Sunday,  December 17, 2000		Keeping fit

Breast cancer: Early detection is the key

N.M Gupta, Professor of surgery, PGI, and B.K Sharma explain how important in the cancer of the breast is early diagnosis and treatment. To achieve this goal, every woman past 35 years of age should have her breasts examined at least once a year by a doctor or a trained nurse. This would pose a problem from the standpoints of both time and economy and is hence not practical. Therefore, it is recommended that ladies should themselves perform a thorough and fairly frequent proper examination of the breasts. In case of detection of any abnormality, prompt medical advice should be sought.

THERE is an increasing awareness that along with rising longevity, industrialisation, changes in lifestyle and progressive control of the major infectious diseases, the incidence of cancer (including breast cancer) is increasing steadily. Cancer is the leading cause of mortality in the USA, next only to cardiovascular diseases. In many industrialised countries, breast cancer is at the top among cancers in women. According to the hospital records of PGI, Chandigarh, breast cancer is the second most common cancer in the females, cancer involving the uterine cervix (opening of the uterus) being the most common. Similar figures have been reported from the other parts of the country. It has been estimated that there are about one and a half million cases of breast cancer in the country at the present time with about half a million new cases being added every year.

A large majority (over 90 per cent) of women with breast cancer complain of a lump. Classically, the lump is hard, painless, immobile and demonstrates a degree of fixity to the surrounding tissues or the overlying skin. The lump may be visible on inspection and may cause distortion of the breast on elevation of the arms. A small per cent of women may exhibit diffuse thickening of the breast tissue or skin or retraction and distortion of nipple. In all these cases, the contour of the affected breast alters as compared to the normal breast. Occasionally bloody discharge from the nipple may be the only symptom. Sometimes a lump in the armpit which is a manifestation of spread of the disease from the breast may be the only symptom. The patient may not be aware of this lump, which may be noticed first by the doctor.

The slightest suspicion of any abnormality in the breast warrants medical consultation. It may be worth emphasising that all the lumps in the breasts are not cancers and breast cancer is not painful in the initial stages.

Breast cancer has been divided into four stages, depending on the local and distant spread of the disease. Unfortunately, a majority of the patients in our country (78 per cent) are diagnosed when they are in stage III and IV of the disease. Factors causing delay in seeking treatment include absence of pain, low economic status, ignorance and fear, poor facilities for transport and communication as well as lack of easily accessible facilities for treatment. Because of these problems, many patients seek medical help only when there is large ulceration or fungation of the cancer or pain from the spread of the disease.

It may be mentioned here that uncalled for shyness or inhibition on the part of the patient or the doctors is often responsible for the delay in diagnosis. Examination of the breast is as important a part of physical diagnosis as any other part of the body. A very senior and bright nursing sister of PGI was discovered in stage four of the disease when nothing could be done.

Although the exact cause of breast cancer is unknown, there are certain well-defined factors that indicate an increased liability to develop the disease. Though breast cancer affects both sexes, it is 100 times more common in women than men. Majority of the women having breast cancer are over the age of 30. A family history of breast cancer is associated with an increased risk of the disease. The risk is greater in patients whose first degree relatives (mother or sister) are affected, especially if they were under the age of 30 when the disease developed. There is a direct genetic factor involved in the development of breast cancer in about 5 per cent of all patients. Two genes have been identified which are located in chromosome No. 6.

The increased risk is associated with early age of menarche, late age of menopause, late age at first childbirth and multiple pregnancies. The most consistent and apparent factor in the genesis of breast cancer is the failure of the breast to perform properly its normal physiological function.

The females who do not breast feed are more prone to the disease. The estimated risk in women who deliver their first child at about the age of 30-35 is nearly double than those women who have had their first child between the age of 20-25 years. The frequency of breast cancer is higher in spinsters than in married women. In brief, cancer of the breast is a hormonal disease and women who have no functional ovaries do not develop this cancer.

Oral contraceptives do not increase the overall risk of breast cancer. There is a clear association of increased risk of the disease with increased

dietary fat intake, especially of animal origin. The disease is more common in women with increased body weight. Patients who develop breast cancer on one side are more likely to develop the disease in the other breast subsequently. This may be the manifestation of spread of the disease from the first cancer or may be entirely a new cancer. It is mentioned that though very uncommon, this cancer occurs in men also and in fact carries worse prognosis as compared to women.

