Breast Clinic

According to World Health Organization (WHO), deaths from cancer worldwide are projected to continue rising, with an estimated 12 million deaths in 2030. Breast cancer is the most common cancer affecting urban Indian women. The last three decades have seen the numbers of breast cancer patients grow steadily. It is estimated that by 2015-2020, India will be among the world leaders in new breast cancer cases detected every year. Sedentary lifestyle (lack of exercise), increased consumption of fat products, postmenopausal obesity, late marriages, delayed child bearing and lesser number of children being conceived, reduced duration of breastfeeding (less than one year per child) are all believed to be reasons for increased risk of breast cancer.

Cancers if neglected or left untreated will progress to an advanced stage and threaten the life of the patient in the long run. Therefore, it is important to spread awareness on the disease as well as ways and means to prevent the disease or detect it early so that cure rates are maximised. With the latest technological advancements in the medical sector, today there are higher chances of getting diagnosed early leading to better management of the disease. A Comprehensive Breast Care Unit is well-equipped and has highly qualified specialists who guide a patient towards right treatment plan for any breast related disease.

The disease of breast can be described as benign (not cancerous) and malignant (cancerous). Benign Breast Disease includes conditions like fibroadenoma, breast cysts, fibrocystic disease, cyclical mastalgia (breast pain), breast abscess, granulomatous mastitis, etc.
However, breast malignancies depending on their stage can be classified as:

• Operable Breast Cancer – This describes cancer that is confined to the breast and/or the lymph glands in the arm pit (axilla) on the same side of the body

• Locally Advanced Breast Cancer – An invasive cancer that may be large or have spread to several lymphnodes in the armpit (axilla) or other areas near breast, or have spread to other tissues around the breast such as skin, muscle or ribs
• Metastatic Breast Cancer – This is the most advanced stage of breast cancer where the cancer cells have spread past the breast and axillary lymphnodes to other areas of the body (like bone, lungs, liver or brain) and continue to grow and multiply in these affected organs

ideally both men and women can get breast cancer. But more than 99% of the cases occur in women. The greatest risk factor for developing breast cancer is being a woman and the incidence of breast cancer in woman increases with advancing age.

Risk factors for breast cancer include:

• Older age
• Personal history of breast cancer
• Family history of breast cancer or having other relatives (in either your maternal or paternal family) with breast cancer or ovarian cancer
• Changes in certain genes, such as BRCA1 or BRCA2
• Early menarche (onset of menses) or menopause (cessation of menses)
• Nulliparity (no child births) or late childbearing
• Exposure to radiations
• Using Hormonal Replacement Therapy (HRT) for prolonged periods
• Women whose mammograms show a larger area of dense tissue than the mammograms of women of the same age
• Chance of getting breast cancer after menopause is higher in women who are overweight or obese
• Women who are physically inactive throughout life may have an increased risk of breast cancer.
• Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer

Having a risk factor does not mean that a woman will get breast cancer. Most women who have risk factors never develop breast cancer. However, women who think they may be at risk should discuss this with their doctor.

Breast cancer is not always visible to the naked eye. Its early signs are often hidden within the breast tissues. In early stages, breast cancer usually has no symptoms. However, as the tumour progresses, you may note the following signs:

• A lump in the breast, is often the first apparent symptom of breast cancer, breast lumps are usually painless, although some may cause a prickly sensation. Lumps are usually visible on a mammogram long before they can be seen or felt
• A noticeable flattening or indentation on the breast which may indicate a tumour that cannot be seen or felt
• Any change in the contour, texture or temperature of the breast, reddish, pitted surface like the skin of an orange (called peau d'orange) is symptomatic of advanced breast cancer
• A change in the nipple, such as an indrawn or dimpled look, itching or burning sensation or ulceration, scaling of the nipple is symptomatic of Paget's disease, a localised cancer
• Unusual discharge from the nipple that may be clear, bloody or of another colour, is usually caused by benign conditions but possibly could be due to cancer as well
• Swelling in the armpit can suggest presence of breast cancer as this lymph node swelling probably could be felt due to the presence of a primary lump, which may be deep seated and impalpable

If you notice a lump, or are experiencing anything unusual, you must report the symptoms to your doctor as soon as possible.

Screening and early detection of breast cancers with help of mammography, breast ultrasound, magnetic resonance imaging and gene profiling helps in early detection of cancer, thus helping the doctor in better management of the disease. Besides diagnostic methods, a monthly self breast exam is one of the best ways to notice any changes in your breasts.
There is strong scientific evidence to suggest that annual screening mammography starting at the age of 40 years (or 10 years before the age at which a woman's first-degree relative developed breast cancer) reduces the chance of dying due to breast cancer significantly. In younger patients, a sono-mammography is also done as it can provide valuable information that might be missed on a mammogram performed in isolation. Annual MRI screening is recommended in women with hereditary breast cancer, i.e., those women who are BRCA 1 or BRCA 2 positive. The BRCA status needs to be ascertained by performing a genetic profiling in women with more than one first degree relative with breast and/or ovarian cancer.

