Breast Cancer (Symptoms, diagnosis, treatment)
Breast cancer occurs when breast cells develop abnormally and grow out of control forming a malignant (cancerous) tumour. It is possible for cancer cells to spread (metastasise) from the breast to other parts of the body via the lymphatic system and by direct entry into the blood vessels. Once there, they can form "secondary" cancers.
Breast cancer is the most common form of cancer in New Zealand women. Every year in New Zealand over 2000 women are diagnosed with breast cancer and approximately 700 women die from the disease. Prior to menopause the majority of new breast lumps found are benign (non-cancerous). However after menopause one in two new breast lumps found will be malignant. Approximately 75% of all breast cancers will occur in women over the age of 50 years. Overall, 10% of New Zealand women will develop breast cancer at some stage of their lives. Internationally, breast cancer rates have increased in most developed countries over the last 40 years.
Breast cancer can recur. Once a woman has had breast cancer her chances of developing it again are increased fivefold.
Men can develop breast cancer though it is rare. Signs and symptoms are similar and treatments are the same.
Background information about breasts
Breasts are composed of fibrous (connective) tissue, fatty tissue and glandular (lobular) tissue. They lie on a band of strong muscle that sits on the ribs of the chest. Breasts have no useful biological function other than to provide milk for babies.
Fibrous tissue gives the breast its shape and helps to support the fatty tissue and glandular tissue. As women age, the fibrous tissue is replaced with fatty tissue. This leads to changes in the shape and texture of the breasts.
The glandular tissue is made up of a series of lobules. These are small structures that produce milk when stimulated by female hormones during pregnancy. The milk produced in the lobules drains into small channels called ducts which eventually open into the nipple. Glandular tissue also responds to menstrual related hormonal changes, which can cause the breasts to be occasionally tender and lumpy.
Picture reproduced with the kind permission of the Anti-Cancer Council of Victoria
In the breast, armpit and neck there are small glands called lymph nodes, which, along with the lymph vessels into which the nodes drain, are part of the lymphatic system. The role of the fluid filled lymphatic system is to filter infections and prevent them entering the blood stream. Each breast has a network of lymph vessels that drain into a system of about 24 lymph nodes in the armpit. These are called the axillary lymph nodes. There are also lymph nodes behind the breastbone called the internal mammary nodes. Some of these nodes drain into the axillary lymph nodes, with the remainder draining into other nodes in the chest.
Axillary lymph nodes
The causes of breast cancer are not known. However, it is known which women are more at risk of developing the condition. The main risk factors for developing breast cancer are:
- Being a woman over the age of 40 years.
- Having a family history of breast cancer - the younger the family member was
- when they developed breast cancer, the greater the risk.
- Having had breast cancer previously.
- Having had a biopsy showing an "at risk" breast lump or thickening.
- Having a breast cancer gene (BRCA-1 and BRCA-2, AGM gene, HRSA-1).
- Women with a breast cancer gene have a 50% chance of developing breast cancer before the age of 70.
Other risk factors include:
- Having had an early onset of periods or the late onset of menopause.
- Having had a first child after the age of 30 years or not having had children at all.
- A diet high in fat, excessive alcohol and a reduced intake of fibre, fruits and vegetables.
- Being on HRT medication for longer than 5-7 years or taking the oral contraceptive pill may slightly increase the risk of developing breast cancer, but this has not been conclusively proven.
- Having dense breasts - dense breasts do not increase the risk of developing breast cancer, but they may make lumps difficult to feel and see.
- Being in a high socio-economic group or having Jewish ancestry may also be risk factors for developing breast cancer.
There are different types of breast cancers. These include:
- Ductal carcinoma in situ (DCIS): DCIS is when the breast cancer cells are completely contained within the milk ducts and have not spread into the surrounding breast tissue. It is the earliest stage of breast cancer and is almost always completely curable.
- Invasive ductal carcinoma: This is the most common type of breast cancer. It starts in the milk ducts and spreads into the fatty tissue.
- Invasive lobular carcinoma: This cancer starts in the milk glands (lobules) and spreads into the fatty tissue.
Most commonly, the first sign of breast cancer is a new lump in the breast. The lump is usually painless.
Other signs of breast cancer include:
- A new area of thickened tissue in the breast.
- Nipple discharge or a change in the nipple.
- Dimpling or puckering of the skin of the breast.
- A change in breast size or shape.
While these symptoms may not be related to breast cancer, it is important to see a doctor promptly for assessment and accurate diagnosis if any of these symptoms are present. Early detection is vital in the successful treatment of breast cancer.
If an abnormal lump is found, or other symptoms are present, a referral to a breast specialist for assessment and diagnosis will probably be recommended. In order for an accurate diagnosis to be made the three step approach of clinical examination, imaging (mammography and ultrasound scanning), and biopsy will be required.
