Introduction
Breast cancer is the most common cancer in women across all European countries, with approximately 320,000 new cases reported in 2006. Depending on a number of factors, up to one in nine women will be affected at some stage during their life. Breast cancer also occurs in men but is much rarer – less than 1% of the rate in women. Over 80% of women who develop breast cancer are aged 50 or over and 50% are over 60 when diagnosed.
The treatment for breast cancer has improved enormously over recent years and in general the earlier the diagnosis is made, the greater the likelihood of curing the cancer.
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The Breast
Each breast consists of between 15 and 30 lobules that contain glands capable of producing milk, linked to the nipple via milk ducts, all embedded in fatty tissue.
The breast lies in front of the chest wall but a tail of breast tissue extends towards the axilla (the axillary tail). The armpit, or axilla, contains lymph nodes which are important in determining the appropriate treatment as breast cancer generally spreads first to these lymph nodes. Cancer can spread to the axillary lymph nodes, and the lymph nodes above the clavicle (collar bone) and behind the sternum (breast bone - the internal mammary lymph nodes). All of these are referred to as regional lymph nodes.
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Breast Cancer
The most common form of breast cancer arises from the milk ducts (ductal cancer) but some cancers arise from the milk glands or lobules (lobular cancer).
Ductal carcinoma in situ is not the same as ductal cancer, as it is not an invasive form of cancer, but it is regarded as being a pre-cancerous condition.
Paget’s disease is an unusual form of in situ ductal breast cancer of the nipple and areola which usually causes a red scaling rash around the nipple. This is sometimes itchy or feels as if it is burning and used to be mistaken often for an eczematiform (so benign) skin disease. There may be associated lumps underneath the nipple.
One of the characteristics of cancer is that it spreads to other areas of the body, by growing into nearby tissues, or through blood to the lymphatic system. Cancer which spreads to the regional nodes is treated with the original cancer. Breast cancer also spreads to more distant areas of the body, most often in the lungs, the bone, the liver or the brain.
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Breast Cancer Risk Factors
The large majority of breast cancers occur in postmenopausal women.
Having a strong family history of breast cancer is a risk factor and may mean that close family members have a genetic predisposition to breast cancer, but only about 5% of all breast cancer cases can be attributed to breast cancer genes. If you have a relative under the age of 40 diagnosed with cancer, a male relative with breast cancer, a relative with cancer of both breasts, two close relatives under the age of 60 with breast cancer or relatives with ovarian cancer (especially at a relatively young age), you may have a genetic predisposition and so should be even more suspicious of any breast lumps that you find.
Every completed pregnancy lowers the risk of developing breast cancer, and the protective effect is greater in younger women, so not having children or having children later in life is a risk factor. To a large extent this, together with the life expectancy, explains the differences in the breast cancer incidence between countries. Other risk factors are early onset of menstruation, late menopause, obesity and excess alcohol intake.
There are many good reasons for taking Hormone Replacement Therapy (HRT) during and after the menopause, including the treatment of hot flushes, protecting yourself against osteoporosis, countering vaginal and urinary problems as well as memory lapses and loss of self-esteem. HRT helps all these problems but excessive use of hormone replacement therapy, and in particular oestrogen-progesterone preparations, is associated with an increased incidence of breast cancer.
There is also some controversy surrounding the use of the oral contraceptive pill for longer than 8 years. Most of the data are based on women taking the older forms of oral contraception. These patients were at higher risk but women taking newer forms may not be at any increased risk. In any event, once you stop taking the pill, the risk of developing cancer appears to fall gradually back towards the same level as someone who has never taken the contraceptive pill.
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Prevention
In the vast majority of breast cancer patients, there are no obvious risk factors. Reducing obesity, consuming alcohol in moderation and avoiding prolonged use of hormone replacement therapy will all reduce the statistical risk but their impact in terms of prevention is very limited. However, much more important is awareness that breast lumps, discharge from the nipple and any tethering of the skin may be significant signs warranting immediate medical attention. For more details, see Symptoms of Breast Cancer below.
