The incidence of breast cancer is increasing rapidly in India and it has overtaken cancer of the cervix, statistics reveal. Breast cancer is one of the most common cancers affecting females. Recent Indian Council of Medical Research (ICMR) data shows that the incidence of breast cancer is high among Indian females in the metropolitan cities of Mumbai, Chennai, and Delhi. Although the data available in India is not very reliable, it is estimated that one in 22 Indian females is likely to develop breast cancer during her lifetime in contrast to one in eight in America.
It is a fact though not widely known that breast cancer can also affect males, incidence being very low.
It should be remembered that because of its biological behaviour no two cases of breast cancer are similar and hence any comparison is not always valid.
The peak incidence of breast cancer is in the fifth and sixth decades of life. In India, however, the disease is seen a decade earlier (this is true of almost all cancers affecting different organs of the body), probably because of shorter longevity of Indians as compared to Americans.
Causes and effects
Fact file
The exact cause of breast cancer has not been established but clinical data has clearly shown a number of risk factors, which may be responsible for it:
Age: High incidence in the age group above 50 years and very low below 25 years. The disease is more aggressive in younger patients.
Menstrual cycle: Common in the ladies who have a longer menstrual life, i.e. the onset of menarche is earlier and cessation of menstruation is late.
Marital and maternal status: More common in spinsters, or if married then have not given birth to children, or if given birth then have not breast fed their offspring.
A positive history of breast cancer in mother, sisters, and daughters increases the risk.
Smoking and alcohol intake are supposed to increase the risk.
Women with a past history of having breast cancer on one side are at a greater risk to develop cancer on the opposite side also, about 1 per cent per year and the lifetime risk is 10 per cent.
Obesity and higher intake of saturated fatty acids have been also linked .
A woman who exercises atleast four hours per week reduces her risk of breast cancer. Exercise pumps up the immune system and cuts the oestrogen (female hormone) level.
Radiation to chest: Exposure of breast to radiation that may happen during radiotherapy for any cancer disease located either inside the chest or on the chest wall, may make the person more vulnerable to the development of breast cancer. This may happen 10 or 12 years after the exposure.
Oral Contraceptives: Women below the age of 35 years, who have been using oral contraceptive pills for more than 10 years, are at an increased risk of developing breast cancer.
Hormone-Replacement Therapy: It has been shown that continuous or sequential uses of combined oestrogen plus progestin hormone therapy (CHT) after the cessation of menstruation cycle are linked with an increased risk of breast cancer. The researchers also found that the women who have been using only oestrogen therapy as hormone replacement therapy (i.e. not combining with progestin) for 25 years or longer had no significant increase in the risk of breast cancer.
The readers are cautioned that these facts have been derived from the statistical analysis of the factors seen in the breast-cancer patients; they should not be taken as causative or predisposing factors. In the present era when breast cancer has become such a common disease, it is advisable to follow the guidelines.
Global research has focused on finding an answer to this million-dollar question but the knowledge at present is limited to hypothesis only. Breast cancer is supposed to be more common among the affluent and the people exposed to the modern environment. In India the disease is commonly seen amongst Parsi women. However, it is also seen among the poor and the illiterate population. The explanation could be that the majority of our people belong to the lower strata.
Breast cancer has a genetic link too. The disease is supposed to be more common among women whose first relatives had this problem. This is important as such women are bracketed amongst "high-risk patients" and have to undergo the screening process at least a decade earlier than women with a negative family background. The identification of the abnormal chromosome and its treatment by genetic engineering is being tried at the experimental level and it is hoped that shortly the technique will be made available to the patients also.
Breast cancer, with reference to clinical management, is divided in three stages—early breast cancer, locally advanced and late or metastatic condition. Early breast cancer includes tumours of less than 5 cm in diameter. Locally advanced tumours are more than 5 cm in size, fixed to underlying muscles or overlying skin. And any patient with secondaries (metastasis) from the breast tumour in other organs is included in the late stage of the disease. The common sites of secondaries are lymph nodes (at distant sites, axilla being included in early breast cancer), bones, lungs, liver, brain, skin, etc.
In India we hardly see 5 to 10 per cent of early breast cancer patients, whereas in developed countries a majority of the patients belong to this group. As a matter of fact, in America, early breast cancer includes only the tumours that are not palpable from the surface but have been detected by mammography. In India, about 50 per cent patients of breast cancer are in the locally advanced group.
The size of the tumour at the time of starting treatment is directly related to the ultimate result: a 20-year survival rate is found in more than 90 per cent of the patients with a tumour diameter of less than 1cm, whereas it comes down to 50 per cent if the tumour diameter is 3 cm or more. This underlines the importance of early detection of the tumour and it also explains why the outcome is not so good in India.
