BREAST cancer is the most common cancer in women in Brunei Darussalam and around the world. The ‘pink’ month of October is dedicated to breast cancer awareness, symbolised by a pink ribbon.
In Brunei Darussalam, about 80 new cases are diagnosed per year. However, the number of cases is increasing and there is an increasing trend of younger women who are affected where the youngest patient is 18 years old. Most often the cancer is diagnosed in its advanced stage with less chance of cure. Hence, there is a need to increase awareness of early breast cancer detection.
The theme for this year’s awareness campaign conducted by the Health Promotion Centre is ‘Your Health is in Your Hands’.
What is breast cancer?
It is a malignant tumour that starts in the breast, due to uncontrolled growth of cells, that invade neighbouring tissue and spreads to the axilla (armpit) and later to other parts – metastases.
The disease usually occurs in women but about one per cent of men are also affected.
Breast cancers are classified by its type (ductal carcinoma in situ, invasive ductal Ca or invasive lobular Ca), grade of tumour (low, intermediate or high), oestrogen/progestrone receptor status and Her2 status.
Meanwhile, the stages of breast cancer is determined based on the size of the tumour, the nodes affected and if the cancer has spread elsewhere.
How does it start?
Normal breast is made of lobules (milk glands), ducts (tiny tubes that transport milk to the nipple), stroma (connective tissue), blood vessels and lymph vessels.
Most cancers, 80 to 90 per cent, begin in the ducts (ductal cancers) but others begin in the lobules (lobular cancers).
The cancer cells later invade and spread via the lymph channels to the lymph nodes in the armpit (axillary), within the chest (internal mammary) or to the nodes near the collar bone (clavicular).
What are the risk factors?
Increasing age, family history of breast cancer, personal history of breast cancer, certain benign breast diseases, early menarche and late menopause, exposure to oestrogens such as hormone replacement therapy and oral contraceptives, obesity, excessive alcohol intake and exposure to radiation treatment are some of the risk factors of being affected by the disease.
Doing more physical activities, maintaining ideal body weight, reducing fat and red meat intake helps to reduce breast cancer risk.
There is no evidence that use of antiperspirants and underwire bras can cause breast cancer. Breast implants may delay the early diagnosis of cancer.
What is the best way to diagnose breast cancer?
The key message is early detection.
It has been found that if cancers are detected early at Stage 1, patients have greater than 90 per cent chance of cure. If detected even earlier at ductal carcinoma in situ (DCIS) – the patient have nearly 100 per cent chance of cure.
Unfortunately, nearly 40 per cent of cancers are diagnosed in Stage 3 and Stage 4.
Early detection can be made by practicing breast self-examination which is done once a month from the age of 20, usually seven days after start of a menstrual cycle. All women have to learn the proper technique of breast self-exam with supervision. Clinical breast examination and mammogram (breasts ultrasound) can also be done by doctors and healthcare professionals.
Most lumps are detected by the patient themselves. About 80 to 85 per cent of lumps are benign (not cancerous) but usually needs a biopsy to confirm. They could be fibrosis, cysts of fibrocystic disease or fibroadenomas.
Diagnosis can be confirmed by using fine needle aspiration, trucut biopsy, excision biopsy and with additional imaging using mammogram and ultrasound.
What are the signs and symptoms?
The signs and symptoms of breast cancers include lumps, dimpling of skin, inverted nipples, bleeding or discharge from nipple, asymmetry of breasts, lumps in the armpit or neck, abnormal skin rash near nipple and sudden increase in breast size.
Remember that many breast lumps including breast cancer is painless.
How do you treat breast cancer?
General types of treatment are surgery, chemotherapy, radiotherapy, hormonal, targeted therapy, bone directed treatment and palliative.
Different types of surgery done on breast cancer patients are breast conserving surgery, also called lumpectomy, segmental mastectomy or quadrantectomy where only part of the breast is removed; mastectomy where the whole breast is removed; axillary dissection, to remove lymph node in the armpit; sentinel node biopsy – sampling of node in the armpit to decide management; palliative mastectomy, removing large tumour of breast to prevent complications, and reconstruction oncoplastic surgery.
It consists of giving cancer killing drugs, usually through the veins in cycles at the cancer centre. Different situations require different kind of chemotherapy.
Adjuvant chemotherapy is done after surgery to remove the whole cancer growth. The chemotherapy will help to kill remaining cells left behind or those which are not seen during scans. It reduces the risk of recurrence, and improves survival
Before a surgery is planned, neoadjuvant chemotherapy can be done to shrink the large cancer tumours.
A palliative chemotherapy will be needed if the cancer has advanced and spread elsewhere and a curative surgery is not possible.
Due to side effects of chemotherapy, the decision of benefits versus side effects needs to be weighed and drugs to reduce side effects of chemotherapy need to be given.
Radiotherapy is done using special machines in radiotherapy units where the most common type is the external beam radiotherapy. It is done over a period of three to five weeks where each session will take a few minutes for five days a week.
It is usually given following breast conserving surgery to reduce risk of recurrence in the affected breast.
The female hormone, oestrogen, promotes the growth of cancer cells in those who are hormone receptor-positive disease. Two out of three breast cancers are hormone positive. Drugs are usually given in the form of tablets to be taken daily to lower oestrogen levels or prevent the action of oestrogen. They are given after completing the cycle of chemotherapy or after surgery usually for five years. In some high risk groups, there is now evidence for use up to 10 years. The drugs commonly used are tamoxifen, anastrozole, letrozole and exesmestane.
One in five patients has a growth promoting protein Her2 on the surface and has more aggressive disease.
In these cases, drugs that block the Her2 activity such as monoclonal antibody, herceptin, or lapatinib may be used in addition to chemotherapy.
After completing the different modalities of treatment, regular checkups and blood tests are needed to detect any early recurrence. This will also include yearly mammograms and clinical examination and also encouraging patients to do breast self-examination.
Take home messages
- Early detection is a woman’s best weapon
- Breast self-examination should be done by every woman above 20 years of age
- When lump is detected, do not ignore it even if it is not painful
- Seek medical help from nearest clinic, including women’s wellness clinic
- It is important not to be carried away by dubious claims of “cure” by alternative medicines which will end up delaying diagnosis and advancement of disease
- Cancers detected in earlier stages have the highest chance of cure
(Prepared by the Brunei Cancer Centre and Health Promotion Centre, Ministry of Health)