About 100 new cases with breast cancer are diagnosed in Brunei every year, The Brunei Cancer Centre, Pantai Jerudong Specialist Centre stated in a release yesterday.
The release added that the numbers were increasing yearly while there seems to be a trend for younger women to be affected, compared to western countries.
A sizeable number of these patients are in the late 30s and 40s, compared to the western population, where the age group is in the 50s. The release stated that when the cancer is diagnosed in more advanced stages there is less chance of a cure.
“Pregnant and elderly women can also get breast cancer, and tend to be missed while many resort to alternative herbal and traditional medicines in the ‘hope’ of cure, misled by information obtained from dubious sources without seeking expert opinions. Hence, there is a need to increase awareness about early detection,” the release said, adding that about one in eight women will develop breast cancer during their life time.
Breast cancer is the most common cancer in women, in Brunei Darussalam, and the world over. October is dedicated to Breast Cancer – “pink month” and the pink ribbon symbol is to increase awareness of breast cancer among the public.
The Ministry of Health (MoH) and non-governmental organisations (NGOs) in Brunei Darussalam and the world over have used October to promote breast cancer awareness programmes for early detection and education.
This year as part of the Breast Cancer Awareness Month, the MoH with Pantai Jerudong Specialist Centre (PJSC) and vice versa organised the launching of the Breast Cancer Awareness Month at the PJSC on October 7, talks on Fridays at the Early Cancer Detection and Prevention Unit at PJSC, breast cancer talk at the Ministry of Development by Health Promotion Unit, MoH and staff from Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital and PJSC on October 10 and a breast cancer symposium planned for tomorrow at the PJSC for health personnel.
Breast cancer is a malignant tumour that starts in the breast, due to the uncontrolled growth of cells, usually arising in the milk ducts or the glands in the breast. These abnormal cells then invade neighbouring tissues and spread to the axilla (armpit) and later to other parts of the body (metastases) to become Stage 4 breast cancer.
The disease commonly affects women but about one per cent in men.
A 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) or within the chest nearby and later to other parts of the body, to become advanced disease.
The risk factors are: age – increasing risk with increasing age; family history of breast cancer – first degree relatives (mother, sister or daughter) with breast cancer, doubles risk; personal history of breast cancer – the earlier presence of breast cancer in one breast increases the risk to the other breast; hereditary – about five to 10 per cent have hereditary genes like BRCA1, BRCA2 and others; obesity; certain benign breast diseases – atypical ductal or lobular hyperplasia; early menarche and late menopause – the longer the exposure to estrogen, the higher the risk (prolonged lactation actually reduces the risk); exposure to estrogens, including HRT, oral contraceptives – hence worldwide most doctors are reluctant to prescribe hormone replacement therapy post-menopause, and even when prescribed, the patient needs to be monitored; exposure to radiation and the injection of external substances into the breast for cosmetic purposes.
Increasing physical activity, maintaining ideal body weight, reducing fat and red meat intake, seem to reduce breast cancer risk. There is no evidence that the use of antiperspirants or underwire bras causes breast cancer. Breast implants may delay the early diagnosis of cancer.
While stressing that early detection is the key message, the press release added that early detection is done by breast self-examination which is done once a month from age 20s, usually seven days after the start of periods where the technique needs to be learnt under supervision; clinical breast examination by health professionals; and mammogram or ultrasound of breasts. Mammogram is advised once a year above age 40. Screening programmes vary with different countries.
Most lumps are detected by the patient herself. Eighty to 85 per cent of lumps are benign (not cancerous), but usually needs a biopsy to confirm. They could be fibrosis, cysts as part of fibocystic disease, or fibroadenomas.
Studies have shown that early Stage 1 cancers have nearly 100 per cent cure rate, but cure rates in Stage 3 and 4 breast cancers drop to 20 to 30 per cent depending on the different types of breast cancers. With modern healthcare facilities, with good surgical, chemotherapy and radiotherapy interventions, there are those with Stage 4 cancers living longer than eight to 10 years.
Signs and symptoms are 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.
Many breast lumps including breast cancer is painless. The key message is not to ignore a painless lump in the breast and seek professional opinion as soon as possible.
