Be Breast Sure

Breast Cancer is the commonest cancer among females. With rapid industrialisation and urbanization, the incidence of breast cancer is rising fast among Indian women. Proper awareness and treatment under proper guidance can help millions to reduce the brunt of this menace. As per National Cancer Registry, over 1.9 lakh women are diagnosed with breast cancer every year. 55 per cent of these diagnoses present at an advanced stage with less than 15 per cent chance of survival. If these women have been diagnosed early, their survival chances can be more than 90 per cent.

The cure rate of breast cancer if detected early is 97 per cent but, unfortunately, only less than 10 per cent of 100,000 new breast cancers diagnosed in India every year fall into this category. In India, breast cancer presents a decade earlier affecting younger women between 30 and 40 years. Unlike in the West where typically women after 50 years get the early-stage disease, breast cancer in Indian women occurs at a younger age and is usually presented and diagnosed at a later stage due to low awareness of breast screening and self-examination.

Risk factors:

There is no known single specific cause for this illness. Urbanization has bought its own share of grief with pollution in water, air, food etc. Pesticides in fruits, vegetables and other food items are known carcinogens that are creating havoc. In a recent WHO report it was stated that, the Indian people consume pesticides 40 times higher than permissible levels in their food.

Causes like heredity, genetic mutations, environmental toxins, certain physical and chemical hazards, consumption of genetically modified food products, lifestyle factors like stress, smoking, and alcohol consumption, eating junk food, obesity, and lack of exercise lead to breast cancer.

Symptoms:

The main symptoms which one should look out for are a painless lump in the breast or armpit, discharge from the nipples, nipple or skin retraction, thickening, ulceration and redness of the nipple or skin.

Diagnosis:

A proper clinical examination by a cancer specialist is the first step of diagnosis. Mammography and breast ultrasound are the most reliable and cheapest diagnostic and screening tools for breast cancer detection. One should get a mammogram done once every two years after 40 years of age. This should be preferably done once a year after age 50. Biopsy or Fine needle aspiration cytology (FNAC) is done in the case of a suspicious or positive mammography screening to confirm the disease. Further tests to assess the disease spread - metastatic workup - are conducted once the cancer diagnosis is confirmed. Genetic testing for BRCA1 and BRCA2 gene mutations can help determine one's chance of developing breast cancer and ovarian cancer if there is strong family history.

Treatment Outcome:

Management of breast cancer has taken a paradigm shift due to latest advances in medical field. While the overall survival (OS) was low some twenty-five years ago, it has very much improved now due to increased awareness among present day women, better diagnostic techniques and new advanced modalities of treatments like surgery, chemotherapy, targeted immunotherapy, radiotherapy and hormonal therapy. People even live longer than two decades after diagnosis and treatment.

Emerging trends in Breast cancer surgery:

Management of breast cancer is done by multimodality approach. Hence treatment in a comprehensive cancer care centre becomes crucial for a better outcome. Surgery is the mainstay of curative treatment in early-stage breast cancer i.e., stage I and II.

Breast cancer surgery has evolved into a paradigm shift from radical to more conservative approach. Multiple randomized controlled trials have shown that less surgery is as effective as the radical one. Breast conservation Surgery (BCS) combined with radiotherapy (RT) has emerged as a sound oncological operation in terms of overall survival (OS) and local recurrence. Wide local excision of primary tumor along with Axillary clearance gives acceptable cosmetic outcome with minimal risk of local recurrence, uncompromised disease-free survival (DFS) and overall survival. En-bloc resection of tumor with 1.5-2cm normal tissue margin along with regional lymph nodes with frozen section control is essential. Proper selection of patient with consideration of tumor size, tumor to breast ratio is important. Proper knowledge of mechanism and sites of spread is crucial for treatment planning.

Sentinel lymph node biopsy is now being advocated as an initial management largely replacing Axillary lymph node dissection (ALND). Availability of experienced team of surgery, pathology, nuclear medicine and imaging is important. This can reduce morbidities of ALND.

Primary reconstruction of breast for good cosmetic outcome is an integral part of BCS. Educating the patient with the various options of reconstruction available is a primary responsibility of the treating surgeon. Latissimus dorsi (LD) flap is the most commonly used flap for reconstruction in BCS. Reconstruction in case of mastectomy should also be encouraged. Various pedicled flaps and free flap options are available for this purpose. 

In oncoplastic reconstruction surgeries, reconstruction of breast is done combined with aesthetic modification of contralateral breast like breast lift, reduction mammaplasty etc. Therapeutic mammaplasty of the contralateral breast gives better cosmesis. So, present day focus is minimising surgery, maximising life. Well planned treatment by multimodality approach has made this a reality.

Prevention:

Four pillars of health namely, Exercise, positive Attitude, adequate Rest and proper Nutrition play important role to Earn good health as well as in the prevention of lifestyle diseases like cancer, diabetes, hypertension and heart diseases, etc. Consumption of diet with adequate macro and micronutrients, rich in antioxidants has proven to help. Eating fresh fruits and vegetables of different colors is the key. Organic foods like eating colored vegetables, broccoli, cauliflower and cabbage, grape seed extracts, flax seeds, wheat grass, and olive oil are believed to be preventive. This will help to prevent the preventable and delay the inevitable.

Monthly Breast Self-Examination (BSE):

Early detection is the key to surviving breast cancer. Women in the high-risk group must go for breast screening tests after 30 years of age. Monthly breast self-examination is a simple and effective way to detect cancer which every woman should be aware of. The main symptoms of breast cancer like a lump in the breast or armpit, discharge from the nipples, retraction of the nipple or skin, skin thickening, or ulceration can be detected early on time if a woman does self-examination regularly. Doing self-examination of both breast and axillae (armpits) in a standing position in front of a mirror, and in a reclining position in the bed can save many lives.

As we all know, in cancer early detection is the best protection. So, regular monthly breast self-examination is the key to this. Only you yourself can help yourself.  It’s in your hands. So, be breast sure.

Dr Niranjan Naik

Guest Author Director – Surgical Oncology, Fortis Memorial Research Institute (FMRI), Gurugram