Dr. Diab is a Consultant Medical Oncologist at NMC Specialty Hospital in Abu Dhabi
Breast cancer is the most common female cancer in the world and in UAE.
Breast cancer deaths have decreased by one-third or more over the past three decades. This is due in part to increased screening, as well as earlier and improved treatment for breast cancer. Screening usually detects the disease at an earlier stage, when the chances of successful treatment are higher. Early detection and treatment of breast cancer improve survival because the breast tumor can be removed before it has a chance to spread (metastasize). In addition, there are treatments that can be used to prevent cancer cells that have escaped the breast from growing in other organs.
DIAGNOSING BREAST CANCER
Abnormal lump — Breast cancer can be discovered when a lump or other change in the breast or armpit is found by a woman herself or by her healthcare provider. In addition to a lump, other abnormal changes may include dimpling of the skin, a change in the size or shape of one breast, retraction (pulling in) of the nipple when it previously pointed outward, or a discoloration of the skin of the breast.
To evaluate a breast lump, a mammogram and a breast ultrasound are usually recommended. A breast biopsy may also be recommended. A suspicious lump should never be ignored, even if a mammogram is negative. Up to 20 percent of new breast cancers are not visible on a mammogram.
Mammogram — A mammogram is a low-dose X-ray of the breast. The breast tissue is compressed for the X-ray, which decreases the thickness of the tissue and holds the breast in position, so the radiologist can find abnormalities more accurately. Each breast is compressed between two panels and X-rayed from two directions (top-down and side-to-side) to make sure all the tissue is examined. Mammograms are currently the best screening modality to detect breast cancer. Some mammograms capture images digitally, offering better clarity, the ability to adjust the image, and a decreased likelihood that the woman will need to return on a different day for repeat pictures.
Breast cancer is often diagnosed with a routine mammogram, before a lump or other change in the breast develops. Even if the mammogram is performed because a lump was felt in one breast, both breasts need to be examined because there is a small risk of having cancer in both breasts.
Breast ultrasound — An ultrasound uses sound waves to look at breast tissue and can tell if a lump is a fluid-filled cyst or a solid lump. An ultrasound is only used to examine a limited area of the breast, and is not yet used as a screening test of the entire breast.
Breast MRI — Magnetic resonance imaging (MRI) uses a strong magnet to create a detailed image of a part of the body. It does not use X-rays or radiation, but does require injection of a contrast agent (a material that shows up on imaging) into a vein.
Breast MRI is not usually used to screen for breast cancer in most women, but can aid in the diagnosis of breast cancer.
Breast biopsy — If breast cancer is suspected, the next step is to sample the abnormal area with a biopsy to confirm the diagnosis. The best way to do this is with a needle biopsy. A fine needle aspiration may be sufficient to establish a diagnosis of breast cancer, though a core needle biopsy, which utilizes a larger gauge needle, is often preferable as it provides a larger sample to better characterize certain features of the cancer
Types of breast cancer — Although there are several different types of breast cancer, they are treated similarly, with some exceptions.
In situ breast cancer — The earliest breast cancers are called "in situ" cancers.
Ductal carcinoma in situ (DCIS) — If cancers arise in the ducts of the breast (the tubes that carry milk to the nipple when a woman is breastfeeding) and do not grow outside of the ducts, the tumor is called ductal carcinoma in situ (DCIS). DCIS cancers do not spread beyond the breast tissue. However, DCIS may develop over time into invasive cancers if not treated.
Lobular carcinoma in situ (LCIS) — If abnormal cells arise in the lobules of the breast (where breast milk is made), and they do not extend outside of the breast lobules, this is referred to as lobular carcinoma in situ (LCIS). LCIS is not considered a true cancer but instead is considered a risk factor for developing cancer in the future in either breast. Women with LCIS should see a high risk specialist and discuss risk reduction strategies, such as tamoxifen, or anastrozole, to reduce the risk of breast cancer in both breasts.
Invasive breast cancer — The majority of breast cancers are referred to as invasive breast cancers because they have grown or "invaded" beyond the ducts or lobules of the breast into the surrounding breast tissue. Several varieties of invasive breast cancers are possible. In general, they are all treated similarly.
Grade — A tumor’s grade describes how aggressively it grows. Tumors are graded on a scale of 1 to 3, where 1 is the slowest and 3 is the fastest growing type of tumor. Tumors with higher grades are more likely to need chemotherapy.
Hormone receptors — More than one-half of breast cancers require the female hormone estrogen to grow, while other breast cancers are able to grow without estrogen. Estrogen-dependent breast cancer cells produce proteins called hormone receptors, which can be estrogen receptors (ER), progesterone receptors (PR), or both.
If hormone receptors are present within a woman’s breast cancer, she is likely to benefit from treatments that lower estrogen levels or block the actions of estrogen. These treatments are referred to as endocrine or hormone therapies and such tumors are referred to as hormone-responsive or hormone receptor positive.
In contrast, women whose tumors do not contain any ER or PR do not benefit from endocrine therapy, and it is not recommended.
HER2 — HER2 is a protein that is present in about one out of every five invasive breast cancers. The presence of HER2 in the breast cancer identifies women who might benefit from treatments directed against the HER2 protein. Drugs that target the HER2 protein include trastuzumab (brand name: Herceptin), pertuzumab (brand name: Perjeta), ado-trastuzumab emtansine (brand name: Kadcyla), and lapatinib (brand name: Tykerb).
HAS THE BREAST CANCER SPREAD?
Once a diagnosis of breast cancer is established, the next important questions are the following:
OVERVIEW OF TREATMENT
The treatment of breast cancer must be individualized and is based upon several factors. Optimal management in most cases requires collaboration between surgeons (breast cancer surgeons and reconstructive surgeons, who are typically plastic surgeons) and physicians who specialize in radiation and medical oncology. Each woman should discuss the available treatment options with her doctors to determine what treatment is best for her.