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Self-Examination of the Breast
The UK Breast Cancer Awareness Campaign provides advice on how to check your breasts at least once a month. In summary, self checking involves:
- Looking for changes that are unusual - changes in the shape or size of the breast or nipple, or in the position or colouring of the nipple, including inversion, or dimpling, denting, scaling or discolouration of the skin
- Feeling your breasts - feel for anything unusual such as a lump or swelling in the breast or in the armpit, arm or around your clavicle or collarbone
- Being aware - recognising other changes such as discharge from the nipple, pain in the breast or armpit
- Reporting any changes that you find to your doctor without delay, as well as attending routine breast screening if you are aged 50 or over
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Symptoms of Breast Cancer
The main symptoms of breast cancer are a lump or lumps in the breast, discharge from the nipple or developing an inverted nipple, tethering of the skin, any unusual appearance of the breast or breast discomfort and, more rarely, pain.
All these symptoms may be due to a variety of causes one of which is breast cancer. If you develop any of these symptoms, you should seek medical advice urgently.
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Diagnosing Breast Cancer
The discovery of a lump in the breast is always very worrying. Most will be benign or non-cancerous but all lumps must be investigated fully as delay in diagnosis means that treatments may have to be more extensive and may be less effective.
Mammograms, special X-rays of the breasts, are another way in which breast cancers can be found, even before it is possible to feel a lump. Mammography is a very good screening test for women over 40, but is less useful in younger women.
If a breast lump is found, a small sample of cells is taken from the breast for examination under a microscope. Two common ways of doing this are 'fine needle aspiration cytology' (FNAC), or an excision biopsy, in which a whole lump is removed under anaesthetic and then sent to the laboratory to be examined.
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Treatment of Breast Cancer
There is a range of treatments available for breast cancer including surgery, radiotherapy, hormone treatment, chemotherapy and newer biological treatments (monoclonal antibodies). Some patients may have just one of these while others, based on personal and tumour-related characteristics, may receive all five. Exactly what your doctor recommends will depend on a number of factors unique to you, including the type of cancer you have, whether it has been diagnosed early or late in the course of the disease, your age and health as well as your personal views on the options available to you.
Surgery
Surgery is often the first treatment suggested in the treatment of breast cancer and is frequently followed or combined with radiotherapy, chemotherapy and other treatments. The extent of surgery is adapted to tumour size, balancing the efficacy of treatment and risk of complications.
The aim of surgery is to remove the cancerous tumour and this may be done by removing just the affected part – breast conserving surgery, sometimes called a ‘lumpectomy’ – or by removing the entire breast. Reconstructive surgery is now frequently offered to restore the visual appearance of the breasts.
Sometimes surgery will include removing the lymph nodes in the armpit, as these can also be involved, and it is common practice for your surgeon to recommend removal of some of the nodes just to check whether cancer has spread to them.
External Radiotherapy
Radiotherapy can be used in conjunction with surgery to reduce the risk of the cancer recurring (adjuvant therapy). Radiotherapy uses radiation from a range of different sources delivered in a variety of ways to maximise the killing effect of radiation on cancer cells whilst protecting, as far as possible, normal cells from its effects.
Radiotherapy can be given in a number of ways. Two forms of radiation are generally used:
- Photons or megavoltage beams that are both electromagnetic beams, just like visible light, of a spectrum that delivers energy in the tissue that is irradiated.
- Particles like electrons or protons with sufficient energy to affect the cells in the irradiated tissue.
Radiation works by damaging the genetic material in the cell nucleus making it impossible for the cell to grow and divide. Radiation is harmful to normal cells as well as cancer cells. By exploiting the different effects on normal and cancer cells and delivering radiation as precisely as possible to only the cancer, the effect is to shrink the tumour. By directing the beam from different angles the maximum effect of radiation can be targeted at the cancerous tumour with the surrounding non-cancerous tissues receiving much smaller doses. Normal cells are also better at repairing themselves than cancer cells.
