Breast Cancer Incidence, Detection and Treatment A Primer

Cancer may have started the fight, but I will finish it.

 SYNOPSIS

 In India, out of two women with breast cancer one will die within five years. Many of these lives can be saved by early detection of cancer. If cancer is detected at stage 1, that is when it is local within the breast, the five-year survival rate is 99%. If it is detected at stage 3 or 4, that is when it has spread to other body parts and organs, the five-year survival rate drops to 22%.

Cancer is endogenous. It cannot be prevented. Therefore, for cancer, the saying is not “prevention is the cure” but “early detection is the cure.”

By 2030 India will have 200,000 cases of breast cancer and 100.000 deaths. Twenty-five years ago, about 30% patients were below age fifty. Now, about 50% are. And it is affecting younger women, those in 30s and 40s.

Breast self-screening is one way of detection of the cancer. Imaging techniques can detect it even earlier. Women above 40 should have regular screening for breast cancer.

Age, heredity, genetics, obesity, smoking, and late menopause increase the risk of cancer. Lifestyle changes can reduce the risk. Treatment is surgery, chemotherapy, and radiation. Targeted, Hormonal, and Immunotherapy are also used. Gene therapy and High-intensity focused ultrasound (HIFU) are promising experimental therapies. Integrative medicine is a combination of medical treatment and complementary therapies. The latter do not treat cancer but can help cope with signs and symptoms caused by cancer and cancer treatments.

Alternative therapies claim that cancer can be treated by taking certain herbs or supplements, or food and avoiding certain food. But these therapies are disproved or unproved. They do not treat cancer and are often harmful.

Ayurveda, Siddha, Unani, Yoga, Naturopathy, Homoeopathy, Chinese Medicine also have cancer treatment. But these are not proven.

If you loved your life before cancer, do not be afraid of life after cancer. You will find beauty again. “I have loved the stars too fondly to be fearful of the night.” — Galileo.

Introduction

In India, of the two women with breast cancer, one will die within five years. Breast cancer was once a disease of old age. No longer. In India, the age of woman diagnosed with breast cancer has progressively reduced from 50 years to 40 years. And 5% of breast cancer cases occur in women under 40 years of age.

Breast cancer is the most common cancer in women worldwide and in India. In India, one woman is diagnosed with breast cancer every three minutes, and one woman dies of breast cancer every six minutes. Out of one hundred breast cancer women, forty-fifty die within five years in India, but less than five die in the US. The difference in death rates is because in India women come for treatment late, when cancer has advanced to Stage III or IV, and therefore has low survival rate.

Rise in Breast Cancer

Breast cancer in India is rising at a rapid rate. And is affecting younger women, those in 30s and 40s. In 2018, breast cancer had 1,62,468 new registered cases and 87,090 reported deaths. By 2030, the number of cases will rise to about 200,000 a year and deaths to about 100,000 a year. Twenty-five years ago, about 30% patients were blow age fifty. Now, about 50% are.

Improving Survival Rate

Breast cancer survival rate in India is among the lowest in the world because it is detected late. Late detection is because of lack of awareness of breast cancer. Increasing awareness can reduce the death rate. Even if we start a cancer awareness program today, 20-30 years will pass before its effect becomes discernible.

Breast cancer cannot be prevented. But its incidence can be reduced by a few simple lifestyle changes; and the survival rate can be improved by early detection. But let us begin with what is cancer and what is breast cancer.

What is Cancer

Our body is composed of many different types of cells. These cells grow and divide in a controlled manner to produce more cells as required by the body. Also, the older cells and the damaged cells die.

However, sometimes, the genetic material of one cell gets damaged or changed [mutation] and the cell becomes immortal: that is, it will not die. When this ancestor cell divides, its descendant cells are also immortal. This gives rise to a limitless number of immortal descendant cells. The number of cells is far more than what the body needs. The extra cells then form a mass that is called a tumour.

These immortal cells are called cancer cells. The cancer cells are immortal; capable of limitless division, and thus of limitless growth in the number of cells; and capable of spreading [Metises] to other parts of the body through blood and lymph system.

There are more than 100 types of cancers. Not all cancers form tumours. Cancers of the blood and the bone-marrow [leukaemia], for example, do not form tumours.

