Breast cancer is the most common form of cancer affecting women in Malaysia. About one in 19 women in this country are at risk, compared to one in eight in Europe and the United States.
Breast cancer occurs when the cells in the lobules (milk producing glands) or the ducts become abnormal and divide uncontrollably. These abnormal cells begin to invade the surrounding breast tissue and may eventually spread via blood vessels and lymphatic channels to the lymph nodes, lungs, bones, brain and liver.
The exact cause of breast cancer is unknown. Women with a family history of the disease have an increased risk of getting breast cancer. Carriers of the BRCA I and BRCA II genes, especially, have at least a 40 to 85 per cent risk of getting cancer. Other risk factors include exposure to radiation, a history of benign breast lumps, obesity, diet (especially one high in fat), early menarche and late menopause. The possibility that hormone replacement therapy causes breast cancer is still a topic of discussion. It is generally advised that women with a high risk of developing the disease should refrain from taking HRT.
Most women in Malaysia present with a lump in the breast. The lump is usually painless, grows slowly and may alter the contour or size of the breast. It may also cause skin changes, an inverted nipple or bloodstained nipple discharge. The lymph gland in the armpit will be swollen if affected by the cancer cells. In late stages, the growth may ulcerate through the skin and become infected. Bone pain, tenderness over the liver, severe headaches, shortness of breath and a chronic persistent cough may be an indication of the cancer spreading to the other organs in the body.
When a patient detects a lump in the breast, a specialist opinion should be sought to confirm if the lump is cancerous or not. The doctor will perform a through physical examination before requesting for mammography and ultra sound scan of the breast.
A tissue sample in the form of needle suction or biopsy may be obtained. Upon confirmation of the cancer, the patient will be staged with x-rays or scans of the lungs and liver. A bone or brain scan may be ordered to evaluate any spread to the bones or the brain.
Staging is important to determine if the patient is potentially in a curable early stage or otherwise:
Stage 0 - Cancer in Situ
Stage I - Cancer is less than 2 cm.
Stage II - Cancer is between 2 to 5 cm with or without involvement of the glands in the armpit
Stage III - Cancer is larger than 5 cm or there is extensive involvement of the glands in the armpit
Stage IV - Cancer has spread outside the breast and involves other organs in the body
Stage I & II are considered early and curable.
Stage IV disease is not curable.
Biochemical testing of the blood can detect the presence of protein cells excreted by cancer cells. Breast cancer can occasionally exhibit these proteins e.g. CEA or CA15-3. If elevated, these markers can be useful for tracking the progress of treatment or detecting early recurrence after treatment. It is not a screening test for breast cancer.
Surgery can be conservative (removing the lump or a segment of the breast only) or may be in the form of a mastectomy (removing the whole breast). In both cases, the glands in the armpit need to be removed and checked for the presence of cancer cells.
Radiotherapy uses high doses of radiation to kill cancer cells. It is a localised form of treatment and is mandatory after conservative surgical treatment. It is only given after a mastectomy if the breast tumour is locally extensive. Radiotherapy reduces the risk of local recurrence rate. Radiotherapy is sometimes used as a palliative treatment to control bone pain, bleeding or pressure symptoms.
Chemotherapy involves the use of drugs given by injection or, occasionally, orally. It treats the cancer by penetrating the tissues and organ via the bloodstream. These drugs are toxic to the cancer cells but they may also cause some side effects to the normal tissues.
For early stage diseases, chemotherapy is used as an added treatment to improve the outcome and cure rates. It is used to "mop-up" the potential micro spread of cells that may have escaped from the breast to the other parts of the body.
For late stage disease, chemotherapy is used to "control" the rate of growth of the tumour and to downsize the bulk of the disease. The use of chemotherapy may also help to control symptoms, prolong survival and improve the quality of life.
Hormone or anti-hormone treatment is only given to patients whose cancer cells are positive to oestrogen or progesterone receptors. By blocking these receptors the growth of the cancer cells can be curtailed. Drugs such as Tamoxifen and the new generation of aromatase inhibitors may help to control the cancer for many years after primary treatment.
There are many new modalities of treatment such as blocking the small molecules inside the cancer cells or antibody blockage of receptors on the cell surface to prevent the cancer from growing too quickly. These new-targeted treatments are still under investigation. These drugs are available in Malaysia but the oncologists will advise patients appropriately.
Early Detection & Screening
Studies have shown that screening mammography with or without clinical breast examination may decrease the mortality of breast cancer. A mammogram can detect small cancerous lumps as well as cancer in situ (abnormal cells about to form cancer), which may be missed in a clinical examination. A mammogram is recommended for women above the age of 50 years. For high-risk women (with family history), screening is advisable at an earlier age (40 years to 49 years old).
Mammography is advisable every one to two years but for younger women (below 35 years), the ultra sound scan of the breast may be helpful for patients with symptoms.
Breast cancer is curable if detected early. Cure rates for Stage I and II cases may be as high as 80 per cent and above. For Stage III disease the percentage of cure is much lower but for Stage IV disease the aim of the treatment is palliative (control of symptoms).
Patients should discuss treatment options with the oncologist (cancer specialist). While the treatment of breast cancer is standard throughout the world, the oncologist has to carefully assess each patient and tailor-make the appropriate therapy. The oncologist will also be able to advise patient on some of the latest development in the management of breast cancer.
Many patients make dramatic changes to their diet and lifestyle to combat or control their cancer. While it is advisable to lead a healthy lifestyle and eat a well-balanced diet, patients are advised against making drastic changes. Eat healthy food and do not consume excessive vitamins and health supplements. It could potentially do more harm than good.
Breast cancer is a potentially curable disease if detected early. Clinical or self-examination combine with screening mammography can detect the disease early. With appropriate treatment, cure rates are high. There is no alternative to cure except for standard therapy. Patients should not gamble with their lives by delaying treatment or seeking alternative therapies that are not proven.