Breast Cancer – What are the choices?

Introduction 

Breast cancer is the most common cancer among women in Singapore. Worldwide, it is also the most common cancer among women. Breast cancer cases have increased because of the aging population (chances of getting breast cancer increases with age) and more women are now aware and are going for regular breast checks.

Risk factors 

The risk factors for breast cancer are:
• Women over the age of 40 years (but can occur at any age)
• Personal history of breast cancer in the same breast or contralateral breast
• Family history of breast, ovarian, uterine cancer or colon cancer
• Genetic predisposition (defects in BRCA 1 or BRCA 2 genes)
• Radiation exposure (treatment) to the chest during childhood or adolescence or young women
• Early onset of menses(before age 12) or late menopause(after age 55)

Fig. 1

• Use of combined hormone replacement therapy
• Use of birth control pills
• Never had children or had children after age of 30
• Excessive alcohol intake

• Obesity

Signs and symptoms (Fig.1 and 2)

The signs and symptoms of breast cancer are:
• Persistent lump in the breast or axilla
• Change in breast skin colour or appearance such as redness, puckering or dimpling

Fig. 2

• Change in breast size or shape

• Discharge from the nipple especially if it is bloody

• Change in the nipple or areola, such as scaling, persistent rash, or nipple retraction

Diagnosis and Staging Tests

Tests used to diagnose and monitor patients with breast cancer may include:

• Breast ultrasound to show whether the lump is solid or fluid-filled. (Fig.3) 

Fig. 3

• Mammography to screen for breast cancer or help identify the breast lump (Fig. 4 and 5) 

Fig. 4

Fig. 5

• Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram

• Breast biopsy, using methods such as needle aspiration, ultrasound-guided, stereotactic, or open (Fig.6)

• CT(computed tomography) scan to check if the cancer has spread

• PET(positron emission tomography) scan to check if the cancer has spread 

Fig. 6

Staging

Stage 0 (Ductal / Lobular carcinoma in situ or DCIS / LCIS ) (5 year survival 95%)

The cancer cells are found in the milk ducts or lobules of the breast. The cancer cells have not spread out of the milk ducts or lobules of the breast. 

Stage I (5 year survival 90%)

The breast tumour is less than 20mm in size. No spread to lymph nodes

Stage II (5 year survival 75%)

There is breast tumour 20mm in size or smaller and breast cancer cells are found in 1 to 3 axillary lymph nodes or,

There is breast tumour more than 20mm in size without any breast cancer cells in the lymph nodes.

Stage III (5 year survival 55%)

There is breast tumour of any size with breast cancer cells in 4 or more axillary lymph nodes or lymph nodes near the breastbone; or

The breast tumour is more than 50mm in size with breast cancer cells in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone.

Stage IV (5 year survival 15%)

The breast cancer cells have spread to other organs of the body like lungs, bone, liver and brain.

Treatment 

Treatment for breast cancer includes surgery, chemotherapy,  radiotherapy and hormone therapy.

In breast cancer surgery, there is breast-conserving surgery (BCS) and there is mastectomy.(fig.7)

Fig. 7

Breast-conserving surgery (BCS) involves only the removal of the tumour or lump including the surrounding normal tissue (called lumpectomy) or a segment of the breast (segmental mastectomy). In BCS, if the margins of the tissues removed is found to have cancer cells a wider excision should be done to make sure that the margins are clear of cancer cells.

Mastectomy involves removal of the whole breast. In simple mastectomy, the entire breast is removed including the nipple. In skin-sparing mastectomy, the entire breast tissue is removed sparing the skin over it as breast reconstruction can be done. This procedure cannot be done if the breast tumour is too large or the skin of the breast is affected by cancer. In nipple-sparing mastectomy, the entire breast tissue is removed excluding the nipple and skin of the breast. This procedure cannot be done if the nipple or the skin near the nipple is affected by cancer. In modified radical mastectomy, the entire breast is removed including the nipple and the axillary lymph nodes. 

Choosing between Breast Conservation Surgery and Mastectomy (Table 1)

When choosing between BCS and mastectomy, the patient and the doctor should consider 

• the size and number of tumours, 

• location of the tumour in the breast,

• if the cancer cells have spread to surrounding areas, 

• the size of the breast, 

• family history

• patient’s wish

Table 1

Factors to consider	Breast Conservation suitable	Mastectomy advised
Size of cancer	Small	Large esp >5cm
Number of cancers	Only one	Multiple
Location of cancer	Away from nipple	Near the nipple
Involvement of skin or muscles	None	Skin or deep muscles involved
Size of breast	Good size	Small breasts
Family history	Low risk	Strong family history
Pros and Cons	After Breast Conservation Surgery	After Mastectomy
Need for adjuvant radiotherapy	Required treatment to the remaining breast tissue	May not need if margins are clear and muscles not involved
Need for chemotherapy	Depends on stage	Depends on stage
Need for hormone therapy	Depends on hormone receptor status of the cancer	Depends on hormone receptor status of the cancer
Follow up	Close follow up on remaining breast tissue and contralateral breast	Focus mainly on contralateral breast
Survival rate	Same in early stages (together with radiotherapy) as mastectomy

In radiotherapy, x-rays are used to kill the cancer cells before or after surgery. Possible side effects of radiotherapy are diarrhoea, bleeding and fatigue.

In chemotherapy, a drug is used to kill the cancer cells before or after surgery. Possible side effects of chemotherapy are nausea and vomiting, loss of appetite, fatigue, hair loss and diarrhoea. 

In hormone therapy, anti-estrogen or aromatase inhibitors are used to stop the action of estrogen or stop the production of estrogen as breast cancer cells require estrogen to grow and multiply.

Risk reduction

Breast cancer prevention lowers the chance of one person getting breast cancer but it does not guarantee that you will not get breast cancer. 

You can reduce risk by:

• avoiding use of combined hormone replacement therapy

• avoiding use of birth control pills 

• avoiding excessive alcohol intake

• maintaining normal body weight

• having children before age 30

• breastfeeding your children

• knowing your family history and seeking advice if there is a strong family history of cancer

• going for breast screening

Women at high risk of breast cancer may also undergo preventive mastectomy or prophylactic mastectomy. These women are those with personal history of breast cancer, strong family history of breast cancer, women who are genetically predispose to develop breast cancer (women who have defects in their BRCA 1 or BRCA 2 genes like Ms Angelina Jolie) or young women who had radiation exposure (treatment) to the chest.

Screening recommendations

The recommended screening for breast cancer are:

 

• breast self-exam once a month. If you detect or notice any breast lump, please consult your doctor.

• clinical breast exam by a doctor once every year from 40 years and above

• mammogram once a year from 40 to 49 years and every 2 years from 50 years onwards. 

• we also recommend breast ultrasound together with the mammogram to improve detection rate. 

• if mammogram and breast ultrasound results are not clear, CT scan or MRI of the breasts can also be performed.

This article was contributed to Tab A Doctor by,

By Dr Kum Cheng Kiong, Senior Consultant Surgeon, Center of Screening and Surgery