Breast Cancer

Breast cancer in one of the Commonest malignancies in Western Europe and less common in Japan and Africa. Totally there are about 35 000 new cases occur per year. 1 in 9 lifetime risk for women. And the breast cancer incidence increases with age. The chance of getting Breast cancer in Males is 1%. 5% of the cases are related to identifiable genetic abnormality (BRAC1, BRAC2, ataxia–telangectasia genes.) 60% of the cases present as symptomatic disease; 40% during breast cancer screening programs.

Pathological features
Histologically 80% of breast cancers are ductal adenocarcinoma and the 20% of cases are lobular, mucinous tubular or medullary adenocarcinoma. Most carcinomas believed to originate as in situ carcinoma before becoming invasive. 70% express oestrogen or progesterone receptors.

Clinical features

Breast lump : Breast lump is the Commonest presenting symptom. The lump is usually painless (unless inflammatory carcinoma), Hard and gritty feeling, may be immobile (held within breast tissue), tethered (attached to surrounding breast tissue or skin), or fixed (attached to chest wall). Lump is Ill-defined, irregular with poorly defined edges.
Nipple abnormalities : Nipple may be the prime site of disease (Bowen’s disease), presenting as an eczema-like change. Nipples may be affected by an underlying cancer. Nipple is destroyed, inverted, deviated and associated with bloody discharge.
Skin changes: Carcinoma beneath skin causes dimpling, puckering, or colour changes. Late presentation may be with skin ulceration or fungation of the carcinoma through the skin. Lymphoedema of the skin (peau d’orange) suggests local lymph node involvement or locally advanced cancer. Extensive inflammatory changes of the skin are associated with infl ammatory carcinoma which is the aggressive form of breast cancer.
Systemic features : Systemic features include weight loss, anorexia, bone pain, jaundice, malignant pleural, pericardial effusions, and anaemia.

Diagnosis and investigation

Diagnostic tests
- All breast lumps or suspected carcinomas are investigated with triple assessment.
- Clinical examination (as above).
- Radiological assessment:
  - Mammography usual, particularly over age 35y.
  - Ultrasound scan used to assess the presence of involved lymph nodes,sometimes used under age 35 because increased tissue density reduces sensitivity and specificity of mammography.
  - MRI used in lobular carcinoma to assess the extent of the disease, multifocality, and the opposite breast.
- Younger women with dense breast tissue. For screening purpose in patients with strong family history.

Tissue diagnosis
- Core biopsy or fine needle aspiration cytology (FNAC) of the breast lesion 9 axillary nodes.
- Core biopsy also finds oestrogen receptor status, differentiates between invasive carcinomas and in situ carcinoma (ductal carcinoma in situ, DCIS).

Staging investigations
Systemic staging is usually reserved for patients following surgical treatment
with a tumour who are at risk of systemic disease.
- Staging CT scan (chest, abdomen, and pelvis).
- Liver ultrasound.
- Chest X-ray.
- Bone scan.
- LFTs, serum calcium.
- Specific investigations for organ-specific suspected metastases.

Treatment
There are mainly 2 methods of managing the patient. One is medical treatment, other is surgical treatment.

Medical treatment

In non-metastatic disease, medical therapy is adjuvant to reduce the risk of systemic relapse, usually after primary surgery. It is occasionally used as a treatment of choice of elderly or those unfit/inappropriate for surgery.

Endocrine therapy.
- Used in (o)estrogen receptor (ER) +ve patients.
- Anti-oestrogens like tamoxifen or aromatase inhibitors (letrozole).
- Post-menopausal patients—letrozole (caution osteoporosis).
- Premenopausal patients—tamoxifen.
- Herceptin—given in Her-2 receptor +ve patients.
Chemotherapy (e.g. anthracyclines, cyclophosphamide, 5-FU, methotrexate). Offered to patients with high risk features.

In metastatic disease, medical therapy is palliative to increase survival time and includes:

Endocrine therapy.
Chemotherapy (e.g. anthracyclines, taxanes, herceptin).
Radiotherapy :To reduce pain of bony metastases or symptoms from cerebral or liver disease.

Surgical treatment of breast cancer will be discussed later.