Clinical examination:
The doctor will begin by examining both breasts. They will then check the abnormal lump's size, location and other characteristics such as whether it is mobile, hard or soft, regular or irregular. The doctor will ask about the history of the lump such as how long it had been there, has it grown, is it painful. Risk factors such as family history or previous breast lumps will be asked about.
Imaging (mammograms and / or ultrasound scanning):
A mammogram (specialised breast x-ray) shows the soft tissue of the breast and can indicate any suspicious areas. Ultrasound scanning uses sound waves to form an image of the breast tissue. Pictures of any suspicious areas can be taken. Ultrasound scanning is particularly useful for assessing whether a lump is fluid filled or solid.
Biopsy:
There are different types of biopsies used to take cells or tissue samples from a suspicious lump so they can be sent to a laboratory for analysis under a microscope.
- Fine needle aspiration: This is usually the first type of biopsy used. It is performed using a local anaesthetic and involves inserting a fine needle into the lump and removing a small sample of cells and/or fluid. At the laboratory the sample is spread onto a glass slide and analysed. The insertion of the needle may be guided by ultrasound.
- Core biopsy: This uses a larger needle to remove a sample of tissue from the lump. A local anaesthetic is used and a very small incision (1-2mm) is made in the skin over the lump. The needle is usually guided into the lump by ultrasound. At the laboratory the tissue sample is sliced very finely and placed on a glass slide for analysis.
- Stereotactic core biopsy: This is a core biopsy performed on a special x-ray table allowing three dimensional computerised images of the lump to be taken and used to guide the biopsy needle into the lump. This is useful for testing lumps seen on a mammogram that cannot be felt or visualised using an ultrasound scanner.
- Excision biopsy: This is a minor surgical procedure where part or all of the abnormal area is removed. It can be performed using a local or general anaesthetic. If the lump is unable to be precisely located using mammogram or ultrasound scanning, it may need to be marked by a thin wire called a "hookwire". This is inserted under x-ray guidance using a local anaesthetic just prior to the surgery.
If a diagnosis of breast cancer is made, blood tests, x-rays and scans of the bones and liver may be performed to assess whether the cancer has spread to other organs.
Breast cancers are given a "stage". The stage indicates the tumour's size and how far it has spread within the breast, surrounding tissues or to other organs in the body.
Stage one: These tumours measure less than two centimetres. The axillary lymph nodes are not affected and there are no signs that the cancer has spread elsewhere in the body.
Stage two: These tumours measure between two and five centimetres, or the axillary lymph nodes are affected, or both. There are no signs that the cancer has spread elsewhere in the body.
Stage three: These tumours are larger than five centimetres, the axillary lymph nodes are usually affected, but there are no signs that there has been any further spread.
Stage four: These tumours are of any size, but the axillary lymph nodes are usually affected and the cancer has spread to other parts of the body.
Breast cancer tumours are also classified as being "hormone receptor positive" or "hormone receptor negative". Approximately 60% of all breast cancer tumours are hormone receptor positive meaning that they rely on oestrogen or progesterone to grow. The hormone receptor status of the tumour will be taken into account when treatment is planned.
Another classification given is the HER-2 status of the cancer. HER-2 stands for “human epidermal growth factor receptor – type 2.” It is a type of protein that is attached to the surface of normal cells and influences the cell’s growth and reproduction. In HER-2 positive breast cancers there are an abnormally large number of HER-2 proteins on the cancer cells. This can cause the cancer cells to grow and spread at a faster rate. Approximately 15-25% of all breast cancers are classified as HER-2 positive. Women with this type of breast cancer have a poorer prognosis than women who are not HER-2 positive.
Treatment of breast cancer depends on the type of breast cancer, its size and position, whether it has spread, the woman's age and general health and the woman's preference. Generally some type of surgery is recommended followed by additional treatments (adjuvant therapies).
Surgery and radiotherapy are classed as local treatments (as they affect a localised, specific area) while chemotherapy and hormone therapy are classed as systemic treatments (as they have the potential to affect the whole body).
SURGICAL TREATMENT
Lumpectomy/Partial mastectomy:
In most cases, the breast cancer tumour can be removed without having to remove the entire breast (referred to as breast conserving surgery). The area of the cancer is removed along with a ''margin" of healthy surrounding tissue (usually about 1cm), to ensure that all of the breast cancer is removed.
Mastectomy:
This operation involves removing the entire breast and all of the breast tissue from just below the collarbone to the upper abdomen. A "simple mastectomy" is when just breast tissue is removed. A "modified radical mastectomy" is when the lymph glands under the arm are also removed.
Mastectomy may be recommended if the tumour is large, there is more than one area of breast cancer in the breast, or for cases of recurrent breast cancer. A hospital stay of 2-5 days and a recovery period of 3-6 weeks can be expected after a mastectomy.
