Breast Cancer

Miss.Kavishangari Jeyalogaindran A/L - 2010 Batch Bt/Vincent Girls High School Batticaloa

Cancer is a group of diseases with one thing in common: 1).Cells become abnormal and are produced in large amounts 2).Cancer cells interfere with the growth and functions of normal cells 3).They can spread from one part of the body to another Cancer begins in cells the building blocks that make up tissues Tissues make up the organs of the body Normally, cells grow and divide to form new cells as the body needs them When cells grow old, they die and new cells replace them

Sometimes this orderly process goes wrong

Cells keep dividing when new cells are not needed These extra cells can form a mass of tissue called a growth or tumour

Types of Tumours

Tumours can be benign or malignant

Benign tumours are not cancer They are rarely life-threatening, can be removed and they usually do not grow back
Cells from benign tumours do not invade the tissues around them and do not spread to other parts of the body

Malignant tumours (cancer)

Cells in malignant tumours are abnormal and divide without control or order They are generally more serious than benign tumours and may be life threatening

Usually can be removed but sometimes they grow back Cells from malignant tumours can invade and damage the tissue around them Cells from malignant tumours can spread to other parts of the body the cells break away from the original cancer (Primary tumour) and enter the blood stream or lymphatic system They invade other organs forming new tumours and damage these organs The spread of cancer is called metastasis

Leading Cancers in Sri Lanka

Breast cancer highest cancer in Sri Lanka cases reported in 2005)

(1908

Lip, oral cavity, and pharynx 2nd highest cancer in Sri Lanka and highest among males(1617 cases in 2005) Oesophagus cancer ranks 3rd in our country (1022 cases reported in 2005, also 3rd highest among males) Cervical Cancer or Cancer of the cervix second highest cancer among females and 4th highest in Sri Lanka (881 cases in 2005) the trachea, bronchus and lungs , Colon and rectum, Larynx, Ovary, Uterus, lymphatic system (Lymphomas), Blood and blood forming organs ( Myelomas and leukaemias ), Liver, bladder, prostate, bones (Osteosarcomas) spine, Brain tissue, thyroid, kidneys, pancreas, skin (melanomas) are the other sites where a person can develop cancer.

Cancer Statistics in Sri Lanka

Year

Males Females Total 1985 2564 2448 5012 1900 2979 3084 6063 1995 3450 3875 7325 2000 5130 5795 10925 2005 6058 7314 13372 After 1985 incidence of cancer in females show a dramatic increase and within 20 years the total cases increased by 260%

Cancer Who is at risk

No one knows the exact causes of cancer Doctors can seldom explain why one person develops the disease and another does not It is clear that cancer is not contagious no one can catch this disease from another person Research has shown that people with certain risk factors are more likely than others to develop cancer A risk factor is anything that increases a persons chance of developing a disease These risk factors vary for different types of

Breast Cancer
The Breasts are glands that produce milk Each breast sits on the chest muscles that cover the ribs Each breast is divided into 15 to 20 sections called lobes Lobes contain many smaller lobules Lobules contain groups of tiny glands that can produce milk Milk flows from the lobules through thin tubes called ducts to the nipple Fat fills the spaces between the lobules &

Other contents of the Breast

The breast also contain lymph vessels which carry a clear fluid called lymph Lymph vessels lead to small round organs called lymph nodes Groups of lymph nodes are found near the breast in the axilla (underarm) above the collarbone, and in the chest behind the breastbone. The lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the

Risk factors for Breast cancer

Age chance of getting Br.ca goes up as a women gets older. A women over age of 60 is at greatest risk. Br.ca is very uncommon before menopause Personal history of Br.ca A women who has had Br.ca in one breast has an increased risk of getting this disease in her other breast. Family history A womens risk of Br.ca is higher if her mother, sister, or daughter had breast cancer, especially at a young age (before age 40) Certain breast changes some women have cells in the breast that looks abnormal under a microscope. Having certain types of abnormal cells increases the risk of breast cancer.

Risk factors - continued

Genetic alterations changes in certain genes (BRCA 1, BRCA 2 ) increase the risk of Br.Ca Reproductive & menstrual history: 1. the older a women is when she has her first child, the greater her chance of Br.Ca 2. Women who began menstruation (had their first menstrual period) at an early age ( before age 12), went through menopause late ( after age 55 ) or never had children also are at an increased risk. Women who take menopausal hormone therapy ( either estrogen alone or estrogen +

Other risk factors

Race : Br.Ca occurs more often in white women than Latin, Asian or African American women. Radiation therapy to the chest: women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of Br.Ca This includes women treated with radiation for Hodgkins lymphoma. Breast density: older women who have mostly dense tissue (not fatty) on a mammogram (X-ray of the breast) are at an increased risk of Br.Ca. Taking DES (diethylstilbestrol): a synthetic form of estrogen that was given to pregnant women in the USA between 1940 and 1971(DES is no longer given). Women who took DES during pregnancy have an increased risk of Br.Ca

