MDT or Multidisciplinary team management involves a 360-degree assessment of the patient clinical condition and involves the medical, surgical and radiation oncology specialities apart from the radiology, oncopathology, physiotherapy and palliative care units. The best multimodality treatment options for the patient are decided upon the inputs from these specialities to provide the best treatment plan for the patient.
Breast Cancer: Symptoms & Treatment
What is the breast? Where is it located?
The breast is a superficial organ attached to the muscle on the rib cage. It is present in both males and females and is however more well developed in females. In women, it is made up of milk-producing glands and ducts that carry milk to the nipple. The glands and ducts are supported by fat and fibrous tissue which gives the shape of the breast.
What is breast cancer?
Normally, the healthy cells in our body grow old and replace themselves with new cells in an orderly manner. When there are abnormal changes in this process, the cells go haywire and there is no control of the growth of new cells. This purposeless proliferation of cells takes over the body’s function and is called cancer. When this happens in the breast its called breast cancer.
- How do we approach as MDT?
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- Why have I developed breast cancer?
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Approximately 80 percent of women who develop breast cancer have no known risk factor. Some risk factors make women more prone to developing breast cancer and this is associated with prolonged exposure to the hormone oestrogen. However, one must keep in mind that just because one or two of these factors may be present, it does not necessarily mean that this is the cause for the cancer
- Early menarche
- Late menopause
- No pregnancies
- Late first childbirth
- Lack of breastfeeding
- Use of OCP (oral contraceptive pills) or HRT ( hormone replacement therapy)
- Obesity
Nearly 5 percent of breast cancers are genetic and have a strong family history of cancers. Certain genetic mutations like BRCA, P53, can increase the risk of getting cancer.
- What are the symptoms of breast cancer?
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The presentation of breast cancer can be varied. The following symptoms should raise awareness and one must see a doctor for the same
- New-onset change in the size of one breast
- Lump in the breast
- Skin thickening or ulceration
- Redness in the breast
- Nipple discharge
- Nipple inversion
- Puckering or dimpling, particularly while raising the arms above the head
- Lump in the underarm area
- Any new or unusual change in the breast.
In Western countries, owing to the higher incidence of breast cancer, screening strategies are employed. By this, all patients above the age of 40 years are advised to have a mammogram either yearly or once in two years.
In India, while a formal screening programme does not exist, it is advisable for adults above the age of 40 years, especially those with a family history of breast cancer, to get themselves tested with a baseline mammogram and then a decision of how frequently it needs to be done can be discussed on a case-by-case basis with your doctor.
- What investigations will I be subjected to?
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The best investigations to help diagnose breast cancer is a mammogram combined with an ultrasound. A mammogram is an x-ray of the breast and the breast is flattened in different positions between two plates for compression. An ultrasound of the breast is many times done in addition to the mammogram and is a painless procedure which not have any radiation. Some jelly is placed on the breast a probe is used to visualize all areas of the breast systematically.
If there is an abnormality or lesion detected in one of these reports, then it is recommended to undergo a core needle biopsy. This helps to confirm as to whether the lump is cancerous or not. It is a small procedure that takes less than 5-10 minutes and is done under local anaesthesia. A small needle is used to get tissue from the lump that can then be sent to the pathologist for testing. The report usually takes a couple of days and hormone receptor testing (including ER/PR/ Her 2) can be done on this sample to give us more information regarding the tumour.
Depending on the stage of the disease, a PET CT may be asked to check for a spread of cancer to other parts of the body.
If an operation is being planned, some more tests may be necessary to decide the fitness of the patient for general anaesthesia.
- At what age can you get breast cancer?
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Breast cancer is the commonest in the 40-70-year age bracket, however, it is known to occur in women in their teens as well as in women older than 70 years.
- How does breast cancer start?
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Breast cancer starts as an uncontrolled division of cells which then increases in number to form a tumour/lump. Each cell of the body carries a “program “inside its nucleus in the form of DNA. One or more mutations in the DNA, a cell may become trigger this uncontrolled growth.
