Screening is the cornerstone of early detection of breast cancer

Breast cancer is a leading health concern all over the world, and has emerged to be a leading cause of morbidity and mortality among women. In India, breast cancer accounts for 20% cases of cancer in women and is second only to cervix cancer. Trends indicate towards increased incidences of breast cancer to the tune of 50 to 100% in last 20-30 years. Breast cancer is most commonly reported in women but less than 1% cases occur in males also.

Breast cancer occurs at a site which can be easily noticed and thus ought to be detected and treated early. Studies revealed poor outcome and high fatality rate from breast cancer because of diagnosis of cancer in advanced stages. Although easily detectable by simple breast self examination, maximum (>90%) cases are still diagnosed in stage II, III and stage IV. The first sign of the lump or tumor is generally detected during breast self examination. Early detection of breast cancer can increase the chances of successful treatment and cure of the disease and also minimize the associated morbidity and mortality.

 Early manifestation

Usually, no symptoms can be detected in the early stages of breast cancer. But with the growth of the tumour, some or all of the following changes can be detected.

1. A lump or thickening in or near the breast or underarm area
2. Change in shape and size of the breast
3. Dimpling or puckering in the skin of the breast
4. Invagination of the nipple
5. Unusual discharge from the nipple, especially if its bloody
6. Scaly, red or swollen skin of breast, nipple or areola, or the skin may have ridges or pitting

Detection and diagnosis

Breast self examination (BSE), clinical breast examination (CBE) and mammography are the recommended screening test for early detection of breast cancer. If any of the screening test comes positive, then some more tests may be required to confirm the type, exact location and stage of breast cancer.

 Breast self examination (BSE)

BSE familiarize women with the normal appearance of their breast and aids in early detection of any abnormality including tumor. It encourages preventive health behavior and healthcare seeking behavior in woman. Finding a change in breast must be reported to a health professional as soon as it is found, though it doesn’t mean there is a cancer.

Clinical breast examination (CBE)

CBE is a physical examination of breast done by a health professional such as doctor or nurse. It should be a part of regular health checkup of a woman. CBE is done to find a lump or change in the breast which may indicate towards a serious problem, including breast cancer. It also helps in finding other problems such as mastitis or a fibroadenoma. Clinician examines each breast, underarm and collarbone area for changes in breast size, skin changes, or signs of injury or infection such as bruising or redness. Lumps are feeled through finger tips, lymph nodes near breast to see if they are enlarged. A hard, oddly shaped lump that do not moves is very likely to be cancer, but further tests are always needed for confirmatory diagnosis. A woman is always advised to have at least one CBE in a year which should be six monthly or quarterly after menopause.

Mammogram

A mammogram is an x-ray of the breast, used to look for breast disease in women who have symptoms of a breast problem viz. lump or a nipple discharge, or a patient referred by a clinician after CBE. Mammograms for diagnostic usually take 2 views, from different angles, of each breast. It includes more images of the area of concern. In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.

A mammogram can help to decide that –

-          The abnormality is not worrisome, resulting in patient returning only for routine yearly mammogram

-          A lesion/abnormal area of tissue has a high likelihood of a benign tumour, patient needs to follow up in 4 to 6 months for another mammogram

-          The lesion is more suspicious and needs a biopsy to confirm if it’s a cancer

 Magnetic resonance imaging (MRI) and ultrasound

MRI and ultrasound is used along with mammogram to better examine and correct location of the suspicious area. MRI is used to determine actual size of the cancer and look for another cancer in the breast of previously diagnosed patients.

Ultrasound is less expensive and easy procedure compared with MRI. Ultrasound is also used to target a specific area of concern indicated by mammogram. It helps to distinguish between cysts and solid masses and also help in differentiating between benign and cancerous tuours.

Biopsy

Biopsy is done when mammograms and other imaging tests as well as physical exam indicates a breast change from normal, possibly cancer. A biopsy is the only way to tell if cancer is really present.

A tissue sample of the suspicious area is taken for cytological examination of the tissue taken. Several type of biopsies are used, such as fine needle aspiration (FNA) biopsy, core biopsy and surgical biopsy. FNA is done with a fine needle, if required with the help of ultrasound to guide the needle to desired tissue. FNA is generally most accurate and easy type of biopsy. Core needle biopsy is similar to FNA but it uses a larger needle. Surgical biopsy is rarely done for breast cancer diagnosis. It is done in surgical outpatient to take a large sample of the suspect mass of tissue.

Management after diagnosis

After confirmation through biopsy about the presence of cancerous cells in the breast, management of the tumour cells starts. It is a long and hard fought battle with comparatively good results in terms of survival (≈ 90% 5-year relative survival rate ) in cases which are diagnosed in early stages i.e. stage 1. Sometimes doctors may suggest additional lab tests to assist with prognosis. The two most common lab tests are A) Hormone receptor test and B) the HER2/neu test. These tests can provide an insight into the suitability of most effective treatment options. Treatment options depend on the stage of cancer, it may include chemotherapy, radiation therapy, hormonal therapy or surgery.

Reference:

1.      Peepliwal AK, Tandale P. Breast cancer in India: Etiology, diagnosis and therapy. Research and Reviews: Journal of Medical and Health Sciences. 2013; 2(2): 31-42.

2.      Shrivastava SRBL, Shrivastava PS, Ramasamy J. Self breast examination: A tool for early diagnosis of breast cancer. Am J Public Health. 2013; 1(6):135-139.

3.      American Cancer Society. Clinical Breast Exam. http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs-clinical-breast-exam Revised January 28, 2014; Accessed September 30, 2014.

4.      WebMD. Clinical breast examination. http://www.webmd.com/women/clinical-breast-examination  Accessed September 30, 2014.

5.      American Cancer Society. How breast cancer is diagnosed? http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-diagnosis Accessed September 30, 2014.