Everything You Need To Know About Breast Cancer
With Breast Cancer Awareness Month upon us, Dr Jendana Chanyaputhipong is shining a spotlight on breast cancer and sharing everything you need to know – from the different types of breast cancer and breast cancer treatment options to tips on living with breast cancer and preventing it.
TYPES OF BREAST CANCER
Not all breast cancers are the same. Understanding the type of breast cancer a person has helps guide appropriate treatment options for the patient. To understand the type, several things are analysed from tumour’s tissue.
1. Origin of breast cancer—whether the breast cancer arises from the milk ducts, the milk-producing lobules, or the connective tissue that includes fat,
fibrous tissue and blood vessels. The lobules are connected to the ducts, which carry breast milk to the nipple; the connective tissue holds everything
a. Arising from milk ducts, ‘Ductal Carcinoma’ is the most common type of breast cancer. If the cancer is contained within the ducts, it is non-invasive and is called ‘ductal carcinoma in situ’ (DCIS). If the cancer breaks through the walls of the duct and invaded other surrounding breast tissue, it is called an ‘invasive ductal carcinoma’ (IDC).
b. Arising from milk-producing glands called lobules, Invasive Lobular Carcinoma (ILC) is the 2nd most common type of breast cancer. Lobular carcinoma in situ (LCIS) is NOT itself a cancer but greatly increases a person’s risk of developing cancer.
c. Inflammatory breast cancer is a rare and aggressive form of breast cancer that is often locally advanced at presentation. It is given this name because the affected breast often looks inflamed, red and swollen.
d. Rarely arising from connective tissues, breast cancer that begins here is called sarcoma. Malignant phyllodes tumor and angiosarcoma are 2 examples of sarcomas that can occur in the breast.
e. Paget’s disease of the nipple is a rare cancer affecting the skin of the nipple or areola. It often presents with an itchy rash and scaling of the skin on the nipple or areola and often resembles a skin condition known as eczema.
2. Appearance of the cancer cells under a microscope
a. Subtypes of IDC with unique appearances are tubular, mucinous, medullary, papillary and cribriform carcinoma. Knowing the subtypes provides information about response to treatment and prognosis.
b. The degree of likeness or difference between the cancer cells to the normal cells determine the cancer’s grade. On a scale of 1 to 3, grade 1 cancers are most alike and considered least aggressive, while grade 3 cancer is the most different looking and most aggressive.
3. Hormone status of breast cancers
a. Hormone-receptor positive breast cancer refers to the type of breast cancer that has receptors on the outside of their cancer cell walls that can catch and use specific hormones—estrogen and/or progesterone—to grow. It can be estrogen receptor (ER) positive, progesterone receptor (PR) positive, or ER- and PR-positive tumours. This type of breast cancer can be treated with anti-estrogen therapy to block the growth of the cancer cells.
b. Hormone-receptor negative breast cancer refers to the type of breast cancer cells that do not have hormone receptors on the wall, so it will not be affected by estrogen or anti-estrogen therapy.
4. Molecular and genetic information of breast cancer cells.
a. Cancer cells that overexpress HER2 gene are referred as HER2-positive cancers. HER2 is a growth-promoting protein. There are available ‘targeted therapy’ drugs that can shut down the HER2 protein, thereby slowing the growth and killing the cancer cells.
b. More recently, breast cancers are grouped into 4 major molecular subtypes known as (1) Luminal A, (2) Luminal B, (3) HER2 type cancer, (4) Triple-negative/ basal-like breast cancers, based on various factors including ER/PR/HER2 status. Evidence suggests that each group exhibits distinct behaviour that leads to different treatment responses and prognosis.
MAIN CAUSES OF BREAST CANCER
While the exact aetiology of breast cancer is unclear, we know there are three major contributors that increase a person’s risk of breast cancer:
1) Genetic factors
2) Hormonal influences
3) Environmental/lifestyle factors
Most cases of breast cancer are sporadic, while only 5-10% of cases are linked to gene mutations passed through family generations.
RISK FACTORS OF BREAST CANCER
The main risk factors of breast cancer are:
1. Being female
2. Increasing age
3. A personal history of breast conditions known as lobular carcinoma in situ (LCIS) or atypical hyperplasia from previous breast biopsy
4. A personal history of breast cancer in one breast
5. A personal history of previous radiation treatments to the chest.
6. Having a known genetic mutation, such as BRCA1 and BRCA2
7. A family history of breast cancer in first-degree relatives, especially when diagnosed at a young age
9. A long menstrual history (having menstrual periods that started early and ended late in life)
10. Having never been pregnant or having the first child after age 30
11. Extra consumption of estrogen (hormonal replacement therapy, oral contraceptives)
12. Alcohol consumption
13. Having dense breasts
14. Race—white women are slightly more likely to develop breast cancer than Asian or African American women.
SIGNS AND SYMPTOMS OF BREAST CANCER
In early breast cancer, women will usually not experience any symptoms and the breast will not manifest any signs. A mammogram, however, can detect the earliest sign of breast cancer because an abnormality shows up before it can be felt by the women.