Diagnosis
The cancerous tumour can be detected in the asymptomatic stage (when the person does not have any complaint regarding the tumour) and this is possible by following regular screening protocols. The screening protocol should be started from the age of 45 years( 40 years in the high-risk cases ) and consists of mammography, clinical examination by a specialist and self-examination of breasts by the woman herself.
A progressively increasing swelling in the breast or in the axilla, which, to start with, is completely painless, is the most frequently occurring feature of breast cancer. Bleeding from the nipple, ulceration or eczematous lesion of the overlying skin, orange-peel like appearance of the skin over the breast are the other commonly heard complaints about breast cancer.
Regular screening mammography of both the breasts every second year, coupled with clinical examination by a competent surgeon, are supposed to decrease the number of deaths from breast cancer by almost 30 per cent. Breast screening has not become a common practice in India because of a financial crunch. Mammography costs only Rs 600 and it is a worthwhile investment. Self-examination of breasts has to be learnt so that it can be practised properly.
Mammography can detect a swelling as small as 0.5 cm in the depth of the breast that may not be felt from the surface. A biopsy of this lump requires to be taken for the confirmation of the diagnosis and this can be undertaken by the stereotaxis technique or by mammotome. The former technique is available at a few centres in the country but the latter is still to come into practice.
PET scan and dedicated MRI mammography are newer techniques, are supposed to give better results but are costly and are not widely available in India.
Fine Needle Aspiration Cytology (FNAC) is the commonly used technique for biopsy. A fine needle is inserted inside the tumour, fluid aspirated and smeared over a slide, stained and then examined by a cytologist. It is reliable up to 95 percent but may give false positive or negative results also. Hence a surgeon has to use his clinical judgment for proper correlation. The tissue for biopsy can also be obtained by inserting a wide-bore needle, known as core needle biopsy, and this is subjected to histopathological examination. This is supposed to be more reliable than the FNAC but is more traumatic and is also not practised widely.
Stages of Self-examination
Stages of the disease
The diagram shows four stages of the progression of cancer
Management
A breast cancer patient has to be thoroughly investigated to rule out the presence of metastasis. She also requires to be assessed for her suitability for operation, chemotherapy and radiotherapy. This is mandatory for staging the disease, to know the prognosis and to select judiciously the treatment protocol. It is possible to undertake all investigations within 24 hours and this delay does not affect the well being of the patient in any way.
It has now been conclusively proved that a breast-cancer patient not only requires operation but also has to be treated with the multimodality treatment, which includes chemotherapy, radiotherapy, hormone therapy and immunotherapy. A right combination of different modalities of treatment with proper planning and sequencing is important to provide maximum benefit to the patient. This treatment protocol depends on the stage of the disease, the menstrual status of the patient, the histopathological findings of the excised tumour, the evaluated tumour markers, the most important being the expertise and experience of the treating surgeon. For more than a 100 years, radical surgery for breast cancer was being practised all over the world. This mutilating operation has
been posing a lot of psychological problems to the patients. It has been demonstrated that radical mastectomy, i.e., total removal of the whole breast along with underlying muscles and clearance of the axilla, the armpit, could be easily changed to modified radical mastectomy—Patey’s mastectomy - in which the underlying muscles are not removed.This not only gives better cosmetic results but the hospitalisation period and complications are also fewer. Radical mastectomy presently is done occasionally only for technical reasons when the tumour is fixed to underlying muscles and the surgeon is forced to remove the muscles for proper en block removal of the advanced tumour. Advances in surgery have further proved that removal of the whole breast is not required, the tumour can be excised along with a rim of normal breast tissue and the breast can be preserved giving an excellent cosmetic look to the patient.
This surgery has to be combined with administration of radiotherapy and other forms of treatment modalities to give best results.
Long-term results have clearly shown that the ultimate outcome following proper application of breast conservation surgery remains equally good, if not better, than the total removal of the breast. Unfortunately, this form of breast-conservation surgery is practised at only a few centres in our country, the main reason being non-availability of expertise or experience on the part of the surgeon.
It has been reported that even in USA, 50 percent of the patients, who are suitable for this form of breast preservation surgery, are subjected to total removal of the diseased breast.
Continued follow-up of the patient with the treating surgeon is important not only for the rehabilitation of the patient but also for detecting the recurrence of the disease. The recurrence can be kept under control effectively if it is detected early and proper treatment is started in time.
Rehabilitation
Breast cancer per se and the body image following surgery may leave behind a psychologically disturbed woman, who does not enjoy social life and her sexual activity takes a big beating. These patients require lifetime psychological support from their near and dear ones.