Most cancers are named for the body part in which they begin: colon cancer, prostate cancer, ovarian cancer, breast cancer and so on.

What is Breast Cancer

Breast consists of lobules (milk producing glands), ducts (tiny tubes that carry the milk from lobules to the nipple) and blood and lymphatic vessels.

Breast cancer is a malignant tumour that starts in the cells of the breast. It begins in the ducts; sometimes in the lobules:  and rarely, in other cells of the breast.

It then spreads through the breast lymph vessels to lymph nodes under the arms and thence to other parts of the body

Who is at risk of Breast Cancer?

Every woman is at risk of breast cancer. In India, one in 28 women will get breast cancer. Certain factors increase the risk of BC.

  • Cancer is a disease of old age: most cancers begin to strike at age 60 and above. But now cancer is also striking, though only rarely yet the teenagers. Risk of breast cancer, for example, is about 0.25% for a 30-year-old woman but increases to about 11% in a seventy-year-old. In different countries, breast cancer risk in a 70-year-old is 54% to 154% higher than in a 30-year-old. Thus, as longevity has increased, so has the cancer incidence.
  • Heredity. If first degree relatives [mother/father/brother/sister] had cancer, the risk of cancer is increased.
  • Genetics.A person can be genetically predisposed to get cancer. A woman who has a family history of breast cancer is statistically more likely to get breast cancer. However, only a small percentage, less than 0.3% of population, is genetically disposed to get cancer. And less than 3-10% of all cancers are because of genetic predisposition. In women with BRCA 1 and BRCA 2, the probability of getting breast and ovarian cancer is more than 75%. Mutations in a few other genes [PTEN, CDH 1, TP 53 etc.] also increase the risk though not as much.

Angelina Jolie, Producer | Director | Oscar-winning Actress had both her breasts removed in May 2013 to reduce the risk of breast cancer because of a gene mutation (BRCA1) she has.

  • Obesity. In obese postmenopausal women breast cancer risk is twice that of the non-obese women.
  • Diet. Diet contributes to up-to 80% of cancers of colon, prostate, and breast; and contributes to cancers of pancreas, lung, stomach and esophagus. Alcohol, red meat, sugar increase the risk of cancer.
  • Smoking, night work, no children or child born after age 30, recent use of oral contraceptives (reverts to normal on stopping), HRT, and Chemicals in environment – increase the cancer risk.
  • Menopause. Late menopause increases the risk.

Reducing the Risk

“You beat cancer by how you live, why you live, and in the manner in which you live.” – Stuart Scott

Healthy weight, physical activity – brisk walking, cycling, swimming – 45-60 minutes five or more days a week, breastfeeding, no red meat, less sugar, and less alcohol lowers the risk.

Controversy about whether diet rich in whole grains, fruits, vegetables, and legumes and low in total fat (butter, oil), more vitamins, Marine Omega 3 fatty acids (found in seafood (e.g., fish oils) and in walnut, seeds, flaxseed oil etc.), and antiperspirants and bras reduce the risk. Abortion and Breast Implants have no effect.

Selective Estrogen Receptor Modulators such as tamofoxien reduce breast cancer risk but increase the risk of thromboembolism and endometrial cancer.

Early Detection

“There can be life after breast cancer. The prerequisite is early detection.”

– Ann Jillian

Since cancer-prevention is not possible, the saying, “prevention is the cure” is amended to “early detection is the cure.”

Only about 10% of cancer deaths are because of primary tumour. Most of the deaths are because of metastasis – spreading of the cancer to other parts of the body. Once metastasis happens, it is difficult to treat the cancer. Early detection of cancer is therefore of utmost importance.

Several ways of early detection:

1. Self-examination of Breasts

More than 80% cancers are detected by women doing self-examination of breasts. The examination should be done every month, 5-7 days after menorrhoea. Look for the following:

  • Lumps in breast (less than 20% are cancer) or in lymph nodes in armpits.
  • Thickening of breasts
  • One breast becoming larger than other
  • A nipple changing position or shape or becoming inverted
  • Discharge from nipple
  • Constant pain in part of breast or armpit
  • Swelling beneath the armpit or around the collarbone

‘Breast cancer self-check’ images and videos are available on internet. In case of palpated anomaly, consult your gynecologist.

