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Breast Cancers: All Answers

By Dr Asif Channer

October 14, 2020 01:13 AM

October has been celebrating as breast cancer awareness month throughout the world every year. In 1990’s “Pink Ribbon” was introduced globally as a symbol of breast cancer to express solidarity with patients and as a cardinal insignia to draw attention towards its gravity, reinforcing preventive measures to be taken at all levels.
Mankind has a very long history of breast cancer. The disease was footnoted more than 3,500 years ago by the ancient Egyptians. In 460 B.C Hippocrates described breast cancer as a humeral disease caused by the excess of black bile. 
Breast is made up of three main parts which are lobules, ducts, and connective tissue. The lobules produce milk, ducts are tubes that carry milk to the nipple. The connective tissue consisting of fibrous and fatty tissue which holds everything together. Most breast cancers begin in the ducts or lobules.
There are different types of breast cancers. The most common breast cancers include Ductal carcinoma, Lobular carcinoma, Paget’s disease, Ductal carcinoma in situ (DCIS), Mucinous, medullary, inflammatory breast cancers. It can spread outside the breast through blood and lymph vessels. When breast cancer spreads to other parts of the body like brain, bones, lungs etc. it is called metastasis.
Breast cancer is the second largest cause of deaths in women in the globe followed by lung cancer. Breast cancer can develop both in women and men but it is more common in women.
The most common symptoms of breast cancer are, mass or lump, painless hard mass with irregular margins but sometimes breast cancers are round, tender, soft, Puffiness of all or part of the breast, dimpling of skin looking like an orange peel, pain in the nipple or breast, red, flaking or thickened breast skin, nipple retraction nipple discharge, swollen lymph nodes sometimes a breast cancer appear in armpits or around the collar bone even before this tumour in the breast is large enough to be observable
Unlike other cancers which are mostly hidden inside the body, breast lumps tend to mark themselves as visible or palpable mass hence get the attention of both the patient and health professionals making early diagnosis, treatment and therefore excellent prognosis.
The exact cause of the breast cancer is not known however certain risk factors are associated to its development like being a female is the main risk, other include, increasing age, failure to get pregnant, family history of breast, fallopian tube, ovaries or peritoneal cancer, history of breast cancer in one breast, radiation exposure, female who have mutated BRCA1 and BRCA2 genes responsible for cancer, obesity, starting of monthly period at a younger age for example before age 12 side by side menopause in  relatively older age, first child at an older age for example giving birth to first baby after age 30 or more, , Drinking alcohol and cigarette smoking. 
Breast cancer can be suspected by breast Self-Examination (BSE) by women or clinical examination by health care provider. However, it is confirmed by investigations. The commonly used diagnostic Imaging tests are Mammography, a type of X-ray most helpful in breast cancer screening, Magnetic Resonance Imaging (MRI) and Ultrasound scans.
Biopsy is another diagnostic test which is used. Some breast tissue is removed and examined in biopsy. It describes cancerous and non-cancerous nature of the cells. Diagnosis of breast cancer also helps in determining the size, spread and  aggressiveness like invasive or noninvasive of the cancer
Although, clinical and self-breast examinations (SBE) are not effective strategy for diagnosis, it is still suggested in countries with limited resource having no other screening methods in access of people.
Compared to developing countries, breast cancers in high-income countries are diagnosed at early stages hence have better prognosis. Western countries have a declining or stable incidence rates and decreasing mortality rate that may be attributed to readily available screening and other services.
Multiple dimensions are considered while devising treatment plans for cancer treatment  like age, the overall health of the patient, type, stage, grade of cancer, other medical conditions, socioeconomic status, preferences of the patient and availability of the various therapeutic facilities in the region,
 Currently, different treatment options are available which includes Radiation therapy, Chemotherapy, Hormone therapy, Targeted drug therapy, and Surgery. 
Surgery includes Lumpectomy which involves removing the tumour and a small amount of healthy tissue around it. The spread of cancer can also be prevented by lumpectomy and this may be an ideal option if the tumour is small in size and easy to detach from its adjacent tissues. Mastectomy is the other surgical intervention which involves removing the lobules, ducts, fatty tissue, nipple, areola, and some portion of skin. Sometimes removal of lymph nodes and muscles in the chest is carried out as per requirement.
 Breast Reconstruction and Cosmetic surgery can be performed following mastectomy procedure to reconstruct the breast to give it a natural look. This can help  a lady to handle the psychological impacts of breast removal. Moreover, depending upon different factors single or combination of treatment options as highlighted above can be used.
Breast cancer is prevalent both in developed and developing countries. Every year about 2 million new cases and 500000 deaths have been reporting globally and 39% are from Asia with peak incidence between 40 and 59  years of age. 
