Cancer of the Breast

Breast cancer, with 40,000 cases in Britain and 90,000 in America every year is the most common form of female cancer. It will affect one woman in thirteen and at present 13,000 women a year die of breast cancer in the UK alone.

The type of woman most prone to be attacked by the disease is probably overweight and childless, with a history of menstrual problems stretching over 40 or more years. The frequent onset of breast cancer at the time of the menopause is probably caused by the hormonal imbalance associated with the ‘change of life’.

Another important factor is the consumption of too much dairy produce (whole milk, butter, cream and cheese) which makes the body produce too much of the enzyme lactase. This enzyme is known to be involved in the development of breast cancer. Having a close relative with breast cancer also increases the risk of contracting the disease but this is not as important as being childless. In other words, having a child is very protective and this explains why breast cancer-is so common in nuns.

The commonest breast problem, namely lumpy breasts, may or may not indicate a higher risk; no one is quite sure yet on this point. It is therefore advisable to be watchful and carry out frequent self examinations and when in doubt, to see a specialist and even ask for an X-ray. On the other hand, what we know for sure is that a woman who has had breast cancer in one breast is six times as likely to get it in the other breast; of course, this risk can be reduced by a suitable change in eating and living habits. A patient who continues living in an identical fashion before and after successful treatment for breast cancer is really encouraging the development of a second tumour.

Symptoms

When trying to pinpoint the early signs of breast cancer a woman should look out, first and foremost, for an unusual, firm, round lump (tumour) in the soft tissue of either breast. Sometimes only puckering, dimpling or scaliness of the skin can be detected. Ulceration of the skin is a more advanced sign, as is retraction of the nipple. Stains (pink or clear) on underclothes or brassiere, suggest a discharging nipple which must be investigated at once. Any change in the size or shape of the breasts can be quite serious and requires urgent attention.

Self-Examination

Since one woman in 13 is likely to develop breast cancer, every woman should pay special attention to the breasts by practising self-examination at the same time each month, shortly after the end of her period when the breasts are least active. This applies equally to women who have completed the menopause. It is a simple procedure and consists of feeling the breasts with two finger tips as well as visual inspection.

First, in a standing position, one hand should be raised in the air and using two fingers of the other hand, the opposite breast should be gently explored feeling for any unusual thickening or lumps under the skin. This should be repeated on the other side. Secondly, standing in front of a mirror both breasts should be checked for any signs of puckering, dimpling or of a scaly skin. Leaning forward the breast should be checked for any abnormalities in shape. The nipples should be inspected for evidence of any discharge. Lastly, the fingertip check described above should be repeated, this time lying flat on the back with one arm behind the head. A small pillow should be placed under the shoulder blade of the side to be examined, to flatten out the breast on the chest wall for easier checking.

Diagnosis

In women known to be at risk from breast cancer it may be vital to detect the disease even before a lump can be felt. Several techniques are available for this: the two most common methods use X-rays, either on film (mammography) or on paper (xeroradiography). Another method, thermography, measures the heat from the breast; an increase in temperature in one breast may indicate an abnormal condition, such as cancer. However, these methods can only suggest the possibility of cancer. As at other sites, the final diagnosis is always made from a piece of suspect tissue.

If a lump is present a simple procedure is to suck some cells from it through a needle (this is called aspiration biopsy). if only fluid is present and the lump collapses when punctured, a diagnosis of a simple cyst is made.

Treatment

Once cancer is definitely established, treatment will have to be discussed with the patient, because some women may not be able to come to terms with a breast amputation (mastectomy). This used to be the standard operation for breast cancer until a few years ago and women were obliged to accept the loss of a breast since no alternative method appeared to offer similar results. Fortunately this is no longer so. Provided the tumour is smallish in comparison with the remaining breast, and provided it is situated conveniently at the outside of the breast, any patient may now demand to have the lump removed (lumpectomy).

The treatment results are similar but many surgeons still prefer to remove the whole breast, instead of just taking out the lump. A six week course of postoperative radiotherapy following lumpectomy is usually needed, particularly when enlarged lymph nodes in the armpit are present or suspected. Sometimes these are removed together with the breast lump.

About ten per cent of woman who undergo mastectomy have lasting serious anxiety, depression or even sexual problems afterwards that justify reconstructing the breast. Not all women are able to have this operation and it is not advised in patients who have had a mastectomy for an advanced growth. Reconstructive surgery is not usually carried out for at least a year after treatment which included radiotherapy. However, there are some surgeons who favour reconstruction at the time of operation.

Reconstruction is an attempt to produce a convincing mound that will match as nearly as possible the volume, position, mobility and shape of the opposite breast; this does not include reconstruction of the nipple.

The actual surgical procedure after a simple mastectomy consists of inserting a silicone-gel prosthesis between the chest wall and the overlying pectoral muscle. At body temperature the silicone has a consistency of normal breast tissue.

Sometimes, women request reconstruction of the nipple. This can be done either with the help of a graft from the opposite nipple or, alternatively, an adhesive nipple can be used to give the necessary ‘button’ beneath the blouse or brassiere.

Taking stock of treatment results in breast cancer reveals the same story: the more extensive the disease, the less chance for cure. In the final analysis, the final result will, as always, hinge on the distant spread of the disease (metastases) and no one knows or is likely to find out in the foreseeable future how metastases come about. Since they are as frequent after a mastectomy as after a lumpectomy, unnecessary mutilation, which can cause such a blow to a patient’s feeling of femininity, should be avoided at all costs. In this respect, the patient’s wishes should be paramount.

When the tumour has progressed beyond the earliest stages and has spread outside the breast and armpit lymph nodes, only relief treatment is possible. Radiotherapy, hormone therapy and chemotherapy will then all have a role to play, either alone or in combination.

In breast tumours which are hormone-dependent, treatment by hormones is preferred and can be effective for many months. This form of therapy is usually free from unpleasant side-effects and is therefore always worth trying. Before hormone therapy of younger women is started, the ovaries are generally removed to deny cancer cells their source of growth-stimulating hormones. After the menopause removal of other hormone-producing glands, such as the adrenal glands at the top of the kidneys, or the pituitary gland at the base of the brain, may be considered. However, because of the severity of the surgery and its limited success, these major operations have now gone out of fashion.

Breast cancer metastases favour the bony skeleton, particularly the spine, the pelvis and the thigh bones. The sometimes excruciating pain associated with bone metastases is readily relieved by local radiotherapy. A bonus is that such treatment also helps to prevent a fracture at the site of the metastasis due to tumour-erosion of the bone, because the soft bone, decalcified as a result of invasion, is able to recalcify and become hard again.

The role of chemotherapy in breast cancer is still being considered and several useful drugs are being studied. A new development is the use of long-term oral drug therapy, either in healthy volunteers, or after surgery. The drug is administered in small doses without side-effects. This is an attempt to prevent the disease altogether, or to improve the indifferent results of treatment in most of the early cases of breast cancer.

Little progress has been made in breast cancer cure-rate over the past 40 years and therefore prevention, by means of a diet low in all types of fat, but in particular milk-fat, should form part of health education of every young woman.

Since breast cancer is the most frequent form of malignant disease in women and since early breast cancer, when treated promptly, offers the best chance of a cure, monthly breast self-examination should be practised by every woman. The nature of any breast lump should be discovered by examination of cells or a piece of tissue under the microscope.