Their body image can be improved tremendously by cosmetic surgery or even with the use of special brassieres.
Another important fact that worldwide research has brought out clearly is the relationship of the treating doctor with the ultimate result of the cancer disease. It has been clearly shown that if the treating surgeon is specialising in the management of breast cancer, the results are significantly much better than in the case of a surgeon who has no special experience or expertise in the subject.
Men too can get it
Four months back, a 65-year-old man consulted me for a swelling in the region of his chest, it was difficult for him to understand and, then, to accept that he had the cancer of the breast. A majority of people is unaware that breast cancer can afflict men too.
Breast cancer in males is an infrequent problem; for every 100 cases of breast cancer, 99 are seen in females and only 1 in males. Statistics in the US reveal that breast cancer constitutes only 0.2 per cent of all malignancies seen in males whereas breast cancer is the commonest cancer in females—about 26 per cent.
In India, the incidence is still lower. Because of its rarity, clinicians and researchers have not been able to collect substantial data on the subject and ignorance persists both in the minds of the doctors and the public.
The breast tissue is the same in males and females, and till puberty, boys and girls have a small amount of breast tissue (mainly ducts) under the nipple. At puberty, the hormonal status is vastly changed. An increase in female hormones gives rise to development of secondary sexual characters, the breasts start enlarging in size, whereas in males the male hormones give rise to development of male secondary characters, the breasts hardly increase in size and thus the differentiation takes place.
Males also have a small quantity of oestrogen, the main female sex hormones. The small quantity normally does not give rise to enlargement of breast tissue. Over production of oestrogen, as seen in some diseases ( liver cirrhosis, cancer of the testes or adrenal glands, Klinefelter’s syndrome (a syndrome in which males have an extra X chromosome) chronic renal failure patients on dialysis ), can give rise to enlargement of breasts in the same fashion as seen in females and this enlargement is known as gynaecomastia.
This is also known to occur after the use of certain medicines. The well-documented ones are the drugs used for ulcers, blood pressure, heart failure, migraine, seizures, and also the use of oestrogen commonly prescribed for cancer of prostate. Forty per cent of adolescent boys do experience gynaecomastia but it soon disappears. During old age, when the hormonal balance changes, the breast size may enlarge. The accumulation of fat in obese men (a classical example is Sumo wrestlers) can make the breasts appear enlarged but this is not true gynaecomastia.
Gynaecomastia is not cancer. It is a benign condition; and there is no evidence that it can chance into cancer except for tha onas that have been produced by " "oestrogen. Cancerous changes, like alseshera, can take place in"the breast tissue.
Male and female breast cancer patients have common features. A swelling or nodule in the breast (commonly under the nipple and areola), without any pain (one must remember this) is the common presenting complaint. Bloody discharge from the nipple, retraction of the nipple, ulceration of the overlying skin or presence of nodules in the armpit (palpable lymph nodes) are the other presenting features.
The male breast cancer patients are diagnosed at an advanced stage of the disease, even in developed countries; this delay results in bad prognosis of the male breast cancer patients as compared to females. The small size of the male breast also contributes. The tumour quickly goes beyond the confines of the breast and spreads into the overlying skin and the underlying muscles.
The diagnosis and investigations in a male breast cancer patient is carried out in the same way as in a female. Mammography is not of much help because the small-sized breast can not be satisfactorily examined by mammography machine. MRI, CT scan, Ultrasound are useful.
The line of treatment is multi-modality—comprising of surgery, radiotherapy, chemotherapy and hormone therapy. Mastectomy or surgical removal of breast is the standard treatment and unlike in females where breast conservation (removal of the tumour only) is feasible, because of the small size of the male breast, total removal of the breast is the procedure of choice. In an advanced stage, the surgeon may have to perform a more radical procedure, taking away the underlying muscles and may have to also use skin grafting to cover the resultant defect. Use of multiple chemotherapeutic agents, either before or after surgery, is widely used and gives better results.
Breast tumour tissue contains hormone receptors in a high proportion of men—over 80 per cent as compared to 65 per cent in women but because of the paucity of vast experience on the subject, it is not yet known if positive hormone receptor status indicates a better prognosis as seen in women. Similarly the role of antioestrogen agents has not been well established although it is considered to be beneficial. Surgical castration has been also credited to give beneficial results – regression of the size of the tumour, relief of symptoms and clearance of metastasis in a few patients but the experience is scanty. A patient of male breast cancer may go into a state of depression particularly if he considers himself to be harbouring a disease that is predominantly for females, and one that involves hormone imbalances, this might be perceived as a threat to his masculinity. He definitely requires support and sympathy from his dear and near ones. — Dr S. M. Bose
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