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					                Dr. Boman N. Dhabhar, Consultant Medical Oncologist, Jaslok
                Hospital & Research Centre,

                BND Onco Centre, Boman Lodge, Above Citibank, Dadar T. T.
                Tel : 9223300476

                Dr. Dhabhar has kindly consented to contribution of this article.




                                 Breast Cancer.
Q. How common is breast cancer?

A. There are over 212,000 cases of breast cancer diagnosed in the USA each year. In Canada
the figure is 20,500, Australia 13,000 and in the UK the figure is 41,000. Overall, one woman in
every nine will get breast cancer at some time in her life.

Q. Who is most at risk?

A. Breast cancer is overwhelmingly a female disease, but about 1% of cases occur in men
(around 300 per year in the UK). Amongst women it becomes more common as age increases.
More than 80% of cases occur in women over 50. Taking the contraceptive pill slightly increases
the risk. Taking hormone replacement therapy significantly increases your risk somewhat more,
but the health benefits derived from hormone replacement are better overall. Obesity and heavy
drinking also significantly increase the risk.

If one or more relatives have had breast cancer, this also increases your risk of developing it
(see below).

Q. Does breast cancer run in families?

A. Having one close relative (mother or sister) with breast cancer doubles your risk of getting
breast cancer, when compared to women with no cases in the family. Having two close relatives
affected increases your risk further.

There are a very few families in which breast cancer is very common - ie four or more cases.
Most of these families carry faulty versions of the 'BRCA' breast cancer genes. Women with a
faulty BRCA gene have a 50% to 80% chance of getting breast cancer. Testing for faulty BRCA
genes is available on the NHS.
Q. Are there different types of breast cancer?


A. There are two main places in the breast where cancer can occur: the lobules (the milk-
producing tissue) and the ducts (which carry the milk to the nipple).

       Ductal carcinoma in situ means an early cancer in the milk ducts. It can be detected by
       mammograms and is normally easy to cure.
       Invasive ductal carcinoma means a cancer that started in the milk ducts but has now
       spread beyond them.
       Lobular carcinoma in situ is not considered to be cancer. It is a pre-cancerous condition.
       Most women with lobular carcinoma in situ do not get breast cancer, but they have an
       increased risk of getting it, so they are given frequent checkups.
       Invasive lobular carcinoma is a cancer that starts in the lobules and has spread. These
       can be difficult to diagnose as they do not always form a lump or show up on
       mammograms.

Q. What are the symptoms of Breast Cancer?


A. Screening for breast cancer by mammography (X-raying the breast) is offered every three
years in the UK to all women between 50 and 64. The highest number of cases of breast cancer
occurs in women between these ages.

Mammography can detect very early breast tumours, when they are too small to be felt. In fact,
most of the breast cancers detected by screening are at this very early stage, when they are
relatively easy to cure. Studies have shown that women who take part in screening are more
likely to have breast cancer diagnosed early and more likely to have it cured and, as a result,
are less likely to die from it, than women who do not take part in mammography screening.

Another method of screening available to all women is to feel the breasts for any lumps. A guide
on how to do this properly can be obtained at any doctor's surgery. Women should also check
for the other main symptoms:

       Change in the size or shape of a breast
       Dimpling of the breast skin
       The nipple becoming inverted
       Swelling or a lump in the armpit

Q. Diagnosis


A. The most important method used to diagnose breast cancer is by taking a biopsy (a tissue
sample). A hollow needle is pushed into the breast lump to capture a tiny sample of the tissue.
This is examined under a microscope. The shape and appearance of the cells in the tissue
sample reveals whether the lump is benign, which is true of the vast majority, or if it is
cancerous.
Q. How important is early detection?

A. We can currently cure six out of every seven patients who are diagnosed when their breast
cancer is at the early stage. However, if they are diagnosed when it has become advanced, the
cure rate falls to about one in seven. It is extremely important to catch breast cancer at an early
stage.