Other signs and symptoms of breast cancer include:
• A breast lump or thickened area in the breast or underarm.
• Changes in size, shape or appearance of the breast
• Changes in the skin of the breast, such as dimpling or puckering, redness, swelling or having an orangepeel appearance and increased warmth. Sometimes skin nodule, ulcer or a growth can be seen
• Nipple changes, such as a newly flattened or inverted nipple, itchy rash or scaling/flaking areas affecting the nipple and areola
• Breast pain is not a common sign of breast cancer unless it is advanced.
Women should familiarize themselves with their own breast baseline—how their breasts look and feel—and look out for these warning signs. If you notice a new lump or something in the breast that feels different from before, you should visit a doctor to have it checked out.
LIFESTYLE CHANGES TO PREVENT BREAST CANCER
Being female, growing older, having dense breasts or inherited breast cancer genes are factors that we cannot control. However, we can lower the risk of breast cancer (and other medical conditions too) by simply choosing to live healthy.
Here’s how to adopt healthy lifestyle choices:
(1) Exercise regularly most days of the weeks
(2) Eat a well-balanced, healthy diet rich in vibrantlycoloured vegetables and fruits, healthy fats (olive oil), healthy lean meats and fish, brown rice and whole grain cereals and breads
(3) Omit or limit alcohol consumption to no more than one drink a day, if you choose to drink
(4) Maintain a healthy weight.
For ladies, this includes breastfeeding and avoiding consumption of extra hormones, such as limiting oral contraceptive pills or postmenopausal hormone usage when possible.
LIVING WITH BREAST CANCER
There are several treatment options for breast cancer and treatment is determined based on several tumourrelated factors. These factors include the type of breast cancer, its stage, size, grade and proliferation index (which are features that indicate aggressiveness), and whether the cancer cells are sensitive to hormones or overexpress a protein called HER2.
The patient’s general health, age, menopausal status, and own preferences are also considered. Most women with breast cancer undergo surgery and also receive additional treatment before or after surgery, such as chemotherapy, hormonal therapy, targeted therapy or radiation therapy.
BREAST CANCER SURGERY includes: ▪ Lumpectomy (aka breast-conserving surgery or wide excision) is a surgery that removes the tumour and a small margin of surrounding healthy tissue. This may be recommended for removing smaller tumours located in one quadrant of the breast or after downsizing of the tumour with chemotherapy. The end result is often more cosmetically pleasing to the patient when compared with mastectomy. Occasionally, the margin is involved by cancer cells and another surgery may be indicated. Radiation therapy to the rest of the breast is necessary after a lumpectomy because this reduces the overall risk of the cancer returning in the breast.
▪ Mastectomy. Total or simple mastectomy is an operation to remove not just the area of the breast with the cancer within but all of the breast tissue, some skin and the nipple and areola. In some cases, the skin or nipple may be spared to improve the appearance of the breast.
Because the whole breast tissue is removed, the risk of local recurrence is lower when compared to lumpectomy. Patient may feel numb over the area of surgery. Reconstruction with a breast implant or your own tissue is possible depending on one’s own preference.
▪ Sentinel node biopsy is removing a limited number of lymph nodes in the armpit that are the first to receive the lymph drainage from the tumour. This is performed to determine if cancer has spread to the lymph nodes. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the other remaining lymph nodes is small and, therefore, no additional nodes need to be removed. The risk of arm swelling (lymphedema) is small.
▪ Axillary lymph node dissection or axillary clearance removes several lymph nodes when cancer is found in the sentinel lymph nodes or when a patient presents at more advanced stage. The risk of arm swelling (lymphedema) increases with this.
▪ Removing both breasts may be an option for some women if they have a very increased risk of cancer in the (other) breast because of an inherited gene mutation or a strong family history. Reconstruction can be performed immediately after the removal of the breasts.
In general, breast cancer surgery carries a risk of pain, bleeding, infection, and arm swelling.
Radiation therapy uses highpowered beams of energy to kill cancer cells. This is usually done using a machine that aims the energy beam at the external body. This external beam radiation to the breast is typically performed after lumpectomy and its duration can last up to 6 weeks, depending on your situation, type of cancer and location of your tumour. Fatigue, breast pain, and skin changes (redness, swelling, thickened/rough to the touch, occasionally becoming tender and sensitive) of the treated breast are common early side effects. Over time, the breast may become more firm or shrink in size and the treated skin may become mildly tanned or have a red discoloration, which may be permanent. In patients who need radiation treatment to the lymph nodes in the armpit or above the collarbone, the risk of lymphedema increases. Rarely, radiation therapy itself induces heart, lung, nerve problems, or a second cancer. In cases where cancer has spread to the bones and causes a fracture, radiation therapy may be used to control the symptoms.
