Breast cancer is one of the most devastating news pieces a woman can hear. According to American Cancer Society statistics, roughly 1 in 8 (12%) women will develop breast cancer in their lifetime. This year alone, more than 230,480 women in the United States will be diagnosed with new cases of invasive breast cancer and nearly 39,520 women will lose their battle. There are more than 2.6 million breast cancer survivors living in the United States. Breast cancer is the second leading cause of cancer death in women exceeded only by lung cancer. This type of cancer in men is rare. Of all the ethnic groups in the United States, overall white women have the highest rate of developing breast cancer.
SIGNS & SYMPTOMS
Early breast cancer may not cause symptoms. The most common symptom is new lump or mass. A new painless, hard mass that has irregular edges is more likely to be cancerous. Other symptoms include lumps in armpits, swelling, skin irritation, dimpling of skin, orange skin tone; and nipple changes include pain, swelling, retraction or discharge. Advanced stages of cancer can lead to bone pain, breast pain, and swelling of one arm and weight loss.
SCREENING
Women in their 20’s and 30’s should start doing their monthly breast exam by themselves and by their doctors at least every three years. After age 40, women should have this done every year along with a screening mammogram and continue it as long as they are in good health. Women who are at very high risk (more than 20 per cent lifetime) may be recommended to have a Mammogram and MRI.
DIAGNOSIS
Workup usually starts with a mammogram followed by an ultrasound to see if the lump is solid or cyst. Biopsy is used for definitive diagnosis. There are two types of breast cancer. Ductal carcinoma makes up 80 per cent of cases while Lobular type makes up the rest. Many of these cancers are sensitive to estrogen called estrogen receptor positive cancer. HER2 positive breast cancers are more aggressive and at higher risk of recurrence.
RISK FACTOR
Risk factors for breast cancer includes age over 50, family history of breast cancer (only 20%), BRCAI and BRCA2 gene defect, early start of menstruation and late menopause. Other modifiable risk factors include alcohol use, women who have never had children or had them only after age 30, on hormone replacement therapy, obesity, and radiation to chest area. Breast feeding, mild exercise and maintaining healthy weight can lower the risk of breast cancer.
PREVENTION
Prevention includes eating healthy diet, more fruit, vegetables, wholegrain everyday and limiting processed as well as red meats. Tamoxifen is approved for breast cancer prevention in women who are at high risk. It can also be used to reduce the risk of recurrence in localised breast cancer and as a treatment for advanced breast cancer when the tumour is estrogen receptor positive. In some case, prophylactic mastectomy may be recommended as risk reduction strategy.
TREATMENT
Treatment of breast cancer generally includes surgery. Surgery often is combined with radiation, chemotherapy and hormonal and / or targeted therapy. Prognostic factors are tumour size, lymph node status, estrogen /progesterone receptor and HER2/neu status. The treatment requires a collaborative effort between surgeon, radiologist, medical oncologist, radiation oncologist and pathologist.
ROLE OF VACCINE
Newsweek, Dec. 10, 2011 issue with headline, “Could this be the end of cancer?” reported the case of a woman with metastatic breast cancer cured completely with a newly developed vaccine. Usually stage IV (spread to other part of the body) breast cancer takes the lives of at least 80% of patients within five years. This patient was given vaccine-containing fragment of HER2/neu. She received five more shots within the next five months. Subsequent CT scan several years later detected no cancer anywhere. Enough of the 21 women who received the experimental vaccine for metastatic breast cancer are doing so well that its inventor, immunologist Mary Disis of University of Washington, dares to envision a future in which vaccine can control or even eliminate cancer, according to Newsweek article.
The vaccine seems to be in the last stage of testing before it can be approved and be available to the public. Despite having enormous amounts of resources diverted to breast cancer vaccine, the final product may still be long way off. Even when the vaccine becomes available, it will be interesting to know the cure rate and at what cost. There are already many types of vaccines available for other cancers, which are extremely expensive and add very little to the cure rate or longevity of life. The good news is that with the present treatment breast cancer already has a cure rate of 85-90 per cent.
[Anis Ansari, MD, is Chairman, Department of Medicine, Mercy Medical Centre, Clinton, Iowa, USA]