Facing a cancer diagnosis can appear to be one of the most difficult things to deal with. A million thoughts, worries and scenarios will be running through your mind. It’s totally normal to feel like that. But you’re not alone. Together with your family and friends, we’re here. Your care is our focus, every step of the way. We believe care should be available when and where you need it most and it should be designed to help give you the best life outcomes possible. Over 90% of patients treated by our team are back to their normal life with little impact on their life span.
Today, breast cancer is usually diagnosed at an early stage when it is still confined to the breast and regional nodes. Here, we focus on stage 0 (ductal carcinoma in situ), I, II and IIIA disease, with a concise overview that will aid understanding of the risk of developing breast cancer, the essentials of diagnosis and preoperative assessment and the current approach to treatment and follow-up.
Use Fast Facts: Early Breast Cancer to follow clear diagnostic and treatment pathways, from screening and symptomatic presentation, through triple assessment diagnosis, to treatment and follow-up.
What is breast cancer?
Breast cancer is one of the most common form of cancer affecting women in the UK. A cancerous lump or lesion forms in the breast when there is uncontrolled and excessive growth of cells. Breast cancer can sometimes spread to and grow in other organs, which is the only time it becomes life threatening.
Over the last 50 years, clinical research has led to many new treatment options and a large proportion of women diagnosed with breast cancer today can be treated successfully and can expect to lead a normal life.
What are the causes of breast cancer?
Breast cancer is the most common form of cancer among women. In 2018, with an estimated 2 million new cases diagnosed worldwide. Although breast cancer remains the leading cause of cancer death among women aged 35–55 years, survival has greatly improved in the last 2 decades with development of more effective and less toxic treatments.
How common is breast cancer?
In 2018, there were 2 million new cases of breast cancer diagnosed worldwide. In the UK, 55,000 women are diagnosed with breast cancer and 8000 women with ductal carcinoma in situ (DCIS). DCIS is made of cancer cells that are still within a duct so cannot spread. Every year, there are 12,000 deaths after breast cancer has spread to other organs. Importantly, breast cancer is the most common cause of cancer death in women in their 40s and 50s. Growing awareness of breast cancer and adoption of screening mammography has increased the number of women who are diagnosed with breast cancer.
Is breast cancer becoming more common?
In the last 25 years, the number of women diagnosed with breast cancer has increased by about a quarter. This could be because the national screening programme was introduced in the mid nineties: Screening mammography can find cancers before they develop the ability to spread but it also finds lesions or DCIS (ductal carcinoma in situ) which may never develop into true cancers. Adoption of population screening programme has meant that more women are diagnosed with breast cancer.
Lifestyle changes such as delaying having a first child could contribute to the increasing incidence of breast cancer. We are also living longer, which means that more people will be diagnosed with breast cancer because they were protected against other conditions.
Are there any other factors that increase the risk of breast cancer?
Other factors that one cannot have any control are age (breast cancer gets more common with age: more than half the cancers are diagnosed in women over 60), previous breast cancer, starting menstruating at a young age and reaching the menopause at an older age, having breast tissue that is mammographically opaque (‘dense’).
Is breast cancer inherited?
Familial breast cancer is breast cancer that arises because of inheriting a faulty gene. Less than 10% of cancers are actually familial and develop because of a faulty inherited gene mutation. A few of such genes have been identified in the last 2 decades and we can now do tests to see if you are carrying faults in any of such genes (eg BRCA1 BRCA2, P53, etc.). Such gene tests should be considered if there is a substantial risk of carrying a familial gene mutation. This risk can be determined by specialist breast cancer consultants. Familial breast cancers have certain characteristics : they are more likely if the breast cancer is of a certain type (e.g. triple negative), develops at a young age, and develops in women with certain ancestries such as Polish or Jewish.
What are the lifestyle changes one can make to reduce the risk of breast cancer?
Some aspects of our lifestyle could increase the risk of developing breast cancer. Cancer Research UK estimates that about a quarter of breast cancer cases can be prevented by changing the modifiable factors that increase the risk of breast cancer. In fact, modifying these factors has a much greater health benefit by way of reducing cardiovascular (reducing heart attacks and stroke) risk.
Alcohol consumption: There is no lower limit which is harmless: a small glass of wine per day will increase the risk by 40%. In real terms, for a woman aged 50 this is an increase risk in the next 10 years, from a background risk of 2.3% (1 in 43) to about 3.2% (1 in 30). So avoiding that glass of wine per day, or reducing the total intake will reduce the risk correspondingly.
Physical activity and regular exercise: Two to 4 hours of walking per week reduces the risk of breast cancer by about 15%. In real terms, for a woman aged 50, this is a reduction in risk from about 2.3% (1 in 43) to about 2% (1 in 50). Regular exercise has many other physical and mental health benefits as well
Diet. A diet that has more of fruits, vegetables and grains and <20% of calories made up by fat reduces the number of deaths after breast cancer by about 18%.
