Questions newly diagnosed should ask

The words breast cancer strike fear into the hearts of most women. Yet, it is one of the few cancers that are easily treated if caught early enough.

Let us start by looking at the incidence of breast disease. Every woman will experience a breast complaint at some stage of her life. Importantly, 9 out of 10 breast problems are benign and are in no way related to cancer. Breast concerns can occur at any stage in a woman’s life and overall women have a one in nine lifetime risk of developing breast cancer. Breast cancer accounts for over 30% of new cancer cases in women.

Part of the reason we fear cancer is the thought of a mastectomy – where we lose what to most is an essential part of our femininity. There is good news on that front, however. Surgery is not always disfiguring , breast conservation and reconstruction surgery now play a major role in management.

Many women don’t report lumps in their breasts because they aren’t painful. Nine out of 10 times, however, breast cancer is painless. Any lump you find in your breast should be investigated.

Breast cancer is one of the few cancers which, if detected early, can be cured, so it’s imperative that any woman who finds a lump in her breast consults a doctor who has an understanding of breast management. The big problem with breast cancer in young women is that the lumps in the breast are often ignored by both the patient and the doctor because of the misconception that cancer does not occur in young women. The women is examined and told that the lump does not feel cancerous and asked to return in 3 months for a review.

The doctor uses three modalities to assess the breast, this is called the triple assessment. By using all three modalities together there is a negligible chance of missing a cancer.

These three modalities are clinical examination; mammography and ultrasound and needle tissue biopsy.

All patients should be examined, have sonar or a mammogram, and a needle biopsy to ascertain whether or not the lump is cancerous. Screening mammograms are not routinely performed in women under 40 mainly because these women fall under the age for routinely recommended mammogram. The reason for this is the increased density of the breast tissue, results in a higher false negative finding on mammogram. Breast ultrasound is safe, accurate and provides a rapid differentiation of cystic and solid masses and should be used routinely in young women with breast cancer.

Needle biopsies can be either a fine need aspiration cytology (“FNAC”) or core biopsy. A Fine needle biopsy obtains cells and a core needle biopsy takes a small sliver of tissue. These procedures should not be painful, if you are needle phobic please ask your doctor to prescribe Emla gel ( a local anaesthetic ) which you apply 2 hours prior to the biopsy.

It is important to realise that in most cases it is not necessary for a women to undergo a general anaesthetic to determine whether the lump in her breast is a cancer or not.  This is the important concept behind the triple assessment.

Once a cancer has been diagnosed, there is no harm in taking a few days to discuss the different treatment options. Waiting a day or two, participating in the discussions and understanding what the different treatment options are, will help ensure ultimate psychological, cosmetic and best cancer management.

Again to stress once the diagnosis is made, there is no need to jump into a decision. Breast cancer is not flu – patients need to explore their options and find out what treatment is available to them. The average doubling time of breast cancer cells in 40 days, the cancer did not arrive yesterday and will not be gone tomorrow so go for a second opinion, speak to other patients who have been treated by the doctor you chose.

Instead of looking at treatment of breast cancer stage for stage, it is important to remember that each patient presents, as an individual and the specialist must tailor the treatment to each individual patient. There are certain fundamental treatment principles that should be adhered to, such as who should receive chemotherapy, who should receive radiation therapy and what different surgical options available for each patient.

In other words, the size of the tumour, the type of cancer the size of the breast and position of the tumour and the state of general health and the psychological make-up of the patient help determine which treatment options are utilized and in what order they are employed.

The treatment of breast cancer is a multimodal approach involving three lines of attack.

	surgery
	radiotherapy (DXT)
	oncology (chemotherapy and hormone manipulation)

These are often used in various combinations with each other, as is decided by the “breast team”.  An oncologist uses medication to fight cancer cells.

Oncology treatment plays a fundamental role in all women presenting with breast cancer even when the breast cancer is diagnosed early and is still confined to the breast.

This means using hormone (endocrine) manipulation and/or chemotherapy shortly after surgical treatment of early breast cancer, at a time when the tumour burden from the micrometastases is small. This will achieve a higher cure rate and is called adjuvant therapy. In the past couple of years, many oncologists (cancer physicians) are indeed using such therapy even before the operation. This is called neo adjuvant therapy (primary medical treatment or induction chemotherapy). Should your doctor suggest this please pick up the relevant reading.