The average incidence rate of breast cancer in Asia is 7.9 per 100 000, USA has 92.9 per 100000, Europe  has 80.3 per 100 000 and the World had 43.1 per 100000 The low incidence rates  as documented in Asia could possibly be attributed to under diagnosis, ineffective reporting or due to the lack of radical primary healthcare infrastructure. Furthermore, In low and middle-income countries the incidence has been rising up steadily during the last years.
 Amazingly, developing countries such as Asia, Africa and Central America have low incidence rates but with high mortality rates whereas developed Western Europe and North America, have high incidence but low mortality rates.
Unfortunately in Asia Pakistan is at the top regarding cases of breast cancer followed by China and India. 1 in 9 Pakistani women at some stage of lifespan may develop breast cancer. According to the World Health Organization (WHO) about 100000 new cases and 17,000  to 40,000 female deaths are being recorded in the country every year.
Remarkably, black women have lower prevalence of breast cancer compared to white women side by side black women develop  it at a much younger age and it  is an aggressive type/ 
In the 21st century, the top ten counties with high cases of breast cancer in the world in a chronological order are Belgium, Luxembourg, Netherlands,France,Lebanon, Australia, UK, Italy and New Zealand. 
The majority of deaths occur in low and middle-income countries, where most women with breast cancer are diagnosed in late stages due to the fact that developing countries lack resources, have poor access to cancer screening and prevention programs, lack of awareness about the disease, fear of surgery, chemotherapy, cultural, social taboos and using other traditional nonscientific treatments thus failing in limiting mortality rates.
There are huge Challenges ahead for diagnosis and treatment of breast cancer as early diagnosis of breast cancer is crucial in the management and prognosis of the disease. Early detection can be achieved by regular screening processes that include Breast Self-Examination (BSE) and Mammography. in addition the American College of Radiologists recommends screenings of all ladies above 40, once a year. 
Always remember that all lumps and swellings in the breasts are not cancers  however, if there is a  single or even small size lump noticed it must be immediately evaluated by health professional without any social stigma, shame or fear, for early diagnosis, treatment and for better outcome.
In high-income countries, all treatment options are available for patients who can afford them which contribute to  low mortality and excellent prognosis of breast cancer
Breast cancer burden can be minimized by strengthening healthcare systems, government prioritization to change public health policies and provide adequate diagnostic systems, creating awareness about the disease and implementing international  guidelines for diagnosis and treatment.
It is a well-documented  fact that in spite of being leading cause of deaths in women across the globe, since 1989 improvements in screening and treatment have enhanced women’s survival rates.
Nevertheless, breast cancer risk can be reduced by  regular exercise,healthy diet containing abundantly fresh vegetables, fruit, nuts, keeping a healthy body mass index (BMI), restraining postmenopausal hormone therapy, avoiding excessive alcohol intake ( habit less common in Muslim world) and cigarette smoking.
In this era of information technology, various modern awareness tools are available like The Breast Cancer Health line Apps etc connecting to online breast cancer communities thus gaining support  and advice through group discussions.
As Pakistan is at top position in the breast cancer cases in the Asia which is alarming scene therefore, its  early detection remains the keystone of breast cancer control programs. If  detected early, adequate diagnosis and treatment are made , there is excellent opportunity that breast cancer may be cured. Contrarily, if spotted late, the curative treatment is no choice. In such cases only palliative management is there to soothe misery of patients and their families.
As already pointed out Mammography screening program is very effective in the detection of the disease at early stage but it is expansive. Common man cannot afford it, Federal and Provincial Governments should make necessary arrangement for free screening tests services at  all tertiary care hospitals. 
The simplest technique of Breast self-examination (BSE) to check one-self monthly be taught to Pakistani women especially living in rural areas. 
Establishment of modern state of the art advanced breast cancer care hospitals, at least one at each provincial level are inevitable with the dedicated female health care staff and professionals to overcome the religo-socio-cultural barriers being faced by women in Pakistan for effective diagnostic and therapeutic plans.
Being a woman is main risk factor for breast cancer and Pakistan having about 50%  female population, mass awareness campaigns be launched in all girls schools, colleges. Women universities, medical colleges, professional institutions, Deeni Madaris  through women parliamentarian and prominent female personalities from business, sports, religious, social and media communities to beat the breast cancer in the best interest of their gender and nation.

Dr Asif Channer

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