Surgical treatment may also involve:
Axillary node dissection:
It is usually standard practice during surgery for breast cancer to remove up to half of the axillary lymph nodes for testing. Testing of the lymph nodes can indicate whether the cancer has spread into the lymphatic system, thus increasing the risk of the cancer spreading to the rest of the body.
Axillary node dissection is usually well tolerated but there is a risk that the remaining lymph nodes will not be able to adequately cope with the drainage from the lymphatic vessels in the breast. This can lead to shoulder stiffness, changes in sensation in the area, and a condition known as lymphoedema which is marked by arm swelling.
Sentinel node biopsy:
This is a relatively new type of lymph node biopsy and is appropriate for use in some cases in order to minimise the problems associated with axillary node dissection. During a sentinel node biopsy two special dyes are injected around the breast cancer tumour. One is visible to the naked eye during the biopsy surgery and the other is a weak radioactive substance detectable by either a Gamma camera or a hand-held device like a Geiger counter. The dyes drain through the lymph vessels and into the first node to be involved - the sentinel node. This node is then removed for analysis. If the sentinel node is clear of cancer cells, then it can safely be presumed that the cancer has not spread to the rest of the axillary nodes. If however the sentinel node is positive for cancer cells, a subsequent procedure to remove the remaining lymph nodes would be needed.
Breast reconstruction:
After mastectomy, some women may chose to have the breast reconstructed. This can be done at the time of the mastectomy or at a later date. The surgery is usually performed by a plastic surgeon. The aim of breast reconstruction is to recreate a breast that feels and looks as natural as possible.
The majority of breast reconstructions are performed using muscle and tissue taken from the abdomen in a procedure known as a TRAM flap procedure. Less commonly, muscle and tissue from the back can also be used in a procedure called a Latissimus Dorsi flap. Artificial breast implants can also be used to reconstruct the breast. This is usually done in conjunction with stretching the skin in order to accommodate the implant.
With TRAM flap or Latissimus Dorsi flap breast reconstruction a hospital stay of 4-6 days and a recovery period of 4-6 weeks can be expected.
Occasionally the healthy breast needs to be made smaller to match the breast that has been reconstructed. This surgery would be performed at the same time as the breast reconstruction.
For women who do not wish to have breast reconstruction, an external breast prosthesis can be used. This is a jelly-like breast shaped mould that fits into a specially fitted bra and comes in a variety of shapes and sizes. When worn, the appearance is the same as that of a normal breast. Wearing the prosthesis also helps to maintain proper balance and posture. The New Zealand government provides funding of $600 every four years for the prosthesis and bras.
NON-SURGICAL TREATMENT
Additional treatments are commonly given after surgical removal of the breast cancer. One or a combination of these treatments may be recommended. An oncologist (cancer specialist) will be involved in deciding which treatments will be given.
Radiotherapy:
This uses radiation to destroy any cancer cells that may be left in the breast. It is most commonly used after lumpectomy/partial mastectomy. However, it may be used after mastectomy if there was more than one tumour, the tumour was large, or the tumour was growing close to the chest wall. Radiotherapy is usually given according to the "rule of five" - five minutes per day, five days per week, for five weeks. Side effects of the treatment include severe tiredness and burns similar to bad sunburn on the treated area.
Chemotherapy:
This may be given if spread of the cancer is suspected or confirmed and is usually given soon after surgery. Chemotherapy medications can be given by tablet or as injections into the blood stream. Usually it is a combination of both. The medications aim to kill off any cancer cells that may be circulating in the body. There are different strengths and combinations of chemotherapy medications, which are given in cycles. Side effects of chemotherapy treatment may include nausea, hair loss, sores in the mouth and diarrhoea.
Hormone therapy:
For cases where the breast cancer is hormone receptor positive, hormone therapy may be prescribed to help prevent recurrence of the breast cancer. These medications work by blocking the hormone receptors on the breast cancer cells, preventing hormones binding to them and stimulating growth. One common example of this type of medication is tamoxifen. This is commonly given for up to five years after diagnosis of breast cancer.
Biological therapy:
This type of treatment includes a class of anticancer medications called “monoclonal antibodies”. These medications are formulated to target cancer cells, rather than normal healthy cells. A monoclonal antibody medication used in New Zealand is Herceptin (trastuzumab). This is used to treat women with HER-2 positive breast cancer. Herceptin works by binding to the HER-2 proteins, preventing them from stimulating the cancer cells to grow. It also acts to “flag” the cancer cells to the body, which then stimulates the immune system to destroy the abnormal cells.
In New Zealand, Herceptin is funded and approved for use in the treatment of women with advanced breast cancer. Some clinical trials results (eg: the HERA Trial) have indicated that Herceptin reduces the recurrence rate of breast cancer.
