breast cancer or at the earliest sign of any abnormality or symptoms of breast cancer. If you observe any abnormality during BSE, it’s advised to get a CBE done immediately to investigate further.

3. Blood marker tests

Also known as blood tests for tumor markers, these tests help to detect cancer activity in the body. In addition to being diagnostic tests, these can also help to determine whether the cancerous cells have moved to other areas of the body or to assess how the treatment is working. If you have already recovered from cancer, then these tests can help to check if the cancer has come back (recurrence). Some of the common blood markers that your doctor might recommend:

• CA 15.3 

• CA 27.29 (Breast cancer marker)

• Carcino Embryonic Antigen (CEA)

4. Mammography

Mammography is basically an X-ray of the breast tissue. It should be done by all women once a year after the age of 40 years or as advised by your doctor. Mammography alone is not useful in women with dense breasts. In these women, it has to be done in conjunction with ultrasonography or as advised by your doctor.
 

5. Magnetic resonance mammogram

This method uses magnetic and radio waves to take pictures of the breast and check for abnormalities. It is considered to be better than mammograms and CBE for screening women with a high risk of breast cancer such as those with BRCA gene mutation. For women in high-risk groups, MRI along with mammography and CBE is used as a screening tool. As breast MRIs may appear abnormal even if there is no cancer, they are not advised for women who have an average risk of cancer.

6. Other tests

In case of any abnormality being detected in the screening tests, the woman might be directed to take further tests to diagnose the condition. This includes:

• Excision biopsy: A mass of tissue is removed for examination. This is used to determine the types of cells involved in breast cancer. 

• FNAC (fine needle aspiration cytology): A fine gauge needle is used to remove fluid from the breast tissue for microscopic evaluation.

• CT scan: It helps to check whether breast cancer has spread to other regions.

Prevention Of Breast Cancer

1. Go for regular physical activity

A sedentary lifestyle and physical inactivity increase the risk of breast cancer. Women who get regular physical activity have a 10%-20% lower risk of breast cancer compared to women who are inactive. This could be attributed to the effect of exercise on systemic inflammation, hormones, and energy balance. Even walking seems to exert beneficial effects. So make sure you go for moderate-intensity exercise 30 minutes a day for at least 4 days a week for better personal health. 

2. Quit smoking

Heavy smoking over a long-time is linked to a higher risk of breast cancer. Moreover, it is also reported that exposure to secondhand smoke may increase the risk of breast cancer, particularly for premenopausal women.

3. Restrict alcohol intake

Cut down on your alcohol intake as excess intake can increase the risk of breast cancer. If you have to, then restrict the alcohol consumption to only social gatherings.

4. Get rid of excess body weight

Obesity is an important risk factor for breast cancer. Postmenopausal breast cancer risk is about 1.5 times higher in overweight women and about 2 times higher in obese women than in women with healthy weight. This might be due to higher estrogen levels as fat tissue is the largest source of estrogen in postmenopausal women. Therefore, it is important to maintain your weight within the normal range.

Opt for a regular fitness program and try to stay active throughout the day. Make healthy dietary choices and cut down on refined, processed and oily foods.

5. Do breast self examination once a month

It is important to do a regular self-examination of the breasts since they might help in early detection. First of all, look at your breasts in the mirror with your shoulders straight and arms on your hips. Look for any dimpling, bulging of the skin, or inverted nipple. Now, feel your breasts using the first few finger pads of your hand moving in a circular motion. The easiest way to feel breasts is when the skin is wet and slippery while taking a shower.

6. Get clinical examination done yearly

After the age of 35, it is recommended to get a clinical examination done by an experienced breast surgeon every year. In women with a family history of breast cancer, it is recommended to get an annual clinical examination done after the age of 25.

7. Get mammography/ultrasound done

A mammogram is an X-ray picture of the breast. It can be used for screening purposes when you have no symptoms of cancer. It can also be used if you have a lump or other sign of breast cancer. It is recommended to get regular mammograms done yearly after the age of 40 years. But if you are below 40 years of age, then an ultrasound of the breast is the recommended test to know the changes in your breast. 

8. Take special care in case of family history

If there is a family history of breast cancer, do consult your oncologist to discuss your risk of breast cancer. If you or any woman in your family is above 40 years of age, then get mammography done. Remember, early lump detection can aid in early detection of breast cancer which in turn can help in a complete recovery from breast cancer.

Specialist To Visit 

See a doctor if you feel a lump in your breast or have a discharge from the nipple. It is wise to opt for regular mammography (once a year) if you have a family history of breast cancer. 

