Breast Cancer

Breast cancer originates from the tissues of the breast which maybe in the tubes that transport milk toward the nipple (ducts) or glands that make milk (lobule).
Breast cancer incidence has been increasing in India and is now the most common cancer in large cities in India, and the second most common in the rural parts of the country.

TYPES AND SUBTYPES
Breast cancer maybe classified in a several ways by a doctor:

• Invasive vs Non-invasive: Defined based on whether the cancer cells are in the ducts only (non-invasive) or involve both the ducts and healthy breast tissue (invasive). Non-invasive cancer is called a pre-malignant lesion, meaning that it is not yet cancer but can progress to the invasive form.
• Early, Locally-advanced, Metastatic, Advanced: Early breast cancer is when the tumour has not spread beyond the breast or axillary lymph nodes. If it has spread to nearby tissue or lymph nodes it is locally advanced. Metastatic is when it has spread to other parts of the body, such as the liver, lungs or bones. Advanced is the late stage of breast cancer, which maybe locally-advanced inoperable breast cancer and metastatic breast cancer.
• Other classifications based on hormone receptors and gene expression: If the growth of the tumour is stimulated by the hormones oestrogen and progesterone, the clinician will want to test for oestrogen receptor (ER) or progesterone receptor (PgR) activity. This is an indication for specific hormonal therapies. HER2 is a receptor that is involved in the growth of cells and is present in about 20% of breast cancers. HER2 positive tumours is treated with specific types of chemotherapy.

STAGING OF BREAST CANCER

If you are diagnosed with cancer, your doctor will run more tests to determine the extent (stage) of your cancer. Your cancer's stage is an important input in deciding on your treatment. The stage of a cancer describes the size of the cancer and how far it has spread. It may be described as stage 0 to stage 4 and takes into account: the size of the cancer, whether the lymph nodes are affected, if the cancer has spread to other parts of the body.

• Stage 0: In this stage the cancer is limited only to the inside of the milk duct and the treatment is more conservative than invasive breast cancer.
• Stage 1: It is divided into two groups. Stage 1A (the cancer is 2cm or smaller and hasn’t spread outside the breast) Stage 1B (No cancer seen in the breast, but a few cancer cells found in the lymph nodes under the arm or the cancer in the breast is 2cm or smaller, and a few cancer cells found in the lymph nodes)
• Stage 2: It is divided into two groups. Stage 2A (No cancer seen in the breast or cancer smaller than 2cm but with spread to one to three lymph nodes or a tumour between 2-5 cm with no spread), Stage 2B (The tumour is between 2 to 5 cm with spread to the lymph nodes or larger than 5cm with no spread to the lymph nodes)
• Stage 3: It is divided into three groups. Stage 3A (No cancer in the breast, but cancer present in four to nine lymph nodes under the arm or near the breastbone; a tumour less than 5 cm with spread to four to nine lymph nodes under the arm or near the breastbone or breast tumour larger than 5 cm which has spread to up to three lymph nodes). Stage 3B (a tumour of any size that has spread to the skin of the breast or chest wall. Cancer is found in up to nine lymph nodes under the arm or near the breast bone. Stage 3C (tumour in the breast of any size, may have spread to the skin of the breast or chest wall and cancer is found in 10 or more lymph nodes)
• Stage 4: It is also known as secondary breast cancer. The cancer has spread (also known as metastasised) to other parts of the body. The spread may be to distant lymph nodes, lungs, bones, liver or the brain.

Sources: European Society for Medical Oncology (ESMO); Breast Cancer India; Breast Cancer Care UK; American Cancer Society

SCREENING & DIAGNOSTIC TESTS IN BREAST CANCER

Screening tests (such as clinical breast examinations & ) are routine tests for healthy individuals to identify breast cancer early before any symptoms have developed. Diagnostic tests are for those suspected to have breast cancer, based on symptoms or a screening test result. Monitoring tests are used during and after treatment to monitor how well therapies are working and to check for signs of recurrence.