Depending on the pathology, your treating doctor will decide what treatment/s will bring better results. Some of the treatment methods are as mentioned below:

• Surgeries for breast cancer include Breast Conservation Surgery or Modified Radical Mastectomy with or without whole breast reconstruction
• Oncoplastic Breast Conservation Surgery for Breast Cancer combines the principles of plastic surgery and cancer surgery to facilitate cosmetic surgery in patients with breast cancer and allow reduction or augmentation surgery in the same sitting
• Partial and Whole Breast Reconstruction with or without silicone implants, followed by reconstruction of nipple and areola
• Counselling the patient and relatives over the histopathology report and discussing therapeutic options regarding adjuvant therapy along with individual risk-benefit ratios and overall risk reduction after adjuvant therapy
• Placement of indwelling chemotherapy ports for administration of adjuvant chemotherapy and management of patients with chemo ports
• Delivery of adjuvant chemotherapy and targeted therapy by a medical oncologist specialised in breast cancer chemotherapy
• Specialised Radiation Therapy (whole breast or chest wall radiotherapy) delivered by experts in the field, using the latest technology. Radiation therapy also includes palliative radiotherapy in metastatic breast cancer for bone and brain metastases
• detailed instructions on exercise and diet by the respective experts after completion of therapy and follow-up advice
• Diagnosis, counselling and medical/surgical treatment of benign breast conditions such as cyclical mastalgia (breast pain), breast cysts, fibrocystic disease (ANDI)
• Diagnosis and treatment of significant nipple discharge
• Management of breast abscess by conservative treatment (if <3cm) or surgical drainage (if >3 cm)
• Genetic Counselling in patients with a family history of breast cancer or hereditary breast cancer

Prognosis of a case widely depends on the type of the disease, how much the disease has progressed at the time of diagnosis and how the disease has reacted to the treatment given. For cancer, staging is the process physicians use to assess the size and location of a patient's cancer. identifying the cancer stage is one of the most important factors in selecting treatment options. Several tests may be performed to help in grading breast cancer including clinical breast exams, mammogram, biopsy, LFT (Liver Function Test) and certain imaging tests, such as an isotope bone scan, CT (Computed Tomography) scan of chest abdomen & pelvis and PET CT (Positron Emission Tomography CT) scan. These tests are not performed on every patient but only those who have extensive disease within the breast, i.e., breast lump more than 5 cm or tumour involving skin or presence of large matted axillary or neck nodes.

The greatest misconception that the common person has about cancer is that all patients eventually die of cancer. It is very important to realise that breast cancer is one of the most curable cancers in the human body. All patients who are cured live a normal life for their entire lifespan. Regular follow ups after the treatment will help in identifying relapse, if any.

Pregnancy can be planned after treatment of breast cancer in selected patients. Pregnancy is safe and does not increase the risk of relapse. Patients who receive chemotherapy can get chemotherapy-induced premature menopause, thereby interfering with post-treatment fertility. Cryopreservation of oocytes and ovarian tissue are the common methods that can enable such patients to bear children even if they become menopausal after chemotherapy.

Worldwide, there are specialised breast care units that deal with patients with breast diseases, including breast cancer. Well-equipped with state-of-the-art radiation machines and day care chemo suites, Kokilaben Hospital CBCU is a dedicated service that has been created to specifically diagnose and treat entire spectrum of conditions affecting mammary gland. The breast unit has been designed on the guidelines laid down by the European Union Society of Mastology (EUSOMA) and is based on two fundamental principles – Evidence-Based Medicine and Multidisciplinary Approach.

Evidence-based medicine

Over the years, a lot of research has been carried out in the field of breast diseases -benign and malignant - spanning from diagnosis to treatment. It is important for all clinicians to keep up with this vast reservoir of knowledge, understand it and translate it into guidelines that are applicable in day-to-day clinical practice. This is called Evidence-Based Medicine.

At Kokilaben Hospital, we follow the model of Evidence-Based Medicine so that our patients can receive the highest level of care in surgery, chemotherapy or radiotherapy that is prevalent in the world. For instance, in the field of breast cancer management, the next step of individualising treatment for each and every patient using new molecular predictors of recurrence, by techniques, such as microarrays and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) is already a part of treatment plan at Kokilaben Hospital. Such advances in technology have allowed us to quantify the risk of relapse for an individual patient and tailor the therapy accurately, like avoiding chemotherapy in patients who are at low risk of relapse as estimated using these new assays. Such advances in management are practiced on a regular basis in the CBCU at Kokilaben Hospital.

Multidisciplinary approach

Today, Centres of Excellence all over the world and at Kokilaben Hospital treat their patients using multidisciplinary teams. With growing awareness on breast cancer, more and more patients are being diagnosed in the early stages, consequent to which the cure rates have risen to up to 85-90%. This has made post-treatment quality of life and rehabilitation very important and relevant in addition to treatment issues.