- How long can you have breast cancer without knowing?
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By the time a breast lump becomes palpable, it has been present in the body for several years. However, lumps can be detected before they become palpable, by screening normal women using a mammogram, which is a soft X-ray of the breast.
- Where the first place breast cancer spreads?
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Cancer can spread locally to infiltrate the skin or the muscles of the chest. Also, it can spread to glands that lie in the armpit, above the collar bone and behind the breast bone. It can also spread to other organs; the common organs that breast cancer metastasizes to i.e. spreads to are liver, lungs, bones and brain.
- Stages of Breast Cancer & Prognosis
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The stages of breast cancer can broadly be divided into 4 based on the extent of the lump in the breast, the involvement of the glands that the breast drains into, as well as the presence of disease outside the breast.
Stage I: A small lump with no disease elsewhere except for tiny deposits in the glands in the armpit. In this stage, there is an excellent chance of long-term control subject to the grade of the lesion.
Stage II: In this stage, the patient has either a small cancerous lump with a few affected glands or a large lump with no affected glands. Patients with stage II breast cancer have an excellent chance of cure.
Stage III: Implies the presence of a large lump with affected glands in or the presence of 4 or more involved glands in the underarm.
Stage IV: Indicates advanced disease, such as infiltration of the skin, chest wall, or involvement of glands in the armpit and also centrally. Spread of disease to other distant organs is also termed stage IV cancer.
- Types
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Ductal carcinoma in situ (DCIS): most common precursor stage of breast cancer that means it is localised and do not spread to nodes or distant sites. It is usually asymptomatic but may present as a swelling. 30 -50% of DCIS can develop into invasive breast cancer later. Tamoxifen 5mg daily for 3 years have shown to reduce the chances of developing invasive cancers.
Inflammatory breast cancer:
Inflammatory breast cancer is a rare and very aggressive disease in which cancer cells block lymph vessels in the skin of the breast. This type of breast cancer is called “inflammatory” because the breast often looks swollen and red, or inflamed.Inflammatory breast cancer is rare, accounting for 1 to 5 per cent of all breast cancers. Most inflammatory breast cancers are invasive ductal carcinomas, which means they developed from cells that line the milk ducts of the breast and then spread beyond the ducts.
Invasive lobular carcinoma: a type of breast cancer that originates in the milk-producing glands (lobules) of the breast. They have the potential to spread to the lymph nodes and other areas of the body. Usually, they occur in later ages (above 60yrs). They are rare when compared to the invasive ductal carcinoma. They are mostly oestrogen receptor (ER) and progesterone receptor (PR) positive and HER2 negative.
Lobular carcinoma in situ (LCIS: is a type of breast changes that seen when a breast biopsy is done and is considered as precursor lesions for Invasive Lobular Carcinoma. In LCIS, cells that look like cancer cells are growing in the lining of the milk-producing glands of the breast (called the lobules), but they don’t invade through the wall of the lobules. They are usually removed with an amount of normal breast tissue around (Lumpectomy). In the case of high-risk lesions, preventive mastectomy also may be done.