Other risk factors - continued

Being obese after menopause: after menopause, women who are obese have an increased risk of developing Br.Ca obese women have an abnormally high proportion of body fat. Because the body makes some of its estrogen in fatty tissue, obese women are more likely than thin women to have higher levels of estrogens in their bodies. High levels of estrogen may be the reason that obese women have an increased risk of Br.Ca Some studies show that gaining weight after menopause increases the risk of breast cancer. Physical activity: women who are physically inactive throughout their life have an increased risk of breast cancer.

Detection and Diagnosis

Screening : screening for cancer before there are symptoms can be important It can help doctors find and treat cancer early Treatment is more likely to be effective when cancer is found early Doctor may suggest screening tests to check for Br.Ca before any symptoms develop Screening mammogram Clinical breast exam Breast self - exam

Screening Mammogram

Mammograms - are pictures of the breast made with X-rays To detect Br.Ca early it is recommended that Women in their 40s and older should have mammograms every one to two years Women who are at higher risk of Br.Ca should talk with their doctor about whether to have mammograms before age 40 and how often to have them Screening mammograms can often show a breast lump before it can be felt They also can show a cluster of very tiny specks of calcium called microcalcifications Lumps or specks can be signs of cancer

If the doctor sees an abnormal area on the mammogram the women may need more pictures taken Also the women may need to have a biopsy A biopsy is the only way to tell for sure if cancer is present Although mammograms are the best tool to find Br.Ca early a women must keep in mind that it may miss some cancers that are present it may show things that turn out not to be cancer Some fast growing tumours may already have spread to other parts of the body before a

Clinical breast exam

During a clinical breast exam the doctor feels the breast for lumps while the women is standing or sitting up and lying down Women may be asked to raise her arms over her head, let them hang by her sides or press her hands against her hips Doctor looks for differences between the two breasts including size or shape Skin of each breast is checked for a rash, dimpling or other abnormal signs Nipples may be squeezed to see if fluid is present Doctor checks the entire breast, the underarm and the collarbone area A lump is generally the size of a pea before anyone can feel it The lymph nodes near the breast may be checked to see if they are swollen

Breast Self-Exam
Some women perform monthly breast selfexams to check for any changes in their breasts When a women does this exam, it is important to remember that each womens breasts are different And that changes can occur because of aging, the menstrual cycle, pregnancy, menopause or taking birth control pills or other hormones Also, it is common for a womens breasts to be swollen right before or during her menstrual period Women who notice anything unusual during a

Symptoms
Br.Ca can cause changes in the breast or nipple 1. A change in how the breast or nipple feels a lump or thickening in or near the breast or in the underarm area nipple tenderness (painful when pressing) 2. A change in how the breast or nipple looks a change in the size or shape of the breast the nipple is turned inward into the breast The skin of the breast or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange

Diagnosis
If a women has a breast change, her doctor must determine whether it is due to Br.Ca or some other cause The women has a physical exam The doctor asks about her personal and family medical history She may have a mammogram or other imaging procedure that makes pictures of tissues inside the breast After the tests the doctor may decide that no further tests are needed or the women may need a biopsy to examine the suspicious area

Diagnostic mammography
If any area of the breast looks abnormal on a screening mammogram diagnostic mammogram must be taken to see clear and more detailed pictures of the breast Diagnostic mammograms help the doctor learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape

The following procedures may be helpful 1. Clinical breast exam doctor feels each breast for lumps and looks for other problems 2. Benign lumps often feel different from cancerous ones 3. The doctor can check the size , shape and texture of the lump and feel whether it moves easily 4. Lumps that are soft, smooth, round & movable are likely to be benign 5. A hard, oddly shaped lump that feels firmly

How the diagnosis is made?

Ultrasonography (US scanning)

Using high-frequency sound waves (ultrasound), ultrasonography can often show whether a lump is fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer) Doctor can view these pictures on a monitor Magnetic Resonance Imaging ( MRI) for MRI a powerful magnet linked to a computer is used to make detailed pictures of tissue inside the breast MRI and US scan may be used along with a

Biopsy

Fluid or tissue must be removed from the breast to help the doctor learn whether cancer is present this is called a biopsy For a biopsy the doctor may refer the women to a surgeon Surgeon can remove tissue from the breast in different ways 1. Fine needle aspiration : doctor uses a thin needle to remove fluid and/or cells from a breast lump. If the fluid contains cells it is sent to the lab where a pathologist checks for cancer cells using a microscope If the fluid is clear may not need to be checked by a lab

