WHAT IS BREAST CANCER?
Breast cancer a form of cancer that develops when cells within the breast begins to grow out of control. These cells form a tumour within the breast and these present as lumps that can be felt within the breast or seen on an x-ray. According to a Vanguard Newspaper report, In Nigeria alone, the federal government estimates a breast cancer rate of 102,000 cases annually and an annual date rate of about 72,000 individuals. The report estimates that in combination with cervical cancer, breast cancer makes up for over 50% of reported cancer cases in Nigeria. Globally also, it is reported that breast cancer accounts for about 25% of all reported cancer cases (WHO, 2014).
Though breast cancer cases are more prevalent in women with a projected estimated rate of about 100 times more, men can also develop breast cancer.
TYPES OF BREAST CANCERS
- Ductal Carcinoma in situ (DCIS)
- Inflammatory breast cancer
- Invasive lobular carcinoma
- Male breast cancer
- Paget’s disease of the breast
- Recurrent breast cancer
Angiosarcoma is an uncommon malignant neoplasm. AS is a type of cancer that affects the cells that lines the walls of blood vessels or lymphatic vessels. It is rarely reported as a form of breast cancer but because of its metastatic capability, they can be carried by blood vessels to distant sites and this can include the breast. It can also be as a result of complications arising from a previous radiation therapy to the breast. When women are treated for cancer surgically or by radiation, a form of swelling called lymphedema may occur. AS can occur on the affected arms of women with lymphedema.
Statistically, less than 10% of all angiosarcoma cases originates from the breast. When talking about breast cancer alone, angiosarcoma account for a very small percentage of cases; less than 005% or approximately, 1 in every 2500 breast cancer cases.
Breast Angiosarcoma is also referred by other names such as mammary angiosarcoma, and lymphangiosarcoma, when it develops in the area of the lymph nodes. Once angiosarcoma develops, it can easily grow and metastasize, spreading rapidly.
Breast Angiosarcoma may be graded as low grade, intermediate grade, and high grade, for staging purposes, based on the histological evaluation of tumour cells and upon the degree to which malignant cells exhibiting vascular differentiation have infiltrated the breast parenchyma.
Ductal Carcinoma in situ (DCIS)
Also known as intraductal carcinoma, this is the most common type of pre-cancerous non-invasive breast cancer. This type of cancer occurs within the milk duct, hence the name. While carcinoma is a generic name that describes every form of cancer that begins or occurs in the skin or other tissue that covers or lines the internal organs, in situ is an English word that means “in its original place or location”. Though DCIS is not life threatening and invasive, it can increase the risk of developing other forms of invasive breast cancer with time.
In breast cancer staging, DCIS is classified as stage 0. It is rare for DCIS to produce symptoms or lumps and can only be detected through mammographic scans and when it does cause any symptoms, it is most usually characterized by a bloody nipple discharge.
Inflammatory breast cancer(IBC)
Inflammatory breast cancer is a rare and very aggressive form of breast cancer. It develops rapidly and occurs when cancer cells block the lymphatic vessels in skin covering the breast, causing a characteristic red and swollen appearance of the breast.
IBC is one of the most aggressive forms of breast cancer and can occurs in women of any age and rarely in men. Because of its presentation as an inflammation, IBC can easily be confused with a breast infection. It is considered a locally advanced cancer because it can spread from its point of origin to nearby tissue and possibly, nearby lymph nodes.
Compared with other forms of breast cancer, inflammatory breast cancer tends to be diagnosed at younger ages. It is more common in blacks and African Americans and is more common in obese women than in women with normal weight.
Invasive lobular carcinoma(ILC)
From its name, invasive lobular carcinoma is a type of cancer that begins in the lobules (each breast contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk for breastfeeding) of the breast. This cancer then invades the surrounding tissue. This form of cancer is also called infiltrating lobular carcinoma. It is the second most common type of breast cancer after ductal carcinoma. In a nutshell, ILC refers to a form of cancer that has broken through the wall of the lobule of the breast and begun to invade other tissue of the breast. If left undetected and untreated, overtime, ILC can invade and spread to the lymph nodes and possibly other parts of the body.
Unlike inflammatory breast cancer that is diagnosed earlier in women, invasive lobular carcinoma is reported by the American Cancer Society as diagnosed in older women. It is reported that about two-thirds of the cases of women reported with invasive lobular carcinoma are 55 and above.