Male breast cancer:
Rare cancer with less than 1 % of all breast cancers and incidence in males in 0.1%. Usually presents as hard lump below the nipple-areola and usually the treatment for localised disease is mastectomy followed by systemic therapy like chemotherapy, hormonal therapy (Tamoxifen) and local radiation. The major risk factors for the development of male breast cancer include advancing age, hormonal imbalance, radiation exposure, and a family history of breast cancer. BRCA2 mutation also increases the risk for male breast cancerPaget’s disease of the breast; Paget’s disease of the nipple, also known as Paget’s disease of the breast presents as eczema-like changes to the skin of the nipple and the area of darker skin surrounding the nipple (areola). It’s usually is associated with breast cancer in the tissue behind the nipple and is rare. Paget’s disease of the breast occurs most often in women older than age 50. Most women with Paget’s disease of the breast have underlying ductal breast cancer or less commonly, invasive breast cancer. Only in rare cases is Paget’s disease of the breast confined to the nipple itself. It causes oozing, itching, redness and sometimes ulcers on the nipple-areola complex. The disease stage of underlying breast cancer decides on the management and usually involves surgery, radiation hormonal therapy and chemotherapy
Triple-negative breast cancer: TNBC constitutes 10-15% and is a specific subtype of breast cancer that behaves aggressively when compared to the other subtypes like hormone-positive or Her 2 positive. In these cancers, the oestrogen receptor, progesterone receptor and Her2 receptor are absent. They are mostly associated with BRCA gene mutation but can exist without mutation also. They are usually seen in young females and those with family history. The treatment includes surgery, radiation therapy and chemotherapy in early and locally advanced stages. In metastatic breast cancer, chemotherapy is the preferred treatment. Immunotherapy also has shown to have effects in TNBC.
Breast cancer in young women: Around 10-15% of all breast cancers occur in less than 45yrs of age and is considered separately as they have different biological behaviour. The risk factors include a family history of breast cancer, history of radiation in the childhood or adolescence etc. The management also includes special concerns like psychological impact, fertility issues etc. apart from surgery, chemotherapy, endocrine therapy, radiation therapy
Inherited breast cancer: BRCA1 and BRCA2: They constitute less than 15% of all breast cancers. The most common cause of hereditary breast cancer is an inherited mutation in the BRCA1 or BRCA2 gene. In normal cells, these genes help make proteins that repair damaged DNA. Mutated versions of these genes can lead to abnormal cell growth, which can lead to cancer. They are also associated with increased risk of developing uterine cancer, ovarian cancer, gastric cancer etc. The other conditions associated include hereditary diffuse gastric syndrome, Li Fraumeni syndrome etc.
Non-cancerous breast condition:
Only 1 of 10 breast lumps is cancerous. Mostly in premenopausal and perimenopausal females, there are soft to firm breast lumps which especially get noticed during the menstrual cycles called fibroadenomas. They usually resolve after menopause and don’t need any treatment apart from reassurance. Other conditions include fibrocystic disease, papilloma etc.Metastatic Breast cancer:
Breast cancer which has spread from the involved breast to sites like lung, bone, brain, liver or any other distant part of the body is called metastatic breast cancer (MBC). They usually are seen in 5-25% cases in India due to the absence of early detection by screening. They are unlikely to be cured. However, based on the biological characteristics of breast cancer, survival varies among different types of MBC. There is no role for surgery in MBC except when there is ulcerated disease causing pain/discharge etc. The main treatment in MBC includes chemotherapy, targeted therapy (anti-HER2) and endocrine therapy based on the immunohistochemistry of the disease.Angiosarcoma: is a rare soft tissue tumour of the breast. It occurs in both a primary form without a known precursor and a secondary form that has been associated with a history of irradiated breast tissue.
Why APCC for Breast Oncology?
Breast Cancer management in this current era is multidisciplinary and involves the combined team effort of surgical, medical and radiation oncologists.
In APCC, we follow the site-specific oncology practice which means the concerned oncologists have developed an expertise in the management by focussing care on the same site over many years.
Each cancer behaves differently based on the site and type of cancer. Thus having breast oncologists for taking care of a breast cancer patient helps in fighting the disease with much more clarity and expertise.
Current medical oncology relies greatly on the molecular landscape of cancer.
At APCC, we aim at identifying the best-personalised treatment for the patients and thus promote the international standards in the clinical management available at the best centres around the world.
Risk Factors
Who is at high risk for breast cancer?
- Patient with BRCA 1 or 2 mutation
- Obese patients
- Family history of breast cancer
- History of childhood radiation to the chest wall
- Patient with high-risk behaviour like smoking, alcoholism
Various risk factors:
Obesity or lack of physical exercise, Smoking, Alcoholism etc are considered as high-risk factors which cause breast cancers.
