Everyone Should Know About Breast Cancer.

Breast cancer is the most commonly diagnosed cancer and leading cause of death worldwide in females and accounts for 24% of all female cancers. Risk is so high that one in every 14 women will develop this malignancy by the age of 75 years. Every year around 20 lakh new cases are diagnosed globally and 6 lakh people die of this disease.

In Nepal, according to Globocan 2020, cervical cancer is the most common cancer in females, followed by breast cancer but the difference is merely 1%. The cases are exponentially increasing and in the coming future, breast cancer will surpass cervical cancer and become the most common cancer in females of Nepal as well. This is because it is well known that cervical cancer is caused by Human Papilloma Virus which is transmitted sexually and has a long course of time from infection to overt malignancy. Knowing this fact, multiple measures can be applied for the prevention and early diagnosis of cervical cancer. But there is no definitive cause of breast cancer. It has a multifactorial etiological status. Where there are a lot of Best Path labs in Nepal, you can check your health. Now let’s discuss the risk factors of breast carcinoma.

Causes of breast cancer:

1) Reproductive lifestyle:  In today’s world, most of the women are well educated, career driven and ambitious. To fulfill the ambition, the practice of marrying late and postponing conceiving a baby is very common. After delivery of the baby, breastfeeding is hard to manage for a working lady as well. Full term pregnancy followed by lactation makes the breast more mature and less responsive to harmful effects of estrogen and progesterone and ultimately prevents malignancy.

2)Diet: Acquiring western dietary lifestyle with high calorie diet rich in animal fat and protein combined with lack of physical exercise and obesity increases the risk of developing breast cancer. Alcohol intake and cigarette smoking also contribute to causation of the disease.

3)Hormones: Estrogen and progesterone are the hormones that have a direct impact on breast cancer. These hormones are taken frequently in the form of contraceptive methods, treatment of menstrual disorders, as hormone replacement therapy in post-menopausal women etc. Prolonged use of these hormones develops increased risk for breast cancer.

4)Genetics: Genetics is a topic that is very hard to explain. Let me make it simpler for you all by telling a story of a famous Hollywood star: Angelina Jolie. Angelina Jolie lost her grandmother, mother and aunt of the same disease: Breast and ovarian cancer. This was because there was a genetic disorder running in their family: BRCA1 mutation. If one has BRCA 1 or BRCA2 mutation, there is 55-70% chances of acquiring breast and ovarian malignancy in a lifetime of a female. After this knowledge, Jolie got herself tested which showed positive results. To reduce the risk of getting malignancy, she got her both breasts removed in 2013 and ovaries removed in 2015. Thus if someone has breast cancer, genetic counseling and testing for this notorious mutation is very important.

 Clinical Features:

There is usually a painless lump in the breast.

Most of the time it is fixed in the breast with no mobility and irregular margin. Sometimes the overlying skin is also involved with ulceration. One in a hundred cases present with an armpit lump with no palpable lump in the breast. That is because of metastasis in the axillary lymph node.

There can be retraction in the nipple with blood tinged fluid discharge.

Note: - NPL has facilities for cheap PCR tests in Kathmandu. Where you check and get your report soon.

 Diagnosis:
           This  is a very important part that I am going to discuss. There are three diagnostic aspects; we call it “the triple test”. It includes self breast examination,  USG/Mammography and FNAC/Biopsy. All the  three should not be done in isolation. All the methods complement each other in different ways.

1)Self Breast Examination:  It is a three step process in which one should observe her breast in front of the mirror with her hands on her waist and hands above head to look for symmetry, any changes in the nipple like retraction or any changes in the skin color. The third step should be done under shower with foam on hand and breast. One should examine by gently pressing the pulp of three fingers barring thumb and little finger on all the quadrants of the breast to feel for any lump.

This process should be done often, like once every 2 months especially after 35 years of age.

2)USG/Mammography: It is the radiological evaluation of ones’ breast. Determination of the procedure depends on the age of the patient. Before 40 years of age and for very dense breast; USG is preferred whereas beyond 40 years of age, mammogram is preferred. In western countries with high prevalence of breast carcinoma, yearly mammogram screening is done to look for any unnatural changes in the breast after 40 years of age.

3)FNAC/Biopsy: Fine needle aspiration cytology is a minimally invasive procedure in which a syringe with a fine needle is inserted on  a suspected breast lump and is aspirated to look for any abnormal cellular changes leading to the diagnosis of malignancy. It’s a very simple test with early reports done by an expert Pathologist. Core cut biopsy is also a similar technique but in this case tissue changes are scanned. It is superior to FNAC but results are delayed due to a series of  processing and staining procedures.

Once confirmed by all these means the next step is treatment of the patient.

Treatment:

There are three modalities of treatment as in any other malignancies.

1)Surgery: The most commonly practiced surgery is mastectomy with axillary lymph node dissection. In this surgery, the whole breast is removed along with the lymph nodes in the armpit. Later, breast reconstructive surgeries can be performed for cosmetic purposes. The removed breast along with axillary lymph nodes are sent for histopathological examination. By these examinations, we get to know about the grade and stage of the cancer. Further, another important test; immunohistochemistry is performed by which we get to know whether the cancer cells are hormone (estrogen and progesterone) sensitive or not by identifying their receptor present in the cancer cells. We also know about the aggressiveness of the tumor by this test by examining Ki67. This test is important for chemotherapy which will be discussed below.

2)Chemotherapy: After immunohistochemical assessment of the tumor, if we find out that the cancer cells are hormone responsive, chemotherapeutic agents working against the receptor are given. This kind of chemotherapy is known as targeted chemotherapy which focuses on working on specific receptors of the breast. Whereas general chemotherapeutic agents used in other cancer targets on every growing cell of our body.

3)Radiotherapy: It is used to destroy the rest of the cancer cells which might be staying in the breast after its removal.

From a laboratory point of view, in NPL (Best Pathlab Nepal), we perform all the kind of tests which are required for the diagnosis and prognosis of the breast cancer, staging and grading as well as immunohistochemical staining to know ER, PR and HER2 status. NPL is also involved in cheap PCR tests in Kathmandu.

Crux of this blog is to spread awareness regarding breast cancer. Breast is a sensitive organ and if anyone who can feel something wrong in it is oneself only in most of the case. So good reproductive lifestyle, proper lactation, low consumption of  exogenous hormones, regular exercise, healthy dietary habits along with regular breast self examination, yearly mammography after 40 years of age and BRCA1 and BRCA2 gene mutational studies in females with family history of breast or ovarian cancer are the key for prevention and early diagnosis of breast cancer.

I hope you are benefited by this article. Please feel free to comment on dojeevando@gmail.com.

Dr. Jeevan  Adhikari

MD, Pathology.