Other factors that have had a smaller impact on the rise in breast cancer cases are the use of oral contraceptives and use of hormone replacement therapy. However, these hormonal medications have their benefits too and it is best to discuss the balance of benefits vs risks with your doctor and consultant.
There are other changes in modern lifestyle that cannot be easily changed. The cells and glands in the breast reach full maturity only with breastfeeding. Immature tissues and cells are thought to be more susceptible to cancerous changes. So breastfeeding early in life (in 20s, rather than late thirties) appears to protect against breast cancer. The duration of breast feeding seems to be important too: breastfeeding can reduce the chances of developing breast cancer by about 4% per year of breast feeding. More women are delaying or not have children, which could be the reason for the increasing incidence of breast cancer in recent years.
How is breast cancer diagnosed?
The aim of screening is to reduce mortality by detecting tumors before they have spread beyond the breast. Screening by regular mammography in 50-65 year olds can reduce the relative risk of mortality from breast cancer by about 18%. The absolute risk reduction is much smaller (0.5%), because the background risk of dying from breast cancer is about 3% in the general population. The trials have not proven an reduction in overall death rate.
Is it necessary for me to do regular breast self examination (BSE)?
Large randomised trials have shown that systematic monthly breast self examination (BSE) does not reduce deaths from breast cancer. Women who perform regular breast-self-examination certainly find more lumps and this means they undergo more consultations, more tests, and more anxiety but regular breast self examination does not save lives.
So, while it is worthwhile to be aware of how your own breast feels so you will notice any lumps or changes such as dimpling of skin easily, you should not feel guilty if you don’t do regular breast self examination.
Of course, if you notice any changes or have any symptoms related to the breast such as breast lump, change in the shape of the breast, dimpling of skin, pulling in of the tissues, nipple discharge, nipple inversion, change in size of the breast, breast swelling, lump in the armpit, localised breast pain after menopause, you should see a breast specialist to get it checked out.
Breast Cancer Surgery & Radiotherapy
Local treatment for early breast cancer consists of surgery and radiotherapy, which aim to remove the cancer and achieve cure by preventing the spread of the cancer and reducing the likelihood of local recurrence within the breast, chest wall or axillary nodes.
Chemotherapy Before Surgery (Neoadjuvant Chemotherapy)
The aim of neoadjuvant therapy (preoperative systemic therapy) is:
To enable surgery in patients in whom the cancer is too large to be operable
To reduce the size of the tumor in patients who are borderline for breast conservation to try to avoid a mastectomy
Neoadjuvant treatment regimens are usually similar to the adjuvant regimens used after surgery. Most are anthracycline- and taxane-based therapies with or without HER2-targeted agents. Neoadjuvant hormonal therapy can also be given in strongly ER-positive postmenopausal women who are borderline for breast conservation because of the tumor size.
Endocrine and Chemotherapy (Adjuvant therapy)
Adjuvant therapy unequivocally provides a significant and prolonged improvement in survival. It is based on the principle that breast cancer is, for many women, a systemic disease at the time of diagnosis with undetectable dormant micrometastases. These micrometastases may develop into clinically relevant metastases years after primary diagnosis.
It is logical for surveillance to follow the hazard of relapse, which is highest after 2–3 years and low after 5 years. Therefore, a clinical examination every 3–4 months for the first 2–3 years and then every 6 months up to 5 years is appropriate, with yearly follow-up thereafter (specific recommendations vary between countries). For this approach to work, however, it is vital that the patient should be well informed and present promptly should symptoms develop.
It should be remembered that regular and intensive follow-up does not improve the success rates for treatment of a recurrence. However, it may serve other purposes. The patient’s perceived need for follow-up may mean that visiting her doctor regularly for reassurance (even if it is sometimes proven false) will improve her personal well-being.
The Good News About Breast Cancer
The real good news is that fewer women are dying from breast cancer now than ever before. In the last 30 years, the number of women dying from breast cancer in the UK has reduced from about 60 per 100,000 per year to 35 per 100,000 per year. This reduced mortality is mainly due to improved treatments.
It is also worth remembering that the lifestyle factors that increase the risk of breast cancer can be under our control. You can make changes to reduce the risk of breast cancer – taking more fruits, vegetables and grains in your diet, reducing fat and alcohol intake, and importantly, increasing physical activity – a 20 to 30 min brisk walk every day – can make a large difference. Living a healthier lifestyle will also help to protect you against a wide range of other cancers and health conditions such as heart disease and mental health.
Although we can’t eliminate the risk of breast cancer, there are steps we can take to reduce it. We can also ensure that we check for signs of breast cancer regularly so that it will be detected and treated as soon as possible.
© Prof Jayant S Vaidya
Fast Facts Early Breast Cancer, Author Jayant S Vaidya and Vivek Patkar