Diagnosis
- How can I test for breast cancer at home?
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The self-breast examination is a periodic examination by the patient of both the breasts as per the protocol taught by a health worker. Usually, the technique involves the use of the flatness of the palm to palpate the breast in a clockwise direction so that all the quadrants of the breast are examined.
However, in case of any doubt, the patient should consult her doctor and get a screening mammogram done in case the doctor suggests so.
- How does a doctor diagnose breast cancer?
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Breast cancer diagnoses are usually after a clinical examination by the doctor who examines both the breasts, both armpits and the bilateral neck apart from the general physical examination. After that, the patient is subjected to bilateral mammogram which helps in identifying the site and size of the lump if any. Thereafter, Biopsy is done in which under local anaesthesia, a small piece of the lump is removed and sent for pathology examination. This will confirm the diagnosis of breast cancer
- Prevention
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Ways to prevent breast cancer: Breast cancer prevention includes both primary prevention measures and secondary prevention. Primary prevention includes measures to reduce the risk of developing cancer: daily physical exercise (30min per day), maintaining optimum BMI (to avoid obesity), breastfeeding, avoiding smoking and alcohol, higher intake of fruits, vegetables, avoiding red meat etc
Secondary prevention includes early detection and prompt treatment. Screening by Mammogram annually has found to prevent cancer-related mortality in studies and is an effective population-based screening measure. The self-breast examination also is advised as part of a disease awareness program.
- Screening
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Preventive screening for breast cancer: The national and international guidelines recommend annual screening with Mammogram for breast cancer prevention in females 40yrs and above. The annual mammogram should be complemented by self-breast examination monthly and 3 monthly examinations by the physician or gynaecologist. In females with a higher risk of breast cancer because of family history or childhood radiation, MRI breast screening is also considered from the age of 30yrs. The guidelines recommend the upper age limit of screening as 75yrs but vary according to different organisations.
Treatment
- Surgical
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Which kind of surgery is done for breast cancer?
Surgery for breast cancer can be divided into two parts- surgery for the breast and surgery for the axilla (axillary lymph glands)
Surgery for the breast:
1. Breast preserving operation- Tumor size, breast size, presence of more than one tumour in the breast and stage of the disease all help to determine if the breast can be preserved during surgery. If you are a candidate for breast preserving option and offered this option, you should know that the survival ( longevity of life) is not affected by preserving the breast and that it is a safe surgery. One must note that if you choose to have a breast preserving surgery, it must be followed up with radiation.
2. Mastectomy ( removal of the whole breast)- When it is not possible to save the breast, or the patient chooses to have her breast removed, then a mastectomy is done. The skin is put together after the surgery and there is no raw area. At the end of the surgery, there is a flat straight surgical scar.
3. Oncoplasty- Sometimes when a large area of tissue has to be removed during a breast conservation surgery, the gap to fill is large and just closing it as it is may give an ugly result. Therefore, tissue and fat from the neighbouring areas like the back or side fat or breast tissue itself is remoulded to fill in the gap and give a better outside.
4. Reconstruction- There are options to create a new breast with ones own tissue ( commonly the tummy fat) or with an implant ( made of silicon) to make a new breast after a mastectomy. This can either be done at the time of the first surgery itself or as a second surgery anytime in the future.
Surgery for the axilla- Surgery for the axilla is always part of the treatment for any breast cancer. If done with the mastectomy, there is no separate scar; but if done with breast conservation there may be a separate scar in the area of the armpit.
1. Sentinel lymph node biopsy- This is a procedure where the first set of lymph nodes draining the breast in the axilla are marked out by special techniques and they are removed and sent for testing. If cancer has spread to these lymph nodes, then an axillary clearance is usually done and if the nodes do not have cancer, then there is no further surgery done in the axilla. This all usually happens when one is under anaesthesia itself ( frozen section for the lymph nodes) and does not need to be done as a separate procedure.