It is generally believed by the lay public that the transition from being normal to having breast cancer and thence to dissemination of the disease in the body is a rapid process. The reverse is, in fact, the case in breast cancer. The normal history of breast cancer is normally characterised by long duration. When compared to cancer of the lung, stomach or food pipe, it is a slow growing tumour. However, there are exceptions to the rule in which the disease takes on a more aggressive form.

Once the breast cancer is clinically apparent, it tends to spread locally and to regional and distant sites. The regional spread is to the lymph glands in the armpit and chest. Distant spread which is mainly to the lungs, liver and bones is through blood. However, any part of the body can be involved by distant spread.

Young women are known to develop soft lumps in the breast (fibroadenomas). They do not turn cancerous but still need removal. As the age advances, the soft rubbery feel of the breast is replaced by nodularity (chronic cystic mastitis). This is due to repeated episodes of hormonal changes produced by menstrual cycles and pregnancies. As a result, the breasts usually become heavy and painful before the periods. These are normal changes and have no relation to cancer.

The diagnosis of breast cancer is made by an examination of the patient. Confirmatory diagnosis is made by pathology. Commonly performed test for this purpose is FNAC (Fine Needle Aspiration Cytology). A very thin needle (thinner than the one used for injections) is inserted into the suspected breast lump and tumour cells are sucked into the syringe. Examination of these cells help in confirming the diagnosis. The method has the advantage of being performed as an outpatient procedure and producing almost immediate results which are quite reliable. The procedure is painless and no dressing is required. The test is being performed in the PGI for the last 30 years. Ultrasound and x-rays are required to rule out dissemination of the disease.

Mammograph is useful in certain situations. It is useful in cases of a doubtful small lump within a breast. It is very useful in high risk group and as a follow-up procedure for the detection of spread of cancer to the contralateral breast. Mammography is, however, not available as a general facility in our country except to a small segment of urban population. Clinical examination and self-examination (described below) are the mainstay of the diagnosis. Most of the lumps in the breast can be palpated and the diagnosis confirmed by FNAC.

The treatment of breast cancer is surgery which does not require elaborate and sophisticated equipment and facilities. Newer anti-cancer drugs and radiotherapy are helpful in the management of cancer more effectively but surgery remains the mainstay of treatment.

Early diagnosis is imperative for better management and results. Cancers detected in the initial stages (stage I, II) can be cured and the individual can lead a normal life. Early tumours can be treated by the removal of a segment of breast only. However, tumour detected at late stage require extirpation of the affected breast. The psychological trauma produced by the removal of the breast can be minimised by the reconstruction of breast. In the initial stages, artificial breasts can be used for aesthetic purposes.

The bottom line in cancer of the breast is early diagnosis and treatment. To achieve this goal, every woman past 35 years of age should have her breasts examined at least once a year by a doctor or a trained nurse. This would pose a problem from the standpoints of both time and economy and is hence not practical. Therefore, it is recommended that ladies should themselves perform a thorough and fairly frequent proper examination of the breasts. In case of detection of any abnormality, prompt medical advice should be sought.

Self-examination of breast is best made just after the menstrual cycle. As she stands before the mirror, the woman should carefully inspect her breasts. She should know that although disparity in the size of the two breasts is not unusual or significant, asymmetry of the breast is suggestive of an abnormality. Retraction or erosion of the nipple is of paramount importance. Any dimpling of the skin or discharge from the nipple is abnormal.

After this superficial inspection, the woman should lie down on a firm mattress. The right arm should be elevated above the head, and a large bath towel should be folded and placed beneath the right shoulder. With the flat surface of the fingers of the left hand over the inner half of the right breast, she should gently palpate the entire breast, beginning at the nipple line and progressing to the margin of the sternum. The pad beneath the shoulder should then be removed, and the outer half of the breast should be examined similarly. With her right arm hanging over the side of the bed, the entire breast should again be palpated from the nipple line upward to the axilla. An identical manoeuvre should be repeated for the other breast. The woman who follows this routine month after month will become familiar with the contour and consistency of her own breasts and will achieve skill in performing the examination. Many tumours will thus be discovered at an early stage.

Like any other disease, in breast cancer, too, prevention is better than cure. Based on the predisposing factors described above, certain guidelines for prevention do emerge. High-fat died and excessive body weight should be avoided which would also pay dividend in many other areas of health like cardiovascular diseases. Reproductive period should be started in early twenties and finished well before thirty. Women with family history of breast cancer should be on the alert so that it can be detected and treated early. Since two genes have been identified it may be possible to detect the onset even earlier. The essence is early diagnosis and prompt treatment.