There has been considerable media coverage of this issue. In March 2006 the Medicines and Medical Devices Safety Authority (Medsafe) gave provisional approval for the use of Herceptin in the treatment of HER-2 women who have early stage breast cancer.
After the diagnosis and treatment of breast cancer, regular follow up visits with the healthcare specialists involved in the treatment will be scheduled. This will include seeing the oncologist and surgeon. Initially this may be as frequently as every three months, but will eventually be less often. During these visits monitoring procedures such as imaging (mammograms/ultrasound scans), blood tests and clinical examinations will be conducted.
Other healthcare professionals who may be involved in the ongoing care and monitoring include the patient's GP, a breast physician, breast care nurse and physiotherapist.
Some women may find it beneficial to see a counsellor to help them deal with the emotional and psychological impact of the breast cancer diagnosis and the implications of treatment.
As the cause of breast cancer is unknown, the condition cannot be prevented as such. However, there are many things women can do to minimise their risk of developing breast cancer. Women who are at increased risk of breast cancer should be monitored by their GP or a specialist. This may include clinical examinations and imaging. Early detection is vital. Breast cancer detected early has a much better chance of being effectively treated than breast cancer that has been detected late.
Ways in which all women can work to reduce their risk of breast cancer include:
Screening:
It is recommended that all women have annual mammograms from the age of 40 years. Women in high-risk groups may be recommended to start having regular mammograms at an earlier age.
Women aged from 45 to 69 years who have had no history of breast abnormalities can have annual mammograms through Breast Screen Aotearoa, a free national screening program.
Breast self examination (BSE):
It is recommended that women check their breasts regularly. This enables them to learn what their breasts feel like normally so that they are better able to detect any changes or abnormalities in the breast.
Lifestyle factors:
Eating a diet low in fat, undertaking regular exercise and limiting alcohol intake may also help to reduce the risk of breast cancer.
In rare cases where there is a strong family history of breast cancer or other factors such as a cancer gene or previous breast cancer, a woman may chose to have both breasts removed - usually with breast reconstruction. This will reduce her chances of developing breast cancer. However, it is possible for the cancer to develop in remaining breast tissue.
International trials of genetic testing are underway. The hope is to be better able to clearly identify which women are at risk of developing breast cancer. These trials are not currently being conducted in New Zealand.
Further Information and Support
The following organisations can offer further information, support and resources about breast cancer.
Cancer Society of New Zealand Information Service
Staffed by specialised cancer nurses, this service provides information on all types of cancers. They have an extensive library of resource books able to be lent out. They also have details of the Lymphoedema Support Network.
Ph: 308 0162 (within Auckland)
or 0800 800 426 (outside Auckland)
BreastScreen Aotearoa
This free national mammography service that helps check for early breast cancer. The program is offered to all women in New Zealand aged between 45-69 years who have no symptoms.
New Zealand Breast Cancer Foundation
This organisation aims to educate women and the wider community about breast cancer. Guest speakers are bought to NZ and the foundation holds fundraising and awareness events.
Breast Cancer Network (NZ) Inc.
This organisation is for survivors of breast cancer and their supporters. It aims to promote increased efforts to prevent and cure breast cancer - by advocacy, education, information and networking.
Look Good….Feel Better
This registered charity offers free workshops teaching techniques to restore appearance and self-image to women coping with the side effects of cancer treatment. Group workshops are held nationwide.
Freephone: 0800 865 432 (for callers outside the Auckland area)
Ph: 09 308 0245 (for callers within the Auckland area)
Sweet Louise
Provides support and information for women with metastatic breast cancer
Anti-Cancer Council of Victoria (2001) How is breast cancer diagnosed? Anti-Cancer Council of Victoria.
www.cancervic.org.au/cancer1/patients/breast/howdiagnosed.htm
Anti-Cancer Council of Victoria (2001) Tell me more about breast cancer. Anti-Cancer Council of Victoria.
Cancer Society of New Zealand Inc (2001) Breast Cancer (pamphlet). Wellington. Cancer Society of New Zealand Ltd.
Cancer Society of New Zealand Inc (2001) Risks of Breast Cancer (pamphlet). Wellington. Cancer Society of New Zealand Ltd.
Consumers' Institute of New Zealand Ltd (2000) A woman's guide to health.- New Zealand Edition (J. Parker ed). Consumers' Institute of New Zealand Inc. Wellington.
Everybody (2001) Breast cancer. Auckland: MediMedia (NZ) Limited:
http://www.everybody.co.nz/page-753d513f-0152-4957-adbc-557a9f786dd0.aspx
Taylor, L (2006) Herceptin (trastuzmab) provisionally approved. Ministry of Health Media Release. Ministry of Health. Wellington.
The New Zealand Breast Cancer Foundation (Date unknown) Important Information on Breast Cancer (Pamphlet).
Last Reviewed – 13/12/06