2. Axillary clearance- This is a surgery to remove all the lymph nodes in the armpit and is also done in the same anaesthesia as the breast surgery. If we know before surgery that the lymph node is involved or if there was a positive node on sentinel lymph node biopsy then this procedure is performed.
At the end of a mastectomy and/or an axillary clearance, a drain is placed and these come out below the wound and are left in place for 7-10 days. They are meant to drain the fluid from the wound and this may be a little blood-tinged. Once the amount coming out reduces, the drain is removed.
Are there any alternatives besides surgery?
Till date, surgery is the only proven curative option for breast cancer.
How do I prepare myself for surgery?
The preparation is generally similar to any major surgery. Breathing exercises using the incentive spirometer should be started. Wherever needed, a sports bra, pocketed bra and appropriate clothing can be planned and taken to the hospital. Follow the anaesthetist’s advice regarding the continuation of medications if you are on any.
How major is surgery? What are the possible complications?
Surgery for breast cancer, both mastectomy and breast conservation surgery (even with oncoplastic procedures), although referred to as major surgeries do not usually have any serious complications.
The complications of these surgeries include:
- Wound Infection
- Flap necrosis
- Bleeding
- Numbness in the medial aspect of the arm and scar site
- Lymphedema
- Prolonged seroma
For how long do I stay in the hospital?
Most of the surgeries for breast cancer are done as a daycare procedure; that is you can get the surgery done in the morning and go home the same day. Sometimes you are asked to stay for one night just so that you can be monitored and then are sent home the next day morning.
Will I need any further treatment after surgery?
The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. Depending on the report, the decision to give chemotherapy (with or without targeted therapy) is taken. Radiation is generally given if you have had a breast conservation surgery or if you have had a mastectomy, and the pathology report shows that the size is large or that your lymph nodes are positive. Hormone therapy (which is in the form of tablets) is given for 5 or ten years if you have a hormone-positive tumour.
What will be my survival after surgery? Are there any chances of cancer coming back?
Survival depends on the stage of the disease. The average 5-year survival for all stages after curative surgery and treatment for breast cancer is between 80-95% depending on the stage of cancer. As of date, there is no foolproof way of predicting which patients will have a recurrence and which patient will not.
Are there any special precautions I need to take to prevent cancer from coming back?
A good healthy lifestyle, prevention from weight gain and taking your medications regularly can all add to helping cancer from coming back.
How frequently should I follow up after surgery?
After completion of treatment, you will be advised to follow-up once in 3 months in the first year. Then the frequency will be reduced to once in 6 months for the next 4 years. Subsequent follow up will be once a year. Each year, you will be asked to do certain blood tests and an ultrasound of the abdomen. You will also be asked to do a mammogram yearly; if you have had a mastectomy, you will be asked to do a mammogram of the opposite breast and if you have had a conservation surgery then you will be asked to do a bilateral mammogram. It is similar to a routine master health check-up that people without cancer have yearly and any abnormality can then be investigated further.
Will I be able to adjust to this disease well?
It is only the duration of the treatment that everything may seem to be difficult and there may be small challenges along the way. The first few days of diagnosis are the hardest because you have to both accept what has been told to you and you have to make decisions quickly while your mind is still trying to process the information. Once you start the treatment process, things become easier and after the treatment, you can live a completely normal life and will be able to do almost everything that you were able to do before cancer. Many patients do well and have a full recovery.
- Radiation Therapy
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In radiation therapy, the basic aim is to treat cancer and to minimise the dose on the normal tissues. Hence, the treatment has to be as conformal or shaped according to the treatment area. This can be achieved by the quality of radiation or by the technique of radiation. The most conformal technique is intensity-modulated radiotherapy –image-guided (IG –IMRT)and the most commonly used radiation is photons especially using linear accelerators.
Role of Proton therapy: Protons are better radiation than photons because of their physical properties. Photons always have some dose which goes to normal tissue because they scatter and fall on the normal tissues around the treatment area. This happens despite the use of the best technique of radiotherapy like IG-IMRT. Protons because of their very characteristic property called Bragg’s peak can treat the tumour or target without many doses to normal tissues.
