Dr Asif Channer
OCTOBER has been labelled as breast cancer awareness month throughout the world every year. In the 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 consists 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 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 tumor 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, others include, increasing age, failure to get pregnant, family history of breast, fallopian tube, ovaries or peritoneal cancers, history of breast cancer in other 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 healthcare providers. 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 cancer. Although clinical and self-breast examinations (SBE) are not effective strategies for diagnosis, it is still suggested in countries with limited resources having no other screening methods in the reach.
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 management like age, overall health of 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 tumor and small amounts of healthy tissue around it. Spread of cancer can also be prevented by lumpectomy and this may be an ideal option if the tumor 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. According to a study the use of breast implants is safe and there is no risk of getting breast cancer by breast cosmetic implants.
Breast cancer is prevalent both in developed and developing countries. Every year about 2 million new cases and 500000 deaths are being reported 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 solid essential healthcare infrastructure. Furthermore, in low and middle-income countries the incidence has been rising steadily during the last years.
Amazingly as shown above, 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 rates but low mortality rates. 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 the cancer is very aggressive in nature. 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, New Zealand and Ireland.
The low and middle-income countries report majority of deaths where most women are diagnosed in advanced stages of breast cancer due to reasons that these regions lack resources, offer poor access to cancer screening and prevention programs, lack of awareness about the disease, fear of surgery, chemotherapy, cultural, social and religious taboos and getting other traditional nonscientific treatments thus fuelling the morbidity and 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 cum 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 professionals without any social stigma, shame or fear, for early diagnosis, treatment and better outcome. In high-income countries all treatment options are available to patients who can afford them hence contributing to low mortality and excellent prognosis of breast cancer Breast cancer burden can be minimized by strengthening healthcare systems, Governmental prioritization to influence public health policies and providing 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 the leading cause of deaths in women around the globe, since 1989 improvements in screening and treatment have been enhancing women’s quality and quantity of life.
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 and cigarette smoking. In this age 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 consultations.
Asia is at top ranking in breast cancer cases among all geographical regions with Pakistan, China and India occupying the three uppermost positions respectively. The early finding remains the keystone of breast cancer control programs. If discovered early, with adequate diagnosis and treatment, there is an excellent opportunity of healing of breast cancer. 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, the Mammography screening program is very effective in the detection of disease at an early stage but it is expensive and developing regions cannot afford it. The World Health Organization in collaboration with global philanthropic bodies, local health authorities and Governments should make necessary arrangements for free screening services indiscriminately and timely.
Mass awareness campaigns need to be launched in all regions irrespective of developmental status through celebrities like women parliamentarians and prominent female personalities from business, sports, religious, social and media communities.
The simplest techniques of Breast self-examination (BSE) to check one-self monthly be taught to all women especially living in rural and remote areas. Establishment of modern state of the art advanced breast cancer care hospitals, at least one at national level in each country is also inevitable to beat breast cancer paving the paths to achieve sustainable development goals (STGs).