When it comes to the treatment of breast cancer, there is not just a single doctor but a team of specialists who work together to create a comprehensive plan known as a multidisciplinary approach. Doctors specializing in different areas of cancer treatment include: 

• Oncologist

• Oncosurgeon

• Radiation oncologist

Treatment Of Breast Cancer

There are different types of breast cancer. For example, some tumors are small but grow rapidly whereas some are big in size but grow at a very slower pace. This is why the treatment for breast cancer needs to be customized as per the patient’s profile. Some of the common parameters that need to be taken into account before deciding the type of treatment include:

• The location of the cancer in the breast

• The size of the tumor

• Whether it has spread to other sites of the body

• The type of the cancer

• The stage/grade of the cancer

• Menopausal status of the woman

• The age of the patient

• The presence of any genetic mutations

• The presence of hormonal receptors or proteins on the cancer cells

• The general health & fitness of the patient

The treatment options for breast cancer might involve one or more of the following:

1. Chemotherapy

It involves the use of medications/drugs to shrink or kill the cancerous cells. These medicines can be given either in the form of pills or as injections (through intravenous mode) or both. Usually, chemotherapy involves intravenous administration of the drugs either through a central line (long tube attached to the large vein in the chest) or a cannula (thin short tube attached to the vein in the arm).

Chemotherapy is found to be most effective when these drugs are used in combinations. It can be given before surgery (neoadjuvant) or after surgery (adjuvant). Chemotherapy before surgery aims to shrink the tumour down & lower the chances of recurrence of the cancer. Chemotherapy after surgery might be recommended if:

• There is a presence of cancer cells in the lymph nodes under your arm

• There is a large tumour in your breast

• The cancer cells were of a high grade (grade 3 or more)

• Hormone therapy fails to work (due to absence of hormone receptors on the cancer cells)

How many cycles?
A chemotherapy schedule involves use of a combination of drugs in a specified number of cycles set over a specific time by your doctor. The regimen can be once a week, 2 weeks, 3 weeks or 4 weeks. In most cases, you can have chemotherapy cycles in a day & come back home. In some cases, you may need to stay in the hospital overnight or for a few days.

Some of the common examples of chemotherapy drugs include:

• Cyclophosphamide

• Vinblastine

• Vinorelbine

• Fluorouracil

• Capecitabine

• Gemcitabine

The common side-effects of chemotherapy includes fever, loss of appetite, weight loss, extreme fatigue, risk of infections, bleeding/bruising easily, diarrhoea or constipation & hair loss.

Note: Consult your doctor if you have any signs of an infection following the treatment.

2. Radiation therapy

This therapy uses radiation (high-energy rays similar to X-rays) to kill the cancer cells. This therapy can also be used along with other treatment modalities such as chemotherapy and surgery. The radiotherapy team will work out the radiotherapy which includes the dose of the radiation, where you need it & also the dose of the surrounding tissue.

Types of radiation therapy

• External-beam radiation therapy: Radiation given from a machine outside the body

• Intraoperative radiation therapy: Radiation given using a probe in the operating room

• Brachytherapy radiation: Given by placing radioactive sources into the tumor

External-beam therapy is the most common one which is used for whole breast & partial breast radiation therapy. 

What happens during radiotherapy?
The radiographers will tell you to lie on a special board called a breast board. If you have had a shell (mould) made, it will be fixed over your breast & you might need to raise your arms over your head. After this, the experts will line up the machine using the marks on your body or shell to place you in the right position.

As you lie still on your back, multiple images will be taken before your treatment to make sure you are in the right position. Your radiographer might ask you to hold your breath for a few seconds (at times) during the treatment.

Radiation therapy can cause side effects such as fatigue, swelling of the breast, redness and/or skin discoloration, pain or burning in the skin (at the site of radiation) & pneumonitis (very rare).

How many cycles? 

A radiotherapy schedule involves a specified number of cycles set over a specific time by your doctor for example 5 days a week for 3 to 6 weeks. The daily treatment of radiotherapy is known as a fraction.

It is recommended:

• When the cancerous mass is huge enough that it can’t be removed with surgery

• To treat metastatic breast cancer (cancer that has spread to other parts of body such as bones or brain)

• After breast-conserving surgery (BCS) to lower the risk of cancer recurrence in the same breast or nearby lymph nodes

• After mastectomy (breast removal surgery), if cancer is found in nearby lymph nodes or is larger than 5 cm in size or has spread to nearby skin or muscle

3. Hormonal therapy

This treatment approach works by either lowering or blocking the production of the hormones needed for the growth of the cancer cells. This therapy is often used as an adjuvant therapy post surgery to help lower the risk of recurrence. Most types of hormone therapy either lower estrogen levels or stop estrogen from acting on the breasts thereby aiding in the treatment. 

Who should take it?