The limitations of self-examination are:

  • Only 20% women do self-examination of breasts.
  • The tumour/changes are large by the time they are felt and this delay in detection can adversely affect the treatment outcome.

2. Imaging Techniques

Early detection of cancer is required and is possible by using Imaging Techniques. Six Imaging Techniques are available:

X-rays examination. Small neoplasmatic tissue formations can be seen.

  • Sonography (Ultrasound)

Sonography is done in addition to Mammography to rule out cysts and to estimate the size of the tumour. However, tumours smaller than 5 mm cannot be detected.

  • MRI

MRI is used to detect if the breast has been affected by more than one tumour.

  • Computer Assisted Detection (CAD)

CAD is used to point out diseased regions. It is used as a second opinion to the report of the doctor.

  • CT-scan

CT-scan is most often used to see if breast cancer has spread to other organs.

  • PET

A PET scan is used to detect the cancer cells in the body. It is often combined with a CT scan (known as a PET/CT scan).

Limitations of Imaging

  • Imaging techniques magnify the tumour much as the magnifying glass magnifies the letters in a book. If the font size is very small, a letter cannot be identified even with the magnifying glass. In a similar way, the imaging techniques cannot identify tumours that are very small.
  • The QUALITY of cancer is more important than the QUANTITY. A small tumour can be more dangerous than a large tumour. Imaging can tell the quantity of the tumour, that is, its size, but cannot tell the quality of the tumour.
  • Most of the time, Imaging cannot even tell whether a tumour is cancerous or not.

Confirming Cancer

The only absolute way to confirm cancer is by biopsy: a small tissue from the tumour is taken and microscopically examined to check for cancer.

Types of Biopsies

  • Punching Biopsy. Done in a locally sedated state.
  • Needle Biopsy. Done with a syringe and a special needle. As painful as venepuncture.
  • Advanced Breast Biopsy Instrumentation (ABBI). Done with X-ray to ensure localisation of target. Only a few doctors are experienced in this technique.

Microscopic examination of biopsy is sufficient; but in a few rare cases specialized lab tests are required.

Treatment

Even small, localised tumours have the potential of metastasis and therefore need to be treated. The treatment is surgery, medications (hormonal therapy and chemotherapy), radiation and immunotherapy.

Surgery offers the single largest benefit. Used along with chemotherapy and radiation, the local relapse rate is reduced, and the overall survival rate may increase.

Surgery

  • Mastectomy:  remove whole breast.
  • Quadrantectomy: remove quarter breast.
  • Lumpectomy: remove small part of breast.
  • Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago.
  • Breast Reconstruction Surgery or breast prostheses: to simulate breast.

Neo-adjuvant, which is prior to surgery, and Adjuvant that is after and in addition to surgery, medication is used as part of treatment. For example, Neo-adjuvant use of aspirin may reduce the mortality from Breast Cancer.

Adjuvant Therapies

Radiation (negative effect on normal cells) to kill cancer cells in tumour bed and regional lymph nodes that may have escaped surgery. It reduces the risk by 50 – 66 % (i.e., 1/2 to 2/3 reduction of risk). It is confined to region being treated. But only solid tumour can be treated.

Therapies using drugs/agents etc.

Chemotherapy (negative effect on normal cells). Uses drugs, usually two or more drugs in combination, to destroy cancer cells.

Targeted Therapy

Targeted therapies that became available in 1990s use drugs or other substances to block the specific genes or proteins, or the tissue environment that contributes to a cancer’s growth and survival. Tests are done to identify the genes, proteins, and other factors in the tumor so that the most effective drugs are given. Targeted therapies are also called “molecularly targeted drugs,” “molecularly targeted therapies,” “precision medicines,” or other similar names.

Monoclonal Antibody Therapy in which the agent is an antibody.

Immunotherapy

In Immunotherapy, also called biologic therapy, medicines are used to stimulate, improve, or restore a person’s immune system to recognize and destroy cancer cells more effectively. Immunotherapy can be used to treat some types of breast cancer.

Immune system uses “checkpoints” to avoid attacking normal cells. “Checkpoints” are proteins on immune cells that are turned on, or off, to start an immune response. Breast cancer cells sometimes use these “checkpoints” to avoid being attacked by the immune system. Drugs that target these checkpoint proteins help to restore the immune response against breast cancer cells.