• Clinical History & Examination: The doctor will ask you about a family history of breast and other cancers, menstrual status and will examine the breasts and the lymph nodes. A Clinical breast examination will be conducted as well during which the doctor will carefully feel the tissue in the breast. Breast cancer differs from benign lumps and normal tissue in size, texture, and movement. He/she may also take a blood sample for routine blood tests. 
• Imaging: Mammography is a type of low-dose x-ray that looks for early breast cancers. The breasts are placed on the x-ray machine and pressed between two plates to produce a clear image. If there is a suspicion of cancer in the report, a doctor will investigate further. Some women may have dense breasts which are those with a lot of glandular and connective tissue and not much fatty tissue. On a mammogram, it is harder to detect an underlying cancer in women with dense breasts and further testing may be required.Ultrasound scans let radiologists examine the breasts and the lymph nodes in the armpit. It can help visualize a lump and determine its characteristics. MRI scan: MRI uses magnetic fields and radio waves to produce detailed images of the breast. This is not a routine investigation and maybe be used in patients such as those with a family history of breast cancer or specific genetic mutations. Other radiological scans sometimes indicated include CT scan, PET scan and Bone scan to assess the spread of cancer.

• Biopsy: Imaging studies (mammogram and MRI), often along with physical examinations, can lead doctors to suspect breast cancer. However, the confirmatory test is to take a sample of tissue and examine it under a microscope. A biopsy is essential to plan a patient’s treatment. There are various types of biopsy, such as fine needle aspiration biopsy, core biopsy, incisional and excisional biopsies. The biopsy by the pathologist provides essential information on the type of breast cancer.

TREATMENTS

The choice of treatment in breast cancer is on a number of complex clinical principles which will be explained the doctor. These include: Staging (size, position and spread of cancer), Histology (classify the tumour based on cells and tissue), Grade (how do the cells look and how fast do they grow), Hormone receptor status and HER2 gene expression.

• Surgery: Surgery is done to remove as much of the cancer as possible, identify whether the cancer has spread to the lymph nodes (also know as sentinel lymph node biopsy or axillary lymph node dissection/biopsy), restore the breast’s shape after tumour removal (breast reconstruction) or relieve symptoms of advanced cancer. There are two types of surgery to remove the tumour – Conserving surgery (removes the tumour but tries to conserve as much of the breast as possible), or Mastectomy (removal of the entire breast). A lumpectomy is a form of breast conserving surgery where only a portion of the breast is removed, sometimes referred to as an excisional biopsy, where the tumour is removed along with a margin of normal tissue.
• Radiotherapy: It is the use of ionising radiation which kills cancerous cells by damaging the DNA. The decision of the medical oncologist to administer radio is based on the type of surgery performed, the spread of cancer to the lymph nodes or elsewhere in the body, and the patient’s age. There are two types of radiotherapy, external beam radiation (radiation comes from a machine outside the body) and internal radiation or brachytherapy (radioactive source is put inside the body for a short time). Side effects: Swelling in the breast, skin changes such as redness, skin peeling, darkening of the skin, fatigue, nerve damage (neuropathy). In the case of brachytherapy (local radiotherapy delivered only to the tumour) it may lead to redness or bruising at the treatment site, breast pain, infection, weakness and fracture of the ribs in rare cases and fluid collecting in the breast.
• Endocrine (Hormone Therapy): Endocrine therapies are used in estrogen or progesterone receptor positive tumours. These are called hormone-dependent tumours. The therapy may be taken orally or as an injection. This form of therapy is often used after surgery to reduce the risk of recurrence of cancer or may sometimes be administered before surgery as well. Side effects: Depending on the agent used, the side effects may include: Hot flashes, vaginal dryness, vaginal discharge, mood swings, headache, nausea, bone pain, injection site pain, muscle pain and joint stiffness and/or pain and bone thinning.

