How can we Diagnose breast cancer?

About 90% of the cases of breast cancer are discovered by breast self examination by patient them self.Screening is the method of diagnosing cancer at early stages before it produce any signs or symptoms

which reduce the mortality by 50%.Positive diagnosis can be made by obtaining tissue for microscopic examination.The American cancer society recommends that all women should perform breast self examination monthly.

In addition women from 20-40 years ages should visit the clinician every 3 years and women above 40 years every years.The risk of developing breast cancer increases with age.

Breast Self Examination:

1.Observe for symmetry,lumps,dimpling,nipple discharge or failure of nipple erection

2. Gently squeeze nipple and observe for secretion and nipple erection after each nipple is gently stimulated.

3.While leaning forward observe breast as they are reflected in mirror to detect irregularities, retracted

areas especially one side only.

4.Feel for nodes irregularities and tenderness both in breast and axillaries nodes.

Symptoms of breast cancer:

Most women present with painless increasing mass which may also be associated with nipple discharge, ulceration and in inflammatory cancer oedema and erythema may be seen. There may be some non-specific symptoms such as weight loss,fatigue,anorexia,back or bone pain. This usually indicated more advanced stage of breast cancer.

Character of advance breast cancer:

When breast cancer has advanced oedema,redness,nodularity,ulceration of skin,presence large primary tumorswhich are fixed to chest wall,enlargement,shrinkage or retraction of the breast, marked axillary lymph nodes supra clavicular lymph nodes enlargement,oedema of same sided hand or distant metastasis may be seen.1-2 movable non-tender less than 5mm nodules are not suggestive of metastasis but nodules greater than 7mm usually contains metastasis .Axillary lymph nodes that are fixed to skin or deep structure indicates advanced disease.

What other disease you should consider?

There are several other diseases which may also gives same symptoms and signs as breast cancer. So these disease can be excluded by obtaining a tissue biopsy of the site. Some other disease to consider are:

Mammary dysplasia(cystic disease of the breast)

Fibroadenomas

Intraductal papilioma

Lipoma

fat necrosis

Risk factors of Breast cancer

Breast is the most common site of cancer in women and accounts for second cause of death in women,first being lung cancer.Some risk factors of breast cancer are followings:

1.The most important being dietary factors especially high fat content(eg.red meat which have high saturated

fat and protein content)

2.Women with previous cancer of uterine

3.It is more common in whites than non whites

4.Early menarche( less than 12 years) and late natural menopause( greater than 50 years are at high risk.

5.Late menarche and artificial menopause are at lower risk.

6.Women who had cancer of one breast is high risk of developing the other.

7.There is some evidence that administration of estrogen to post menopausal women has slightly increase risk of cancer

but with higher dose and long term use.

8.Late first child birth(after 35 yrs) may also increase risk of developing breast cancer.

Treatment of breast cancer:

The type of treatment whether surgical,chemotherapy or combination of both therapy is determined by the extent of disease,patient age and her decision.

Early breast cancer treatment:

Surgery with wide local excision and breast conservation or mastectomy with or with out re-construction is done.Amount of breast tissue to be removed still remains controversial. At one time radical mastectomy was done

routinely although still performed,modified radical mastectomy, simple mastectomy or lumpectomy. Lumpectomy only removes cancerous portion of breast and axillary nodes. Radio therapy is given to conserve the breast after wide local excision to reduce local recurrence.

Adjuvant systemic treatment

Tamoxifen adjuvant therapy immediately following surgery is beneficial for estrogen-progesterone receptorpositive disease and has reduced the relative risk of women dying from breast cancer by 25%.Most commonly therapy with cyclophosphamide and 5-Flurouracil plus methotrexate for 5 months reduces the absolute by 10% and relative risk of death by 20%.

Advance breast cancer:

Patient with establish metastasis disease may require endocrine therapy, chemo therapy or radiotherapy.The treatment is not curative but may be of great palliate benefits and consistent often with many years of good quality life. Recently addition of anti HER2 antibodies to chemo therapy has produce a modest survival advantage.

Endocrine therapy of advance breast cancer:

Women who have high level of estrogen receptor and progesterone in their tumor have greater chances of responding to endocrine therapy. A range of hormonal manipulations are as follows:

For premenopausal patients

1.Supression of ovarian function by means of oophorectomy,radiation-induced ovarian ablation

2.Anti-oestrogen,tamoxifen

2.Progestrone

For post menopausal women

1.Tamoxifen

2.Progesterone

3.Aromatase inhibitors(anastrozole)

Chemotherapy

patient who are unlikely to respond to hormonal therapy or who fail to respond to endocrine therapy or who requires rapid response is they are at any risk,they are given chemo therapy. The most common regimen used are:

CMF(cyclophosphamides,

Methotrexate,5-fluorouracil)

MM(mitoxantrone and methotrexate)

Doxyrubicin and cyclophosphamide

Paclitaxel or docetaxel used as single agent or in combination with an antracycline where initial therapy has failed or is inappropriate.

Side effect of chemotherapy:

nausea, vomiting

hair loss

fatigue

Mucositis( eg. oesophagitis,diarrhoea)

Drugs specific:

Anthracyclines causes cardio toxicity

5-fluorouracil causes skin dermatitis

Poor prognostic factors for breast cancer:

Young age

pre-menopausal women

Tumor size

metastasis of tumor

Oestrogen and progesterone receptor negative

positive nodes.

Should see the doctor after my treatment?

After primary therapy ,patients with breast cancer should be followed for life for at least two reason:

1.To detect recurrences and to observe the positive breast for secondary carcinoma.

2.Local or distant metastasis occur frequently with in the first 3 years. So during this period patient is examined every 6 months.Thereafter, every 6-12 months for 5 years, then after every 12 months.