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.
- A
lump or thickening in or near the breast or underarm area
- Change
in shape and size of the breast
- Dimpling
or puckering in the skin of the breast
- Invagination
of the nipple
- Unusual
discharge from the nipple, especially if its bloody
- 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.