Hormone therapy is only likely to work if the breast cancer cells have estrogen receptors (ER). It is seen that around 70% of breast cancers have estrogen receptors. These types of breast cancers are known as estrogen receptor positive cancer or ER positive cancer.

The type of hormone therapy used depends on the status of menopause, chances of cancer recurrence & side-effects of the drug. 

How to take it?

The medicines used for hormonal therapy are available in the form of tablets or injections. The drugs such as tamoxifen or aromatase inhibitors such as anastrozole are usually advised for a period of 5 years (or more depending on the need), whereas fulvestrant is given in the form of an injection once every month.

Examples of these class of drugs include:

• Tamoxifen acts as selective estrogen receptor modulator (SERM) that blocks estrogen receptors

• Fulvestrant acts like an anti-estrogen which blocks and damages estrogen receptors

• Letrozole acts as aromatase inhibitors which lowers the level of estrogen by blocking the  production of the hormone estrogen

• Megestrol acts as progesterone-like drug which lowers progesterone level in the body

The side-effects of hormonal therapy might vary based on the drugs used, however some of the common side-effects include hot flushes and sweating, irregular periods, low sex drive, vaginal dryness or discharge, feeling sick, joint pain, mood changes & tiredness

4. Targeted therapy

Targeted therapy is a treatment in which the drugs are targeted to the cancer’s specific genes, proteins, or the environment that contributes to cancer growth and survival. Unlike chemotherapy, this treatment works in a focussed manner & limits the damage to the healthy cells. As tumors might have different targets, your doctor might need to run a few tests to identify the target before initiating the treatment.

Hormonal therapies were the first approved targeted therapy for breast cancer. Recently, HER2 (human epidermal growth factor receptor 2) targeted therapies were approved for HER2-positive breast cancer. HER2 is a gene that can play a role in the development of breast cancer. 

Targeted therapy is usually recommended: 

• Before surgery (to shrink a cancer)

• After surgery (to reduce the risk of recurrence)

• For secondary breast cancer (if cancer has spread to other parts of the body)

• If cancer recurs

Examples of drugs

Some of the common examples include:

• Trastuzumab approved for non-metastatic HER2-positive breast cancer

• Pertuzumab approved for HER2-positive breast cancer in combination with trastuzumab & chemotherapy

• Pertuzumab, trastuzumab, and hyaluronidase–zzxf approved for people with early-stage HER2-positive breast cancer

• Neratinib approved for higher-risk HER2-positive, early-stage breast cancer 

• Alpelisib used hormone receptor-positive, HER2-negative metastatic breast cancer along with fulvestrant
  
  

The side effects of targeted therapy for breast cancer is dependent on the type of drug, dose of the drug, overall health & other drugs used for the therapy (along with it). Some of the common side-effects seen include feeling sick, breathlessness, allergic reactions, fatigue & tiredness, diarrhea or constipation, body pain, hot flushes, muscle spasms, soreness & loss of appetite

5. Immunotherapy

As the name suggests, immunotherapy works by helping the immune system work to fight cancer cells. This therapy uses substances either made naturally by the body or chemically (in the form of medicines) to:

• Stop or slow down the growth of cancer cells

• Prevent the spread of cancer other parts of the body

• Aid the body to kill cancer cells

Some of the approved immunotherapy drugs to treat breast cancer are:

• Pembrolizumab

• Atezolizumab

• Pertuzumab

How does it work?

One of the immune cells produced by our body is T-cells. These cells fight infection by analyzing and identifying the proteins present on a cell’s surface. If the surface proteins signal that the cell is normal & healthy, then T cells leave it alone. However, if the surface proteins indicate that a cell is cancerous or abnormal, then T cells attack the cell. These specialized proteins that keep healthy cells and tissues safe are called immune checkpoints. Immunotherapy drugs are targeted to these proteins to help identify cancerous cells & attack them.

Immunotherapy medicines are very new and have not been studied as long as other cancer treatments such as surgery, chemotherapy, radiation therapy, and hormonal therapy. However, research has revealed that there is a risk that medicines targeted to specific proteins may help to attack the healthy cells. This in turn can lead to various effects on the major organs of the body such as the lungs, liver, pancreas, kidneys and the intestines.

Watch Dr. Priya Tiwari, expert oncologist, explaining the treatment of breast cancer.

6. Surgery
Some of the common surgical treatments for breast cancer include: 

1. Mastectomy
It involves surgical removal of the entire breast and not just the lump as in the case of lumpectomy. Depending upon the type and the stage of breast cancer, your doctor might decide whether you need to undergo mastectomy or lumpectomy. Your doctor is most likely to recommend mastectomy if you have:

• a large lump (tumour), particularly in a small breast

• a tumour in the middle of your breast

• more than one area of cancer in your breast

• large areas of DCIS in your breast

• had radiotherapy to the breast before
  
  

The type of surgery depends on how big the cancer is, where it is in the breast and whether you have a breast reconstruction. The scar from a simple mastectomy extends across the skin of the chest and into the armpit. Breast reconstruction surgery can be performed at the same time after mastectomy or later as per the convenience. 

