Facts, Diagnosis and Treatment of Breast Cancer
Magnitude of the Problem
- Breast cancer is the commonest cancer in urban Indian females and the second commonest in the rural Indian women.The numerous myths and ignorance that prevail in the Indian society result in an unrealistic fear of the disease. It is hardly surprising that the majority of breast cancer patients in India are still treated at locally advanced and metastatic stages.
- The numerous myths and ignorance that prevail in the Indian society result in an unrealistic fear of the disease. It is hardly surprising that the majority of breast cancer patients in India are still treated at locally advanced and metastatic stages. Lack of an organized breast cancer screening program, paucity of diagnostic aids, and general indifference towards the health of females in the predominantly patriarchal Indian society do not help early diagnosis of breast cancer.Over one lac new breast cancer patients are estimated to be diagnosed annually in India.
- Over one lac new breast cancer patients are estimated to be diagnosed annually in India.
- The incidence of this disease has been consistently increasing, and it is estimated it has risen by 50% between 1965 and 1985.The rise in incidence of 0.5–2% per annum has been seen across all regions of India and in all age groups but more so in the younger age groups (< 45 years).
- The rise in incidence of 0.5–2% per annum has been seen across all regions of India and in all age groups but more so in the younger age groups (< 45 years).
- In general, breast cancer has been reported to occur a decade earlier in Indian patients compared to their western counterparts.While the majority of breast cancer patients in western countries are postmenopausal and in their 60ies and 70ies, the picture is quite different in India with premenopausal patients constituting about 50% of all patients.
- While the majority of breast cancer patients in western countries are postmenopausal and in their 60ies and 70ies, the picture is quite different in India with premenopausal patients constituting about 50% of all patients.
- More than 80% of Indian patients are younger than 60 years of age.Young age has been associated with larger tumor size, higher number of metastatic lymph nodes, poorer tumor grade, low rates of hormone receptor-positive status, earlier and more frequent loco regional recurrences, and poorer overall Survival.
- Young age has been associated with larger tumor size, higher number of metastatic lymph nodes, poorer tumor grade, low rates of hormone receptor-positive status, earlier and more frequent loco regional recurrences, and poorer overall Survival.
Diagnosis in Breast Cancer
- Fine needle Aspirations or core needle biopsies to prevent scarring incisions.Imaging modalities like C.T. and MRI rely on detecting anatomic changes for the diagnosis, staging and follow-up.
- PET has the ability to demonstrate abnormal metabolic activity, and 18F-2-deoxy-D-glucose (FDG)
- PET provides important tumor-related qualitative and quantitative metabolic information that may be critical for the diagnosis and follow-up.
- The combination of PET and CT allows the functional PET and anatomical CT images to be acquired under identical conditions and then they are rapidly co-registered.
- This combined system has advantages over CT alone as functional information is added to morphological data, and this combined system has advantages over PET alone because pathological areas of tracer uptake are better localized and the image acquisition time is reduced.
- Pet CT is recommended for evaluation of clinical stage 3 and 4 patients. The major roles for PET/CT in breast cancer are for detecting and localizing metastasis and monitoring the response to treatment and early detection of recurrence.
Breast Cancer Surgery
- The preferred method of treatment for many women with early breast cancer is conservative surgical therapy (principally lumpectomy and axillary dissection followed by breast irradiation.
- Sentinel node biopsy is being investigated as an alternative to standard axillary lymph node dissection.
- For women who choose mastectomy, immediate reconstruction of the breast is now routinely performed with a prosthetic implant or autologous tissue.
- Stage I and Stage II breast cancers are early cancers that are not fixed to the skin or muscle. If lymph nodes are involved, they are not fixed to each other or to underlying structures. Modified radical mastectomy continues to be appropriate for some patients, but breast conservation therapy is now regarded as the optimal treatment for most.
- Six prospective randomized trials have shown no difference in survival when mastectomy is compared with conservative surgery plus radiation for Stage I and Stage II breast cancer.
- Reconstruction is available for women who need a total mastectomy or whose partial mastectomy leaves an unacceptable deformity.
- Reconstructive surgery can be delayed or performed immediately, and uses either breast implants or autologous tissue.
- The most commonly used autologous tissue is the TRAM (transverse rectus abdominis myocutaneous) flap. The latissimusdorsi muscle also can be used.
- In some cases, free flaps are used.
- Reasons for undergoing reconstruction include Inability to wear clothes, dislike of the external prosthesis and weariness of the mastectomy deformity.
- Women tend to be satisfied with the result of reconstruction when it is delayed months or years after mastectomy.
- Chemotherapy or radiation therapy will not interfere with the reconstruction.
- Immediate reconstruction is more convenient for patients, less expensive, and limits exposure to anesthesia risk. The aesthetic results tend to be better and the patient does not have to live with a deformity, even temporarily.
Chemotherapy in Breast Cancer
- Chemotherapy and hormonal therapies are very important aspect of breast cancer management from early to Metastatic cancer.
- All patients with tumor size more than 0.5 cm require systemic treatment based on nodal status, hormonal receptor status (ER, PR) and Her 2neu status.
- Select group of patients with tumor size less than 0-5 cm, Grade I, ER, PR positive, Her 2neu negative can be spared of chemotherapy and only hormonal treatment is required.
- All node negative patients requires 6 cycles of adjuvant chemotherapy with Anthracyclines and all node positive patients are treated with a combination of Anthracyclines and Taxanes treatment.
- All patients who are Her 2 neu three plus, in addition require treatment with trastuzumab for one year.
- Patients with Locally advanced breast cancer are treated with neoadjuvant chemotherapy Anthracyclines and Taxanesplus, minusTestzumab depending upon Her 2 neu status.
Radiotherapy in Breast Cancer.
- Adjuvant irradiation improves local control following both mastectomy and breast-conserving surgery. For women at high risk of relapse, it also increases survival.
- The greatest concern following adjuvant breast irradiation is of an increase in cardiovascular mortality after 15–20 years.
- New techniques of breast irradiation including conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have been shown to reduce cardiac and lung irradiation.
- Improved dosimetry within the breast may improve both local control and cosmesis.
- Women are deciding to have treatment of breast cancer with a safe and effective form of radiation therapy known as “breast brachytherapy”.
- This method of therapy, which delivers radiation directly into a tumor site from the inside out, is a way to save most of the normal breast tissue, preserve the cosmetic appearance of the breast, and avoid the physical and emotional trauma of extensive breast removal surgery.
- Accelerated partial breast irradiation (APBI) is currently being explored as an alternative option to deliver adjuvant radiation therapy (RT) after lumpectomy in selected patients with early-stage breast cancer treated with breast-conserving therapy (BCT).
- Although there are several different types of RT that can be used to deliver APBI, techniques using brachytherapy have been the most frequently used modality. The reported 5-year and 10-year rates of local tumor control have been excellent.
- Interstitial brachytherapy can be a difficult technique to teach and learn. It requires the use of multiple catheters, widespread patient acceptance is limited.
- In recognition of these problems, a logistically simpler, technically more reproducible, and patient “friendly” device the Mammo site breast brachytherapy catheter are available to deliver APBI.