Chemotherapy destroy fast-growing cells, like cancer cells. It may be given 1) before surgery in women with large-sized tumors with the goal to to shrink it down, 2) after surgery in women at high risk of cancer returning or spreading to other part of the body, or 3) in patients whose cancer has already spread to other parts of your body to try to control it and decrease any symptoms the cancer may be causing. The side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of getting an infection.
HORMONE (-BLOCKING) THERAPY
Some breast cancers are sensitive to hormones. These cancers are often referred to as estrogen receptor (ER) and/ or progesterone receptor (PR) positive cancers. Hormone therapy is often used after surgery to decrease the chance of cancer returning. In selected cases, it may be used before surgery or on its own to shrink or control the disease. Hormone therapy includes (a) medications that block hormones from attaching to hormone-sensitive cancer cells, (b) medications that stop the body from making estrogen after menopause, (c) medications that stop hormone production in the ovaries and (d) surgery to remove the ovary. Side effects may include hot flashes, night sweats and vaginal dryness. Other side effects depend on the specific treatment and may include risk of bone thinning and blood clots.
These are drugs that target specific abnormalities within cancer cells. Given via infusion into the veins, Herceptin is approved for treatment of breast cancer that is HER2 positive. Depending on the situation, it may be used to reduce the risk of cancer returning or to control the growth of the cancer. Common side effects include nausea, vomiting, infusion reactions, diarrhea, rash, fatigue, muscle ache and infections. Less common side effects include heart failure or a serious form of allergic reaction to the drug.
What to Eat During and After Treatment?
During breast cancer treatment, several things can influence a person’s appetite. This includes stress and anxiety, as well as the nausea, vomiting, mouth sores and fatigue, which are common side effects of breast cancer treatment. Yet, eating a healthy, well-balanced diet is so important so that your body can recover, resist infections and heal from treatment. Often times, we don’t give food the credit it deserves for its ability to nourish and protect the body or even boost immunity. Here are some tips for choosing a healthy diet throughout, and beyond, breast cancer treatment.
1. Choose high-fibre whole grains like brown rice instead of refined white rice, wholewheat bread, oatmeal and quinoa. They are more nutritious and may help with constipation.
2. Take a variety of different and brightlycolored vegetables and fruits daily, as it ensures a greater variety of vitamins, minerals, antioxidants and other healthy nutrients. Cruciferous vegetables like broccoli, cauliflower, kale and brussels sprouts also have antiestrogen properties.
3. Lentils and beans are high in protein and low in fat.
4. Choose healthy sources of protein & unsaturated fats to keep your body strong and helps with repair of damaged tissues.
4. a) Healthy animal sources
4. a) i. Skinless chicken and turkey breasts
4. a) ii. Fatty fish like tuna or salmon, mackerel
4. b) Healthy non-animal sources
4. b) i. Tofu ii. Nuts and seeds
5. Adopt Mediterranean diet high in olive oil and fresh vegetables.
6. Avoid high-fat meats and full-fat dairy products, such as whole milk, butter and cream because these foods are high in saturated (unhealthy) fats.
6. a) Choose low fat dairy products, like skimmed milk and low-fat yoghurts.
6. b) Take non-dairy alternatives, like soy products and almond.
7. Always cook the food well and avoid raw foods during cancer treatment because the body is more vulnerable to infections.
8. Avoid alcohol, because it can interact with the cancer drugs and also is a risk factor for the cancer returning.
9. Avoid sugary treats, like cookies, cake, candy and sodas. They cause weight gain, which is another risk for the cancer returning, and will leave you less room for healthy foods.
10. Stay hydrated by drinking plenty of fluids.
11. If you are unable to eat solid foods, drink smoothies or nutritional beverages.
Once treatment is over, it is important to continue to choose to eat healthy, live active and maintain weight with regular exercise because it has been shown that diet and lifestyle can affect the risk of the cancer returning. Learn to love what is good for you and stick with it.
MANAGING WORK LIFE WITH BREAST CANCER
There is tremendous stress for a person dealing with breast cancer. Not only is the stress about the diagnosis or the experiences of treatment or the fear of the unknown when the breast cancer will return, there are also daily stresses—like finances, family responsibilities, and work commitments—for any ordinary person. You can’t avoid all stress but you can learn to cope with it. It is important to manage the stress because it has physical, mental and emotional consequences.
1. Get the support you need—from family, friends, colleagues and support group.
2. Be kind to your body. Pack healthy food or look for nutrient-rich meals during lunch, avoid alcohol and smoking. Allow yourself a few-minute breaks each day to de-stress completely.
3. Learn to say no to non-essentials so you can focus on caring for yourself better.
4. Admit if you don’t have the time or energy to do what you used to do and delegate.
5. Exercise regularly to stay strong and positive
6. Find hobbies that relaxes you, like meditation, yoga, listening to music, coloring, or gardening.
7. Take time to enjoy life with family and friends, to have fun and laugh because doing what you enjoy gives life meaning.
8. Get good sleep each night to stay strong and keep your energy levels up.
9. Continue with scheduled doctor’s visits to keep the disease in check.