You may also go for prophylactic mastectomy which is preventive removal of the breast to lower the risk of breast cancer in high-risk people.

2. Breast-conserving therapy
Also known as lumpectomy, this technique involves the excision of the tumor and some of the normal tissue that surrounds the cancer cells. Technically, a lumpectomy is a partial mastectomy, because part of the breast tissue is removed.

Before the surgery, your surgeon or a nurse may draw markings on your breast that show where the incision will be made. It is followed by radiation of the entire breast area. The lumpectomy surgery itself should take about 15-40 minutes. 

You may be advised to rest at home followed by instructions to take medications, care for the incision area/stitches, exercise the arm & report any signs of infection at the earliest to the doctor. A follow-up is mandatory as it helps in a prompt detection of local recurrence of the cancer (if any) post the therapy. 

3. Breast reconstruction therapy
It is mostly considered by women who have a mastectomy or lumpectomy. It is a surgical procedure in which a plastic surgeon helps to recreate a breast. There are two main techniques for reconstructing your breast. These are: 

• Implant reconstruction involves inserting an implant which is a saline-filled or silicone gel-filled forms to reshape the breast

• Autologous or "flap" reconstruction involves use of tissue transplanted from another part of the body such as your belly, thigh, or back

Breast prostheses come in many shapes, sizes, and materials such as silicone gel, foam, or fiberfill interior. The common ones inculde a lightweight model (polyfill or foam) and a silicone prosthesis (look more realistic & feel natural).

Here’s more on cancer treatment options by a medical oncologist.

Note: The prognosis of breast cancer depends on:

• Stage of cancer (lymph node status and tumor size)
• Expression of certain proteins such as estrogen receptor and progesterone receptor (ER and PR) and human epidermal growth factor receptor 2  (HER2)
• If the woman is still menstruating or has had menopause

Regular examination and screening through mammography can help in early detection of breast cancer.

Home-care For Breast Cancer

There are certain changes that happen in the breast as you age. But these changes should not be ignored as they could indicate an underlying breast cancer. This is the reason why every woman above 25 years of age or those with a family history of breast cancer are recommended to do a self-breast examination as it could indicate early changes that happen in the breasts.

In addition to following your treatment routine such as radiation and chemotherapy, here are a few tips you need to keep in mind.

• Eat foods rich in antioxidants as they help the body to fight free radicals

• Stay away from processed and oily foods

• Check your weight as obesity is also a risk factor for breast cancer

• Exercise daily without fail as it helps you to stay active and strong

• Stay away from stress

• Boost your immunity to fight free radicals which can put you at risk for various illnesses

• Quit smoking & limit your intake of alcohol as it is known to up the risk of breast cancer

Complications Of Breast Cancer

If left untreated for a long period of time, breast cancer can be life threatening. In case of metastatic breast cancer, there is a high risk that the cancer can spread to the lungs known as lung metastasis. It often does not cause any symptoms but is discovered only on chest CT scan.

That's why it is recommended that you should consult a doctor if you experience any symptoms of breast cancer to diagnose it at an early stage and get appropriate medical treatment. There have been various treatment advances against breast cancer, bringing new hope and excitement for better self care. And, the silver lining is that if detected early, it has high chances of cure.

Living With Breast Cancer

Breast cancer can affect daily life in different ways, depending on what stage it is and the treatment received. How a woman copes with her diagnosis and treatment varies from person to person, but there are several forms of support needed.

• Talk to your friends and family as they are your biggest support system.

• Communicate with other people in the same situation and make time for yourself and engage more in physical and spiritual activities that calm your mind. 

• Tiredness and lethargy can be a problem during treatment but some gentle physical activity can help in alleviating the pain and symptoms. Avoid doing too much work or overexerting yourself when the body feels low.

• Breast cancer and its treatment are likely to cause a few physical problems. Changes to the shape of one or both breasts and scarring after surgery can affect self-esteem and confidence. If possible join support groups and activities that divert your mind and make you happy. 

• You may find it helpful to talk to a trained counselor or psychologist, or any expert. Taking to a professional can be helpful in getting all the information about breast cancer and post-treatment queries. Talking openly and knowing everything about what's happening with you and your body, gives a sense of confidence. 

Recovery and follow-up after treatment 

As most women with breast cancer undergo surgery, getting back to their normal life can take time. During recovery, avoid lifting things such as heavy shopping bags, doing excessive household chores. Post treatment, a regular follow-up with routine blood tests and mammogram is necessary.