• Chemotherapy: Chemotherapy uses anti-cancer drugs that may be injected into the vein or given orally and reach the cancer cells through the bloodstream. These agents may be used before surgery, after surgery or for advanced breast cancer. Not all women with breast cancer will need chemotherapy. Side effects: Hair loss, nail changes, mouth sores, loss of appetite or weight changes, nausea and vomiting, diarrhoea, increased chance of infections, easy bruising or bleeding, fatigue, changes in menstrual periods, cardiomyopathy (heart damage), nerve damage (neuropathy).
• Immunotherapy: Immunotherapy is a method to stimulate a person’s immune system to recognize and destroy cancer cells and can be used to treat some types of breast cancer. The immune system avoids attacking normal cells in the body by proteins called “checkpoints”. Breast cancer cells occasionally use these checkpoints to avoid being attacked by the immune system. By targeting these checkpoints, an immune response is mounted against the cancer cells. Side effects: Fatigue, cough, nausea, loss of appetite, constipation, diarrhoea. A rare side effect includes the turning of the immune system on healthy cells in the body.
• Targeted therapy: These are drugs designed to block the growth and spread of cancer cells, but unlike chemotherapy drugs, which attack all cells that multiply quickly, these drugs work only against cancer cells. Side effects: Heart damage, severe diarrhoea, hand-foot syndrome (the hands and feet become sore and red with blisters and peeling).
• Palliative care & End of life Care: It involves a number of interventions for those patients with advanced disease, and includes management of symptoms, support for coping with prognosis and diagnosis of advanced cancer, and preparation for end-of-life care. End-of-life care is for patients with incurable cancer and involves keeping the patient comfortable and providing relief from physical and psychological symptoms.

Sources: Breastcancer.org; Cleveland Clinic; European Society for Medical Oncology (ESMO); Radiologyinfo.org; American Cancer Society; Mayo Clinic

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

• Breast Cancer Specialists:

Medical Oncologist: A clinician specialized in the medical treatment of cancer.

Surgical Oncologist: A surgeon specialized in the surgical treatment of cancer.

Breast Surgeon: A surgeon specialized in the surgical removal of breast tumors. This is considered a super specialty in surgery.

Radiation Oncologist: A clinician specialized in treating cancer with radiation.

• Plastic surgeon: A surgeon specialized in breast reconstruction.
• Radiologist: A clinician specialized in reading X-rays, CT scans, MRIs, ultrasounds, and other imaging modalities.
• Pathologist/Onco-pathologist: A clinician specialized in examining tissue samples under a microscope.
• Genetic Specialist: A clinician/scientist who determines the genetic make-up of a tumor. These tests may be done in specific high risk patients or for those in whom a targeted therapy may be beneficial.
• Physiotherapist: Physical therapists provide support for patients especially to alleviate the effects of some of the treatments for cancer.
• Counselor: Psychologist by training that offers counselling to patients
• Dietitian: Offers personalized support to cancer patients.
• Palliative care specialists: These professionals help patients and families deal with the emotions that come with a cancer diagnosis and cancer treatment such as anxiety and depression as well as keep the patient comfortable especially in incurable cases.

TUMOR BOARD: A tumor board is a meeting where a Multi-Disciplinary Team discusses cancer cases and share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient's case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

BREAST CLINIC: This is a specialized center with a multidisciplinary team of experts to help you with all breast-related concerns, including breast cancer. These are normally found within a hospital and offer personalized care in a supportive environment for breast related diseases. These centers, in many cases, offer access to most or all of the specialists mentioned above. Some hospitals in India have Breast Clinics, do check if you can visit a hospital that has one.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources: WebMD; ​European Society for Medical Oncology (ESMO); National Cancer Institute; Mayo Clinic; Cancer.Net

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on their range of services to treat breast cancer. Use our search tools to find a suitable medical provider. You may get in touch with us for any assistance during selection or booking process. 

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For breast cancer, you can start by visiting a medical oncologist or a surgical oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST

1. Look for Specialists: Look for doctors who treat your specific type of cancer - breast cancer. You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for breast cancer, who have received dedicated training on treating breast cancer. If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – breast cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes.
5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL

1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to breast cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has a Breast Clinic? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
3. Research hospital’s Breast Cancer volumes: How many cases of breast cancer are treated in the hospital every year? High volume centers with multiple specialists available for breast cancer may have better expertise i.e. doctors and specialized medical infrastructure required.
4. Consider Clinical Trials Availability: Do ask about clinical trials. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients. Ask whether the doctor or hospital has access to clinical trials.
5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net