Pembrolizumab (Keytruda) is a drug that boosts the immune response against breast cancer cells and can often shrink tumors. It can be used with chemotherapy before surgery and then given by itself after surgery.

Side effects of these drugs can include fatigue, cough, nausea, skin rash, poor appetite, constipation, and diarrhea. Other, more serious side effects occur less often:

  • Infusion reactions: These are like an allergic reaction, and can include fever, chills, flushing of the face, rash, itchy skin, feeling dizzy, wheezing, and trouble breathing.
  • Autoimmune reactions:These drugs remove one of the safeguards on the body’s immune system. Sometimes the immune system starts attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, or other organs.

Hormone Blocking Therapy

Hormonal or endocrine therapy is effective for treatment of estrogen or progesterone receptors (ER positive or PR positive) cancers. Used either by itself or after chemotherapy it can prevent a cancer recurrence and death from breast cancer.

Hormonal therapy given before surgery shrinks a tumor, makes surgery easier, and/or lowers the risk of recurrence. It is given for at least 3 to 6 months before surgery and is continued after surgery. This is called neoadjuvant hormonal therapy.

When given after surgery solely to reduce the risk of recurrence, it is called adjuvant hormonal therapy.

Experimental Cancer Treatment

Gene Therapy

In gene therapy, a nucleic acid-based drug is delivered to either correct or destroy the genetic aberration (cancer) cells. Its advantages are:

  • It targets tumour cells and does not affect normal cells.
  • It corrects molecular defects and thus retards the cancer progression.
  • It has little toxicity compared to other therapies.
  • It is effective to a particularly stubborn type of breast cancer cells and causes them to self-destruct.
  • It lowers chance of recurrence of the cancer.
  • It helps increase the effectiveness of some types of chemotherapy.
  • It is also used to deliver RNA interference technologies, or cancer DNA vaccines.

It is likely to become a popular therapy for breast and other cancers but at present does not have approved products for breast cancer.

Focused Ultrasound Therapy

High-intensity focused ultrasound (HIFU) is a novel technology which is being investigated. HIFU focuses a pressure wave with a high frequency on a small target volume. It causes an increase in local temperature which induces coagulative necrosis (death) and protein denaturation (disruption of structure) of the target cancer cell within a few seconds. It is used to treat both benign and malignant tumours. Its advantages are:

  • It is an early-stage non-invasive therapeutic technology and therefore has less risk for infection and blood clots and has potential for shorter recovery time.
  • It can be targeted precisely and thus minimizes damage to non-targeted healthy tissue.
  • It has no ionizing radiation and thus can be used repeatedly.
  • It can be used alone, or as a complement to drug therapy enabling enhanced delivery of chemotherapy or immunotherapy to tumours.
  • It may induce an anti-tumour immune response.
  • It can improve the quality of life and decrease the cost of care for patients.

Integrative Medicine

Integrative medicine is a combination of medical treatment and complementary therapies. The latter do not treat cancer but can help cope with signs and symptoms – such as anxiety, fatigue, nausea and vomiting, pain, difficulty sleeping, and stress – caused by cancer and cancer treatments.

Complementary therapies

Types of complementary therapies that can improve well-being include Hypnosis, Massage, Meditation, Relaxation techniques, Exercise, Yoga, Acupuncture, Aromatherapy, Hypnosis, Music therapy, Tai chi, Chiropractic therapy, Reflexology, Reiki, Therapeutic touch, Biofeedback, Imagery (Imagining scenes, pictures, or experiences), Creative outlets (art, music, or dance).

It also includes Vitamins and dietary supplements, Botanicals, which are plants or parts of plants (e.g., cannabis), herbs and spices such as turmeric or cinnamon, and special foods or diets.

Most of the complementary therapies are safe and effective.

Helpful Supplements

Clinical trials show that some herbs and nutritional supplements help to manage specific side effects of cancer treatment. For example, American ginseng and Astragalus root used in traditional Chinese medicine may help reduce some side effects of chemotherapy, such as fatigue. Nutritional supplements like glutamine, vitamin B6, vitamin E, and omega-3 may help treat peripheral neuropathy. However, these supplements are not appropriate for everyone, and more research is needed to confirm their safety and effectiveness.