Success rate of proton therapy
Why proton therapy for breast cancer: Because of the physical properties of proton, the final treatment plan is very effective in ensuring the right dose for the tumour/target area and the surrounding normal tissue is spared well. This is especially important for left-sided cancers as the dose to the underlying heart can be reduced considerably. This helps in reducing long term cardiac side effects. Also, the dose of the lung can be reduced
How safe is proton therapy: Proton therapy is safer to normal tissues like lung, heart, spinal cord etc because they have a very sharp dose fall in the treatment area and so cause sparing of tissues
Radiation after mastectomy: Radiotherapy is usually started after mastectomy once the planned chemotherapy is completed. The indication depends on the cancer stage and biology
Side effects of radiation: Early side effects include skin discolouration, mild swallowing pain etc and long term side effects include toxicities of lung, heart etc.
- Systemic therapy (Chemotherapy, Endocrine therapy, Targeted therapy)
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Systemic therapy plays an essential role in this disease as breast cancer is a systemic disease.
Except for very small tumours (<0.5cm), most of the patients receive systemic therapy.
- Chemotherapy
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Involves the oral or mainly intravenous administration of cytotoxic agents for the treatment of cancer. In breast cancer, chemotherapy is either given before surgery (neoadjuvant), after surgery (adjuvant) or in advanced (metastatic) cases as palliative chemotherapy. The drug, dose and duration are decided as per the disease and patient characteristics. Main side effects of chemotherapy are vomiting, blood count drop, diarrhoea, oral ulcers, hair loss etc. However, during chemotherapy, currently, we provide good supportive care medicines which have reduced the side effects very well. Thus, chemotherapy has become tolerable for many patients.
Endocrine therapy: Patient is often started on oral tablets as per the special tests in the histopathology report after the biopsy called Immunohistochemistry. Mainly 3 tests are done: Estrogen receptors (ER), Progesterone receptor (PR) and Human Epidermal Growth factor receptor (HER2). If ER or PR is positive then, the patient is given oral hormonal tablets which work in the body against estrogen. Usually, after surgery, they are given for 5 or 10 yrs (high risk). In the case of advanced diseases, they need to be given continuously daily till there is no response or there are side effects. Newer drugs like CDK4 inhibitors are also used in the treatment and show excellent response. Usual side effects are arthralgia, lipid level changes, liver dysfunction etc.
Targeted therapy: anti Her2 therapy: Trastuzumab is a very useful drug in the treatment of breast cancer. It has considerably reduced cancer-related deaths. It is given only in Her2 positive breast cancer. In patients after surgery, one year of trastuzumab is given every 3 weeks for preventing recurrence of breast cancer. In some patients depending on the risk of disease recurrence, shorter duration of targeted therapy also is given. In metastatic breast cancer, trastuzumab is continued till the disease in responding. The main side effect is on heart, so 2DECHO is done at regular interval. Other anti Her2 therapy includes pertuzumab, lapatinib etc.
Immunotherapy: currently no much role for immunotherapy in breast cancer
- Care & Lifestyle
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Living beyond Breast cancer: Breast cancer survivors can have long term problems related to psychosexual health, body image issues, depression etc which needs to be prevented and taken care from the beginning of treatment itself. The assessment has to be continued during follow up and addressed appropriately. Meditation, Yoga, Creative skill learning, Music etc are different ways which are helpful apart from professional guidance as required.
The patient also is on long term endocrine therapy which can cause side effects like arthralgia, loss of libido, depression, dyslipidemiaetc and they will need medical and psychological support.
Nutrition & Care: Patients on treatment are encouraged to take plenty of fresh vegetables and fruit which are hygienic. They must continue their routine diet but avoid alcohol and red meats. Adequate water is always encouraged. They must avoid taking complementary medications and exotic fruits which can be harmful when taken along with chemotherapy and endocrine medications in the view of drug interactions.
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