Treatment


The main treatment for breast cancer is surgery. In most cases, conservative surgery is used,
which preserves the shape and appearance of the breast. For very early breast cancer, only the
lump and a small area of tissue around it is removed. For later stage breast cancer, much more
tissue is removed but it is replaced with muscle to rebuild the breast. Since breast cancer cells
usually spread first to the lymph node in the armpit, the surgeon will usually cut into it to check
for any spread.

The surgery may be followed by a short course of radiotherapy or chemotherapy, depending on
the type of tumour and how advanced it is. In most cases, the patient will be given a longer
course of hormone therapy (eg tamoxifen) which reduces the risk of the cancer recurring.

The treatment for breast cancer has been improving for the last twenty years. In the early
1970's, only half of all women diagnosed with the disease survived for five years. Now, over
three quarters survive for that long and most of them will live for very much longer.

Q. What is chemotherapy?

Chemotherapy means treatment with drugs. But in cancer treatment it means 'cytotoxic
chemotherapy' - drugs that kill cancer cells. Chemotherapy uses these cytotoxic drugs to
destroy cancer cells. The drugs work by disrupting the growth of cancer cells. As they circulate
in the blood, they can reach them wherever they are in your body.

The drugs can't tell the difference between cancer cells and normal cells. They just kill cells that
are actively growing and dividing into new cells. Cancer cells do this much more often than
normal cells, so they are more likely to be killed by the treatment. Cancer cells are not as good
at repairing themselves as normal cells. Normal cells can often repair any damage caused
by chemotherapy.

For breast cancer, you may have chemotherapy

      Before surgery to shrink a tumour down (neoadjuvant therapy)
      After surgery to reduce the chance of it spreading or coming back (adjuvant
       therapy)
      As treatment for breast cancer that has spread or come back

We have information about developments in chemotherapy and current trials on the what's new
in breast cancer treatment page.
Treatment before surgery

Chemotherapy before surgery can make a tumour smaller. This can mean you need less
surgery. For example, you may be able to just have the cancer removed instead of having a
mastectomy. But you will still need surgery, and sometimes radiotherapy or other treatments
after the chemotherapy. Your specialist may suggest neoadjuvant chemotherapy because
they think it may help to stop your breast cancer coming back.

Treatment after surgery

Chemotherapy after surgery is called adjuvant therapy. You may have this treatment because

      The lymph nodes under your arm contained breast cancer cells
      You had a large primary cancer in the breast
      Your breast cancer cells were high grade (grade 3)
      Your cancer cells did not test positive for hormone receptors and so are not likely to
       respond well to hormone therapy

Doctors use adjuvant therapy when they think there is a significant risk that cancer cells could
have broken away from the tumour in the breast and spread. So there may be cancer cells
elsewhere in your body. Adjuvant therapy can kill these cells off and so reduce the risk of the
cancer coming back.

Often, doctors use more than one chemotherapy drug at the same time. In 2004, the Cochrane
collaboration reported that giving chemotherapy in this way increases survival from breast
cancer and reduces the chances of it returning. The multi drug chemotherapy helped women
under 50 the most. but older women up to age 69 also benefited. There isn't enough evidence
at the moment to say how much this treatment helps women over 70. If you would like to, you
can read this review on multi drug chemotherapy in the Cochrane Library. It is written for
researchers and specialists, so is not in plain English.

If you are still having periods, chemotherapy may help in another way. It can stop your ovaries
from making oestrogen. Oestrogen can stimulate some breast cancer cells to grow. Some
specialists think this may be the main reason chemotherapy is such a successful adjuvant
treatment in pre-menopausal women. Unfortunately, the loss of oestrogen means you may
have an early menopause and become infertile. This is not always the case. Some women find
that their ovaries begin working again after chemotherapy. This depends on your age when you
have the treatment. And on the chemotherapy drugs that you are given. If you still don't have
periods a year after your treatment, unfortunately it is not likely that your ovaries will recover.