A diagnosis can be confirmed by a fine needle aspiration, trucut biopsy, excision biopsy and a mammogram and ultrasound may be needed. How do you classify breast cancers? Type – ductal carcinoma in situ (DCIS), invasive ductal Ca, Invasive lobular Ca, Grade of tumour – low, intermediate or high grade, Estrogen/Progestrone receptor status, Her2 status – Her2 positive cancers are more aggressive.
The staging of breast cancer (Stage 1 to 4 where Stage 4 is classified as advanced disease) will be based on the size of tumour (T stage), nodes affected (N stage), presence of spread elsewhere- Metastases (M stage).
As for treatment of breast cancer, in many larger hospitals, there are multidisciplinary breast cancer clinics where standard types of treatment are offered, which are all available in Brunei Darussalam, surgery, chemotherapy, radiotherapy, hormonal, targetted therapy and Immunotherapy (recently approved in triple negative breast cancer).
Surgery includes different modalities: Breast conserving surgery – also called lumpectomy, segmental mastectomy, or quadrantectomy. Only part of breast removed. Mastectomy – whole breast removed. Axillary dissection – to remove lymph nodes 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. Reconstruction oncoplastic surgery.
Chemotherapy: It consists of giving cancer-killing drugs, usually through the veins in cycles. In Brunei Darussalam it is given at the Day Care Unit at PJSC. Many patients undergo chemotherapy under the supervision of trained health personnel.
There are several situations by which they are given:
Adjuvant chemotherapy – after surgery has removed the whole cancer growth. The chemotherapy helps to kill remaining cells left behind or those with early spread, not seen on scans. It reduces the risk of recurrence, and improves survival. This has been shown by studies worldwide to reduce the risk of recurrence of the breast cancer.
Neoadjuvant chemotherapy – given in large tumours to shrink the cancer, before surgery is planned. This is also becoming a more common mode of treatment to ensure successful clearance of the breast cancer mass.
Palliative chemotherapy – in advanced cancer, when curative surgery is not possible due to spread elsewhere.
Due to side effects of chemotherapy, proper counselling of the patient and family members needs to be done to explain the benefits versus side effects; and what can be done to reduce side effects of chemotherapy. Medications are available over the past 20 years to help reduce the initial side effects of chemotherapy and make it more tolerable. More than 90 per cent of the chemotherapy is done at day care centres under supervision without the need for overnight admission in the hospital.
Radiotherapy: Radiotherapy is given using special machines in radiotherapy units, commonest being the external beam radiotherapy via a Linear Accelerator (LINAC) given over a period of three to five weeks. Each session has a duration of a few minutes, usually given five days a week.
It is usually prescribed following breast conserving surgery to reduce the risk of recurrence in the affected breast. An extra boost to the site may be needed. In patients with mastectomy, certain high risk groups will benefit from additional radiotherapy.
Radiotherapy is also used for advanced diseases to treat bone metastasis and for brain metastases.
Hormonal therapy: The female hormone, estrogen, promotes the growth of cancer cell in those who are hormone receptor positive disease. Two out of three breast cancers are hormone positive.
These drugs are usually given as tablets and taken daily to either lower estrogen levels or prevent the action of estrogen. They are given after completing the cycle of chemotherapy or in some groups after surgery usually for 10 years.
The drugs commonly used are tamoxifen, anastrozole, letrozole and exesmestane. Newer drugs that help in hormone positive breast cancers are recently available and have helped control the disease in advanced cases without chemotherapy.
Targetted therapy: One in five patients has a growth promoting protein Her2 on the surface and so has a more aggressive disease.In these cases, drugs that block the Her2 activity like Monoclonal Antibody, Herceptin, Lapatinib and newer agents may be used in addition to chemotherapy.
Follow up: After completing the different modalities of treatment, regular check-ups and blood tests are needed to look for early recurrence. This will also include yearly mammograms and clinical examination, and continuous encouragement given to patients to do breast self-examination.
The key messages are early detection is a woman’s best weapon, breast self-examination should be done by every woman above age 20, when a lump/lumps are detected, do not ignore even if there is no pain, seek medical help from the nearest clinic, including well women clinics in the nearest centre where a referral may be required for investigations at specialist clinics, cancer detected in the early Stage 1 will have more than 95 per cent chance of cure and it is important not to be carried away by dubious claims of “cure” by alternative medicines or options, which will end up with delayed diagnosis and advanced disease.