Radiotherapy is normally given as a series of short regular treatments in a radiotherapy department (each treatment is called a fraction).
Radiotherapy – intra-operative treatment
A single dose of radiotherapy during surgery is now being investigated in some centres as an alternative to longer, 5-7 week courses of radiotherapy after surgery. It might be used in the treatment of early stage breast cancer.
Radiotherapy – brachytherapy
In brachytherapy radioactive sources are placed into the breast tissue itself providing extra radiation to the area around the tumour.
Tubes are put into the breast to guide radioactive elements to the part of the breast being treated. These may be left in the breast for several days to enable the delivery of a continuous treatment over several days. Depending on the system being used, the treatment can be interrupted to allow normal nursing care or visitors to enter the room.
Hormone treatment
Tamoxifen blocks oestrogen that can stimulate breast cancers to grow. Tamoxifen has been used for more than 30 years to treat breast cancer in women and men at all stages of the disease. It helps prevent treated breast cancer from returning and helps to prevent new breast cancers developing. Tamoxifen also slows or stops the growth of breast cancer cells that have spread to other parts of the body. The most frequent side effects are the induction of menopausal symptoms, an increased risk of thrombosis, especially in smokers, and an increased risk of endometrial cancer after prolonged use.
Tamoxifen has also been tested to reduce the risk of breast cancer in women with significant risk factors but the positive effect is at least partially counter-balanced by the side effects of long-term use.
Aromatase inhibitors block the production of oestrogen in tissue outside of the ovaries and so work in women who are postmenopausal. Their effect is at least as good as that of tamoxifen but can cause painful joints (arthralgia).
Chemotherapy
Chemotherapy simply means treatment with chemical agents or drugs. In cancer treatment, drugs are used to kill cells in a number of ways and as cancer cells grow and divide more quickly than normal cells, the effect of the drug on the cancer cells is greater. Moreover, unlike normal cells, cancer cells cannot repair the damage caused by chemotherapy to the same extent. These mechanisms are thereby very similar to radiotherapy but the side effects are more general as chemotherapy spreads throughout the entire body, which often limits the dose that can be given to patients.
Drugs commonly used to treat breast cancer include cyclophosphamide, epirubicin, 5-fluorouracil, methotrexate, mitomycin, mitoxantrone, doxorubicin, docetaxel and some others.
Biological treatment – monoclonal antibodies
Trastuzumab is a form of immunotherapy used to kill breast cancer cells. Some breast cancers have an oncogene called HER-2-neu with receptors on the surface of the cell. Antibodies called monoclonal antibodies detect and attach to these receptors. Trastuzumab works in a different way from standard cancer therapy, such as chemotherapy or hormone therapies. It binds to the HER-2 receptors stopping growth and cell division. This adds to the effects of other anti-cancer treatments including chemotherapy. The most common side effect up to now is a decrease in heart function, which is usually partially reversible at least.
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Looking after Yourself
Radiotherapy for breast cancer is highly effective for many patients but can cause a number of side effects. Some patients will not experience any side effects, whilst others may experience several that are troublesome. Fortunately most of these side effects disappear soon after the treatment ends and during treatment the symptoms can usually be treated, so it is important to mention these to your doctor or nurse, so they can give you the treatment you need.
Tight-fitting clothes are best avoided as these can rub against the skin causing soreness, and if there is damage to the skin can even lead to infection. Consequently loose fitting cotton tops are recommended.
Dry skin and soreness of the skin affected by treatment is best treated by limiting washing of that area, combined with the use of a non-perfumed, moisturising cream. In more troublesome cases, a weak hydrocortisone cream helps to ease skin irritation and soreness.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
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Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what this will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits I might get?
- How good are my chances of getting those benefits?
- Could having treatment make me feel worse? If so, in what way and for how long?
- Are there other treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusions
There is no one solution to the management of breast cancer, but for clinical and personal reasons particular treatments will suit some patients better than others. Comprehensive information and advice is available from the clinical team to enable patients to make the right decision for them.
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