The term chemotherapy encompasses treatment with many different drugs that can be used in combination or alone. These drugs target growing cells throughout the body and are therefore very efficient in killing cancer cells that are fast growing. The drugs are given as several courses administered at intervals of a few weeks and so the treatment period may range over several months. Some drugs are given by mouth and some are given by intravenous injection.

Today more and more women get chemotherapy , a good analogy is to compare chemotherapy to toilet cleaner (you look in your toilet bowl and even though it looks clean you still put in the toilet cleaner); same with chemotherapy we give it to sterilise the body not because we think that you have cancer elsewhere , it is merely the realisation that early breast cancer sometimes has micrometastases (possibly tiny single cells sitting else where) at the time of first presentation to the doctor, led to the concept of adjuvant therapy.

A general guide as to who gets chemotherapy is as follows;

	all premenopausal women;
	all tumours greater than 1,5cm cm in women fit  for chemotherapy;
	all patients whose tumours have spread to the glands;
	all patients whose tumours overexpress HER2neu  (C erb B2 family of genes);
	tumours which are receptor negative;
	tumour behaviour (biology)that  shows signs of aggression

There are also different types of chemotherapy that can be used and this needs to be discussed with your cancer team.

Endocrine therapy is the use of hormonal drugs to target the cancer. Hormones are circulating chemical substances that control normal body functions, as well as affecting certain cancer cells. This is particularly true of some female hormones such as oestrogen. Many cancer patients can be treated with drugs which either contain hormones or are anti-hormonal (inhibit the action of the hormone). Hormone drugs are safe to use and their side effects are rarely serious. The types commonly used are Tamoxifen or Fareston in premenopausal women often in combination with Xeloda (ask for separate reading on this) or Aromatase inhibitors (Arimidex and Femara) used only in postmenopausal women. Tamoxifen or Fareston They are often tolerated better than chemotherapy drugs. Oncology treatment encompasses both chemotherapy and hormone therapy.

“Seventy-five percent of patients overseas don’t have mastectomies, so get a second opinion if your doctor immediately suggests a mastectomy and doesn’t present any other options. You can have breast-conserving surgery in many cases, as well as reconstructions. You don’t have to be disfigured for life.” The reconstructive process should be discussed with the patient prior to initial surgery. The psychological impact of loosing a breast varies but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer. Breast reconstruction can be done immediately after the mastectomy or it may be delayed for a few months. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. Having this procedure depends on the patient’s age, the size and location of the tumour and the stage of the disease.

The reason for stressing an aesthetic as well as an oncologically sound operation is that particularly in  young women the surgical margins need to be well clear of tumour.

The EORTC Study 22881 has made clear the significance of free margins for prognosis in women below the age of 35. The minimum requirement is complete excision of the tumour, both the invasive and intraduct component with a surrounding rim of uninvolved normal breast parenchyma and in younger patients the larger the margin the better.

Radiotherapy is also used for the local management of breast cancers. This is effective in the local control of breast cancer.  Its use decreases the incidence of local recurrence. Radiotherapy may improve overall survival in certain patients. Radiotherapy will control the large, fungating mass, which has a foul odour (with or without toilet mastectomy), and prevent local recurrence after breast conserving surgery (it is standard treatment to give DXT to the remaining breast tissue after lumpectomy in Stage I disease). Remember that in medial tumours (inner half of the breast), where there is a chance of internal mammary node involvement (glands under the ribs), the radiotherapist does not only irradiate the remaining breast tissue; he or she may also add an additional blast to the internal mammary nodes. This must be done with caution, as the DXT rays must not hit the heart and lungs. The following patients must get radiation therapy.

	Any person who has had breast conserving surgery.
	Any person who has had a mastectomy and has close margins i.e. margins less than 10mm from the tumour.
	Ulcerated or fixed tumours which are not surgically resectable in patients who are not fit for chemotherapy.
	Any person who has had surgery and chemotherapy for a locally advanced breast cancer.
	More than four axillary lymph nodes positive requires the patient ot get radiation to the chest wall and axilla.
	Isolated bony secondaries may require radiation to that area.