“Every minute, four women are diagnosed with breast cancer worldwide and one woman dies from the disease, and these statistics are worsening”- IARC scientist Dr Joanne Kim.
Causes for concern in the rising rates of breast cancer are well-founded, stemming from the disease’s status as the leading cause of cancer related deaths for women .
The disease Breast Carcinoma occurs where cells in the breast region mutate,typically starting in the ducts or lobules, resulting in a mass of abnormal cells which continuously divide to form a tumor. If the formation of a malignant tumor were to occur, which is cancerous, it would invade nearby tissues and potentially break off in a process known as metastasis, spreading in the blood and lymph to form secondary tumours in the body.
Types of Breast Cancer:
- Lobular carcinoma: Starts in the breast ducts
- Ductal carcinoma: Starts in the milk producing lobules
typical symptoms for the aforementioned disease include:
- persistent pains in the breast or armpit areas
- irritation of the skin covering the breast along with redness and dimpling in the vicinity
- the emergence of a mass
- changes in skin tone in breast region
- nipple discharge
The indicator nipple discharge(ND) merits additional discussion. While 1.6% to 13% of all breast cancer incidences present with said sign, it is largely overlooked. ND associated with Breast Carcinoma is classed as pathological (abnormal) and is distinct from its physiological (normal) counterpart in terms of causes, affected areas and discharge produced. With abnormal discharge, it is mostly independent of breastfeeding reasons (unlike physiological), likely only affects one breast and could produce discharge which is bloody or serous. Likely causes include invasive breast cancer amongst other benign breast diseases.
Causes and risk factors:
While the etiology of breast cancer remains uncertain, risk factors attributed to it include the environment, the individual’s lifestyle, and genetics. With regards to environmental factors, one study by Adams et al. (2021) did not find a consistent association with overall environmental quality (accounted for by EQI score) and invasive breast cancer; however, the investigation instead found land environmental quality to play a pivotal role in increasing risk, where exposure to elements including pesticide use, livestock operations, toxic sites and geochemical exposures all demonstrated a positive association with all invasive breast cancer stages. Lifestyle is widely considered to play a significant role as a risk factor for breast cancer, as evidenced in a large Norwegian cohort study (Furberg et al. 2020), where regular consumption of alcohol increased overall breast cancer risk by 31%, Inactivity and Obesity contributed to higher risk, while other factors such as smoking and high blood pressure play a less obvious role. Even if certain factors showed mixed or weaker associations, the study still makes the point that the cumulative effect is significant. In discussing genetics, those having cancer prone relatives are considered genetically predisposed, with certain genes including (BRCA1, BRCA2, TP53, CDH1 and STK11) being frequently associated with familial breast cancer.
While etiology can contribute to the risk of developing breast cancer, the biological characteristics of the tumor developed (growth rate, aggressiveness and receptor status) influence decisions on treatment.
Diagnosis methods:
The main methods employed to diagnosis of breast cancer are outlined as follows:
Clinical breast exam: This involves a manual examination of the breast by a healthcare professional. The clinical focus is to detect the presence of anything atypical (e.g. lumps, skin changes, nipple discharge or any other abnormalities)
- Breast ultrasound: Where a machine uses sound waves to create sonograms of the breast, this is carried out to gain information on structures within the body, such as being able to differentiate whether a breast lump is a solid (possible tumor) or fluid filled.
- Breast MRI: Magnetic fields and radio waves are used alongside contrast dye to create detailed, 3D images. The rationale for said method’s implementation includes detecting cancerous areas that aren’t visible on mammograms or ultrasound or scanning for cancer in the other breast.
- Mammogram: Split into screening and diagnostic categories, they are taken out in order where if any abnormalities are found within the screening section, a diagnostic mammogram will then be carried out to look at the identified anomalous area.
- Tissue sampling/ Biopsy: Tissue samples are taken from the breast where tests to determine their healthiness can therefore be carried out.
Staging and grading:
Following a positive breast cancer diagnosis, the stage and grade of the disease must be determined to decide on the best possible course of treatment. Where the staging system considers the size of the tumor, number of lymph nodes affected (if any) and whether metastasis has occurred. In terms of grading, it is a comparison between how distinct the cancer cells look compared with normal cells, which reflects on its aggressiveness in terms of growth.
Treatments for breast cancer may include:
- surgery
- radiotherapy
- targeted therapy
- chemotherapy
- immunotherapy
The most frequently used strategy among these modularities is still surgery, with the two main procedures in surgical management being mastectomy and lumpectomy.
(Mastectomy)
Mastectomy is a surgical procedure which, when employed, can play an important preventative or therapeutic role when addressing breast cancer. Its prophylactic functions apply for those either with a strong familial history of breast cancer or have DNA with confirmed genetic mutations which increase the risk of breast cancer. While for its therapeutic role, it covers the physical extraction of cancer cells and tissues from the breast tissue, simultaneously aiding in preventing the process of metastasis. Generally, mastectomy can be carried out for most stages and types of the disease; however, timing for administering the procedure is critical as once breast cancer has metastasized beyond the breast and nearby lymph nodes, it is considered incurable, although the condition can still be managed with systemic therapies to limit disease progression thus improve survival. Historically, radical mastectomy was carried out where the breast skin, nipple areola , underlying chest wall muscles and lymph nodes in the region were removed. In recent years, said type is reserved for patients who have advanced breast cancer that has invaded the muscle wall beneath the breast tissue, as it is considered the most disfiguring of all the different types of mastectomies. Patients can alternatively opt for simple (total) mastectomy, modified radical mastectomy, skin-sparing or nipple-sparing mastectomy, where the difference between the different types lies in the amount of skin removed, and thus the ease of reconstructing the primary breast.
(Lumpectomy)
Regarding the surgical method Lumpectomy, it can also be referred to as partial mastectomy and is another surgical method applied to remove cancerous tissue. But what distinguishes it from mastectomy is its aim to also preserve the overall appearance of the breast. Beyond local disease management, lumpectomy can also be used in a diagnostic manner, where, during the biopsy the abnormal tissue will be removed for examination purposes to verify whether a tumour has a benign or malignant nature. Other treatments typically carried alongside lumpectomy include the sentinel lymph node biopsy, which aims to check whether the cancerous cells have spread to the lymph nodes in the armpit. Another contrasting point between the two procedures lies in the selectiveness of lumpectomy. The procedure is only recommended in cases that the cancer only affects one area of the breast, there is likely to be sufficient tissue for a good cosmetic result to be achieved following surgery, the tumor covers a small area compared to the overall volume of the breast, and it is in a suitable position. Additionally, patients are not recommended to proceed with lumpectomy should they have inflammatory breast cancer, confirmed DNA mutations making them susceptible to recurrent cancer cases (e.g. BRCA1/2), or have had cases of recurring breast cancer following a previous lumpectomy. To evaluate the successfulness of the operation, the cells in the tumor and lymph nodes will be tested for signs of cancer in order to determine their margins. (negative margin = no cancer cells found , positive margin = occasional surgery may be needed to further remove the cancerous cells)
Summation:
Breast cancer is both a social and medical challenge, and promoting awareness, encouraging early detection, and knowledge of treatment options are key to improving not only survival but quality of life.
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