Invasive lobular carcinoma does not form a lump, which is common in most breast cancer types. Instead, there is a change in the breast that feels like a thickening or fullness in the affected area of the breast and is different from the surrounding tissue. It accounts for 5-10% of all cases of invasive breast cancer.
Male breast cancer
Men do not have a pronounced breast like women. Even at this, they still have a small amount of breast tissue. The size of breast of an adult man is similar to the size of the breast of a little girl before puberty. In infancy, all breast sizes seam the same. But as puberty occurs, the breasts begin to develop in girls but it doesn’t in boys. But because it is still tissue, men can still get breast cancer. Men do get all the forms of breast cancer as women do but cases of ductal carcinoma and invasive lobular carcinoma are rare.
Male cancer occurs more in older men but can still occur at a younger age. Men that are diagnosed of breast cancer in the early stages have good chances of a cure. It is however not unseen that men do not turn up to see the doctor when signs and symptoms begin to appear either because of lack of education on breast cancer in men or because they can’t just conceive the possibility of a breast cancer in men.
Breast cancer in men just like it is in women spreads via lymphatics and blood stream. Lesions are easier to find in males rather than females because of the size of the breasts. The presence of gynecomastia (an endocrine system disorder in which there is a non-cancerous increase in the size of male breast tissue) may mask the condition. In male breast cancer cases, lesions are less contained in males as they do not have to travel far to infiltrate skin, nipple or muscular tissue.
Paget’s disease of the breast
First described by Sir James Paget in 1874, it is a rare type of breast cancer that starts on the nipple and extends to the areola (dark circle of skin around the nipple). It has an outward appearance of eczema with skin changes around the nipple. Accounting for between 1-4.3% of reported cases of breast cancer, Paget’s disease of the breast often appears harmless and limited to the surface; thereby causing misdiagnosis.
Paget’s disease of the breast is characterized by Paget cells. Paget cells are relatively large, neoplastic epithelial cells (carcinoma cells) with a hyperchromatic nucleus and abundant palely staining cytoplasm. In Paget’s disease of the breast, such cells occur in neoplastic epithelium in the ducts and in the epidermis of the nipple, areola and adjacent skin.
Paget’s disease of the breast mostly affects women above the age of 50. Most women with this disease have underlying ductal breast cancer which can be in situ or less commonly invasive breast cancer.
Recurrent breast cancer
Recurrent breast cancer as the name indicates is a breast cancer that recurs after it has been treated. This recurrence could be within months or years of initial treatment. When it recurs, it could be at the initial point of occurrence (local recurrence) or within other parts of the body (distant recurrence). However, recurrence is known to occur within the first five years of initial breast cancer treatment.
SIGNS & SYMPTOMS
The most conspicuous symptom of breast cancer is the lump. Major awareness campaigns carried out on breast cancer in Nigeria is aimed at enlightening women on how to identify lumps on their breast and to know when they are not just cysts but malignant tumours.
Most common signs and symptoms of breast cancer are:
• A breast lump or thickening that feels different from the surrounding tissue.
• Redness or pitting of the skin over the breast, having the appearance of an orange.
• One breast becoming larger than the other.
• Inversion of the nipples or the nipples could also change shape.
• Skin dimpling or pickling.
• A rash on or around the nipple.
• Discharge from the nipple, especially around younger women could also be a sign of breast cancer.
• Constant pain in part of the breast or armpit and swelling beneath the armpit or around the collarbone.
• Peeling or scaling of the areola (the pigmented area of skin around the nipple).
• Unexplained weight loss could be a sign of breast cancer, although this is not a definitive sign as it can also be an indicator to some other underlying health issues.
• As with weight loss, joint or bone pains can also be a manifestation of metastatic breast cancer, but this is non-specific as it could also be a sign of other diseases.
As per global standards, though it is quite possible to identify or initially recognize a possible breast cancer case by standard case definition based on signs and symptoms, these may not lead to a definitive diagnosis. It is most common that a health worker may carry out a physical examination of the breast (palpation) and mammography is also commonly applied. Inconclusive results from the mentioned processes may likely result to a health care worker, removing a sample of the fluid in the lump for microscopic analysis in a process known as fine needle aspiration. A clear fluid makes the lump highly unlikely to be cancerous but a bloody fluid is indicative of breast cancer. Breast tissue biopsy (a process where samples of the cells or tissues are extracted medical examination to determine the presence of a disease), may also be carried out by a pathologist to determine whether cancer cells are present and to conclude a case diagnosis as breast cancer. There are also prescribed medical examinations which includes blood tests, x-rays, CT-scans and endoscopy.