You can also have adjuvant hormone therapy after surgery.


Treating cancer that has come back
Many women have no more problems after their original treatment for breast cancer. But
sometimes breast cancer comes back or spreads. Breast cancer that has spread to other parts
of the body is called 'secondary breast cancer' or 'metastatic' breast cancer. Secondary breast
cancer is often treated with chemotherapy.

Remember - secondary breast cancer can often be kept under control with the right treatment.
Q. How you have chemotherapy?

A. You may take some chemotherapy drugs as tablets or capsules that you swallow. But most
of them are injected into a vein.

You have chemotherapy as a course of treatment. The length of time a whole course
takes varies depending on the drugs you are having. Often, you have the drugs for between 1
and 5 days, then have a break for 3 to 4 weeks. The drug treatment, followed by the break
makes up one 'cycle'. Then the cycle begins again. You may have up to 8 treatment cycles.
So a complete course of treatment can take up to 8 months. There is more about cycles and
the planning of chemotherapy in our main chemotherapy section.

The number of courses you have depends on

      The type of cancer
      The drugs used
      In 'metastatic' breast cancer it also depends on how well the cancer responds to the
       drugs

You are most likely to have your chemotherapy treatment in the out patients' department. But
you may have to spend a few days in hospital. This depends on the drugs you have. Each time
you start a new cycle of treatment, your doctors will check your blood cell counts first. They
need to do this to make sure you have recovered from your last lot of chemo. In practice, this
usually just means getting to the clinic early and spending a while waiting for the results. But if
your blood counts are not high enough, your chemotherapy may be delayed for a few days.

Q. Which drugs will I have?
A. There are quite a few chemotherapy drugs commonly used for breast cancer. So we can't
say what your doctor will recommend. Usually you would have a combination of about 3
chemotherapy drugs together. But in some circumstances, your specialist may suggest one on
its own. The drugs are

      Cyclophosphamide
      Epirubicin
      5-Fluorouracil or 5 FU
      Methotrexate
      Mitomycin
      Mitozantrone (mitoxantrone)
      Doxorubicin (Adriamycin)
      Docetaxel (Taxotere)

NICE guidance recommends that adjuvant chemotherapy for breast cancer should consist of 4
to 8 cycles of a combination of drugs, including an anthracycline (epirubicin or doxorubicin).

In September 2006 NICE approved the chemotherapy drug docetaxel (Taxotere) after surgery
for women with early stage breast cancer who have lymph nodes under the arm that contain
cancer cells. NICE say docetaxel can be used in combination with the drugs doxorubicin and
cyclophosphamide (the TAC regime). But NICE didn't recommend the chemotherapy drug
paclitaxel (Taxol) for women with this stage of breast cancer.
Some of the most common combinations used for breast cancer are

      CMF - cyclophosphamide, methotrexate and 5-FU
      FEC - epirubicin, cyclophosphamide and 5-FU
      E-CMF - epirubicin, followed by CMF
      AC - doxorubicin (adriamycin) and cyclophosphamide
      MMM - methotrexate, mitozantrone and mitomycin
      MM - methotrexate and mitozantrone
      TAC – Taxotere, Adriamycin & Cyclophosphamide
      3 FEC  3T – 5-FU, 100 Epirubicin, Cyclophosphamide followed by Taxotere

Different combinations of drugs have different side effects. For example, with AC or FEC, you
are more likely to lose your hair than with CMF. TAC regimen causes neutropenia. But all side
effects are predictable, manageable, reversible and short lived.



LOEB’S RULES OF THERAPEUTICS

   •   IF WHAT YOU ARE DOING IS GOOD       -                     CONTINUE
   •   IF WHAT YOU ARE DOING IS NOT GOOD   -                     DISCONTINUE
   •   IF YOU DON’T KNOW WHAT TO DO        -                     DO NOTHING
   •   NEVER MAKE TREATMENT WORSE THAN DISEASE

				
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