Alternative therapies

Alternative therapies are sometimes suggested as an alternative to medical treatment. These therapies claim that cancer can be treated by taking certain herbs or supplements, or food and avoiding certain food. But these therapies are disproved or unproved. They do not treat cancer and are often harmful. Because they do not stop the growth of cancer. It may therefore worsen and thus reduce the treatment options because of the severity of the cancer.

The claim that these therapies are natural and therefore safe is false. Natural is not necessarily safe. Poisonous mushrooms are natural but not safe. Herbal supplements may be harmful when taken by themselves, with other substances, or in large doses. For example, kava kava, an herb used to help with stress and anxiety, may cause liver damage. And St. John, used for depression, may cause certain cancer drugs to not work as well as they should.

Dietary Supplements

People take dietary or herbal products to improve health, to get additional nutrition, to boost the immune system, or to treat side effects. Dietary products are vitamin and mineral products. Herbal, botanical, and other “natural” products may contain plants or parts of plants, algae, or fungi, or extracts from animals, such as toad or snake venom.

Not all supplements are safe or effective, especially during cancer treatment. For example, supplements like garlic, ginkgo biloba, ginseng, and Vitamin E can increase risk for bleeding. This could be dangerous for patients undergoing or recovering from surgery. Supplements can also interfere with prescription and over-the-counter medications. They may also be unsafe in specific health problems, including high blood pressure, diabetes, mental health conditions, heart disease, or blood clotting problems.

Side effects of supplements

Supplements can cause serious side effects including:

  • High blood pressure
  • Nausea
  • Diarrhea
  • Constipation
  • Fainting
  • Headaches
  • Seizures
  • Heart attack
  • Stroke

Summary

1. No dietary or herbal product can treat cancer.

3. Herbs may interact with chemotherapy and other drug treatments.

4. Antioxidant supplements may make cancer treatments less effective.

Complementary and Alternative cancer therapies do not treat cancer. But they may lessen signs and symptoms – such as anxiety, fatigue, nausea and vomiting, pain, difficulty sleeping, and stress – caused by cancer and cancer treatments. Hypnosis, massage, meditation, relaxation techniques, yoga, acupuncture, aromatherapy, music therapy, and Tai chi – alone or in combination may be beneficial.

But many alternative cancer treatments are disproved or unproved, and some may even be dangerous.

Cancer Treatment in other Systems of Medicine

Ayurveda, Siddha, Unani, Yoga, Naturopathy, Homoeopathy, Chinese Medicine also have cancer treatment. But these are not proven. Though some of these might help cope with the side effects of cancer and cancer treatment.

Type of Treatment Given

Patients with good prognosis are offered less invasive treatment – e.g., lumpectomy + radiation + hormone.

Patients with poor prognosis are offered more aggressive treatment – extensive mastectomy + radiation + chemotherapy + adjuvant medication.

Treatment Success Rate

If the cancer is detected early, that is at Stage 1, prognosis is excellent and usually chemotherapy is not required.

If detected in Stage 2 & 3 prognosis is progressively poorer with a greater risk of recurrence. Surgery, chemotherapy, and radiation are required.

If detected in Stage 4, that is metastatic cancer (spread to distant sites), prognosis is poor. Surgery, radiation, chemotherapy, and targeted therapies are used. But the 10-year survival rate is 5% without treatment and 10 % with optimal treatment.

In India, more than 60% of the Breast Cancer are diagnosed at stage III or IV. Hence the low survival rate.

Psychological and Emotional Aspects

Cancer patients need psychological and emotional support. Besides the family, such support can be given by support groups who are trained and experienced in giving such support. ‘Cancer Sahyog’ is one such support group in India.

Conclusion

“The only person who can save you is you” – Sheryl Crow

Cancer is a 3200-year-old disease. It is endogenous, a part of life-process. So, it can neither be eradicated, nor prevented, nor cured. Yet.

Late detection of cancer is fatal. The causes for late detection are many but lack of awareness is the principal cause. Other main causes are patient being shy, social stigma and doctors’ ignorance because of which the treatment is delayed. An awareness program will address all these issues.

Will some radical discovery in the future make cancer prevention and cure possible? We do not know. But we can always hope.

Because as Richard Causer, Director, NCI, USA, says about the future of cancer cure, “There are far more good historians than there are prophets.”

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