In Nigeria, diagnosis and detection of breast cancer is primarily dependent on typical investigation such as breast tissue biopsy x-rays, abdominal ultrasonographic scan and CT scan. There is limited use of mammography, flow cytometry, frozen section histology. The options to use advanced techniques such as stereotactic core needle biopsy (which measures calcium deposits or masses that are not visible on ultrasound), tumour markers, estrogen/progesterone receptor status and PET (Positron Emission Tomography) scans are not always available.
In ways more than one, women are now educated on how to carry out routine self-examination of their breasts because early detection is important in treatment.
Surgical treatment may include Mastectomy (removal of the whole breast, Quadrantectomy (removal of one-quarter of the breast, and Lumpectomy (removal of a small part of the breast).
Adjuvant therapy (the drugs used in addition to surgery) are available for treatment of breast cancer. There are three types of medications available for adjuvant therapy and they are hormone-blocking therapy, chemotherapy and monoclonal antibodies.
– Hormone-blocking therapy: The presence of high level of estrogen encourages the growth of some forms of breast cancer and this is because of the presence of hormone (estrogen ER+ and progesterone PR+) receptors on the surface of these cancer cells. These ER+ cancers can be treated with drugs that either prevents the production of estrogen or blocks off the receptor binding sites and prevents the estrogen from binding to the receptors; this is known as a competitive inhibition and an inhibitor such as aromatase inhibitors are used.
– Chemotherapy: Chemotherapy is mostly used in treating stages 2-4 cancers that are estrogen receptor negative (does not have estrogen receptor sites on the surface). They are often administered as combination therapy and administered for a period of 3-6 months. Most chemotherapy work by causing DNA damage as cells replicate. In this process, they also damage and prevent cancer cells from replicating.
– monoclonal antibodies: Monoclonal antibodies therapy enlists the natural immunity of the body to combat cancerous cells. Monoclonal antibodies are synthesized to mimic the functions of the natural body immune system. They are designed to bind to antigens that are generally more on the surface of the cancers cells than on the healthy cells. In doing this, it mimics the immune system and attacks these cells. They can work in many ways which may include: triggering cell-membrane destruction which causes the destruction of the outer membrane of the cancer cells. They can also work by flagging cancer cells by coating cancer cells and making them a specific target for the immune system to destroy. They can also block cancerous cell growth and can directly attack these cancer cells.
Radiation therapy delivered in form of external beam radiotherapy or internal radiotherapy (brachytherapy) is given after surgery to the region of the tumour bed and regional lymph nodes, to destroy microscopic tumour cells that may have escaped excision during surgery. Radiotherapy can be administered during the surgery but is conventionally administered after the surgery and can considerably reduce the risk of recurrence up to 50-66% when delivered in the correct dose.
For a proper understanding of prevention of breast cancer, it is important to understand the causes. The causes of breast cancer are unknown, so it is correct to discuss the risk factors. Defining risk factors does not constitute a clear chance to having the disease but it is educative and gives everyone a clear path to understanding possibilities and being on the lookout. Risks factors could be modifiable (such as lifestyle) which could be and fixed factors (such as age, sex and genetics) and hence cannot be changed.
Lifestyles such as smoking of tobacco, sitting regularly for a prolonged period, hormonal birth control medications, and occupational hazards such as radiation and constant contact and inhalation of organic solvents, polycyclic aromatic hydrocarbons, etc, could greatly increase the risk of breast cancer.
Genetics has also been reported to be a minor cause of breast cancer to an estimate of about 5-10% of all cases. Some medical conditions such as atypical ductal hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are correlated with an increased breast cancer risk.
Given that causes and risk factors have been understood, one can begin to lay hands around preventive methods.
– Lifestyle: Women can reduce their chances of having breast cancer by reducing their level of alcohol and tobacco intake maintaining a healthy weight and actively breast feeding their children. Physical activities also reduce chances of developing breast cancer. Reducing exposure to uncontrolled radiations, organic solvents, polycyclic aromatic hydrocarbons and limiting the dose of hormone therapy also reduces the risk of breast cancer.
– Pre-emptive surgery: People with a high chance of developing breast cancer (BRA1 and BRA2 mutation) may be advised to undergo prophylactic bilateral mastectomy (a process whereby both of the breasts are removed before any cancer is diagnosed or the appearance of any suspected lumps).
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