Core biopsy doctor uses a thick needle to remove breast tissue a pathologist checks for cancer cells This procedure is also called a needle biopsy

Surgical biopsy is of two types Incisional biopsy the surgeon removes a sample of a lump or abnormal area Excisional biopsy surgeon removes the entire lump In both types a pathologist examines the tissue for cancer cells If cancer cells are found the pathologist can tell what kind of cancer it is The most common type of Br.Ca is ductal carcinoma which begins in the lining of the ducts Another type, called lobular carcinoma begins in the lobules

Stages of breast cancer

To plan a womans treatment the doctor needs to know the extent or the stage of the disease The stage is based on the size of the tumour and whether the cancer has spread When breast cancer spreads, cancer cells are often found in lymph nodes under the arm axillary lymph nodes The extent of cancer is not known until after the surgery to remove the tumour in the breast and the lymph nodes under the arm

Stage 1 is an early stage of invasive breast cancer Stage 1 means that the tumour is not more than 2cm across and cancer cells have not spread beyond the breast Stage 2 is one of the following 1. tumour in the breast is not more than 2cm across and the cancer has spread to the lymph nodes under the arm 2. tumour is between 2and 5cm & the cancer may have spread to the lymph nodes under the arm 3. tumour is larger than 5cm (2 inches) but has

Stages of breast cancer continued

Stage 0 is called carcinoma in situ Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule These abnormal cells are a marker of increased risk that means a women with LCIS has an increased of developing invasive cancer in either breast in the future Ductal carcinoma in situ (DCIS) is a precancerous condition in the lining of a duct also called intraductal carcinoma The abnormal cells have not spread outside the duct to invade the surrounding breast tissue However, if untreated DCIS sometimes becomes invasive cancer

Stage 3 tumour may be large but the cancer has not spread beyond the breast and nearby lymph nodes It is locally advanced cancer Stage 3 A means tumour in the breast is smaller than 5cm but cancer has spread to the underarm lymph nodes and the lymph nodes are attached to each other or to other structures. Or the tumour is large (more than 5cm) and the cancer has spread to the underarm lymph nodes Stage 3B tumour may have grown into the chest wall or the skin of the breast or the cancer has spread to lymph nodes under the breastbone Stage 3 C cancer has spread to the lymph nodes under the breastbone and under the arm or above the collarbone. The primary tumour may be of any size.

Stage 4
Stage 4 is distant metastatic cancer - it means the cancer has spread to other parts of the body Recurrent cancer is cancer that has come back after treatment (recurred) It may recur locally in the breast or chest wall or in any other part of the body such as bone , liver or lungs

Treatment
Many women with breast cancer want to learn all they can about their disease and their treatment choices The doctor may refer a woman with Br.Ca to a specialist surgeon, medical oncologist, radiation oncologist and plastic surgeon Treatment generally begins within few weeks after the diagnosis Usually there is time for a women to talk with her doctor about treatment options, get a second opinion and learn more about Br.Ca before making a treatment decision

Treatment methods

Treatment for cancer is either local therapy or systemic therapy Local therapy surgery and radiation therapy are local treatments they remove or destroy cancer in the breast Systemic therapy chemotherapy, hormonal therapy, and biological therapy are systemic treatments They enter the blood stream and destroy or control cancer throughout the body Some women with Br.Ca have systemic therapy to shrink the tumour before surgery or radiation Others have systemic therapy after surgery and radiation to prevent the cancer from coming back

Surgery
Surgery is the most common treatment for Br.Ca There are several types of surgery - Doctor can explain each type, discuss and compare the benefits and risks and describe how each will affect the womens appearance Breast-sparing surgery: an operation to remove the cancer but not the breast is called breast sparing-surgery, breastconserving surgery, lumpectomy, segmental mastectomy or partial mastectomy Through a separate incision, the surgeon removes the underarm lymph nodes to learn whether cancer cells have entered the lymphatic system The procedure to remove the underarm lymph nodes is called an axillary lymph node dissection After breast-sparing surgery, most women receive radiotherapy to the breast to destroy cancer cells that may remain in the breast

Mastectomy
An operation to remove the whole breast (or as much of the breast tissue as possible) is a mastectomy In most cases, the surgeon also removes lymph nodes under the arm After surgery, women may receive radiotherapy Women may choose to have breast reconstruction ( to rebuild the shape of the breast) by plastic surgery It may be done at the same time as a mastectomy or later

Radiation therapy ( radiotherapy)

Is the use of high-energy rays to kill cancer cells It generally follows breast-sparing surgery Sometimes, depending on the size of the tumour and other factors radiation therapy is also used after mastectomy The radiation destroys breast cancer cells that may remain in the area Some women have radiation therapy before surgery to destroy cancer cells and shrink tumours This approach is most often used when the

Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells Chemotherapy for the breast cancer is usually a combination of drugs The drugs may be given as a pill or by injection into a vein (IV) In both ways the drugs enter the blood stream and travel throughout the body Most women with Br.Ca have chemotherapy in an outpatient part of the hospital, but some women may need to stay in the hospital during chemotherapy

Types of radiation therapy

Doctors use two types of radiation therapy to treat breast cancer External radiation the radiation comes from a machine For external radiation therapy, a women with breast cancer goes to the hospital Generally treatments are scheduled 5 days a week for several weeks Internal radiation (implant radiation) the radiation comes from radioactive material placed in thin plastic tubes put directly in the breast For implant radiation the women stays in the hospital implants remain in place for several days they are removed before the women goes home

Hormonal therapy
Hormonal therapy blocks cancer cells from getting the natural hormones (oestrogen and progesterone) they need to grow If lab tests show that the breast tumour has hormone receptors, the women may have hormonal therapy Like chemotherapy, hormonal therapy can affect cells throughout the body This treatment may be a medicine or surgery

 Medicine the doctor may suggest a drug that can block the natural hormone Tamoxifen a drug that can block oestrogen Since oestrogen promotes the growth of Br.Ca cells, tamoxifen can prevent the growth of Br.Ca cells Aromatase inhibitors ( anastrazole) prevents the body from making the female hormone estradiol, a form of estrogen this too will prevent the growth of breast cancer cells Surgery if the women has not gone though menopause, she may have surgery to remove her ovaries which are the main source of the bodys estrogen (after menopause, hormone production by the ovaries naturally declines so surgery would not be needed)

Side effects of surgery

Surgery causes short term pain and tenderness (pain when pressing the area) in the area of the operation pain management is the solution Any kind of surgery also carries a risk of infection, bleeding or other problems women who develop any problems should tell their doctor right away Removal of one or both breasts can cause a women to feel off balance - This imbalance can cause discomfort in her neck and back The skin in the area where the breast was removed may feel tight The muscles of the arm and shoulder may feel stiff and week, but these problems usually are temporary The doctor/physiotherapsit can recommend exercises to help a women regain movement and strength in her arm & shoulder Because nerves may be injured or cut during surgery, a woman may have numbness and tingling on her chest, underarm, shoulder and upper arm these feelings go away within a few weeks or months

Side effects of cancer treatment

Because cancer treatment is likely to damage healthy cells and tissues, unwanted side effects are common Specific side effects depend mainly on the type and extent of the treatment Side effects may not be the same for each women, or even for women having the same treatments The doctor should explain the possible side effects of treatment and how to manage them

Lymphoedema

Removing the lymph nodes under the arm slows the flow of lymph fluid The fluid may build up in the arm and hand cause swelling called lymphoedema This problem can develop right after surgery or months to years later A women needs to protect her arm and hand on the treated side for the rest of her life- she will need to 1. avoid wearing tight clothing or jewelry on her affected arm 2. carry her purse or luggage with the other arm 3.use an electric razor to avoid cuts when shaving her underarm 4. have blood tests & blood pressure measurements on the other arm 5.wear gloves to protect her hands when gardening and when using strong detergents Some women with lymphoedema wear an elastic sleeve to improve

Side effects of radiation therapy

During radiation therapy women with breast cancer may become tired, especially toward the end of treatment This feeling may continue for a while after treatment is over It is also common for the skin in the treated area to become red, dry, tender and itchy The breast may feel heavy and tight this problem will go away over time Toward the end of treatment, the skin may become moist and weepy exposing this area to air as much as possible can help the skin heal

Side effects of chemotherapy

As with radiation, chemotherapy affects normal cells as well as cancer cells Side effects of chemotherapy depend mainly on the specific drugs and the dose In general, anticancer drugs affect cells that divide rapidly, especially 1. Blood cells 2. Cells in hair roots 3. Cells that line the digestive tract

Blood cells these cells fight infection, help blood to clot,& carry oxygen to all parts of the body When blood cells are affected, patients are more likely to get infections, may bleed easily, and may feel very weak and tired Cells in hair roots chemotherapy can lead to hair loss. The hair grows back, but the new hair may be different in color and texture Cells that line the digestive tract chemotherapy can cause poor appetite, nausea and vomiting, diarrhoea or mouth and lip sores Many of these side effects can be controlled with drugs Some anticancer drugs can damage the ovaries. If the damaged ovaries stop making hormones, her menstrual periods may become irregular or may stop and she may become infertile ( unable to become pregnant) - For women over the age of 35, infertility is likely to be permanent

Thank You