Breast Cancer

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Clinical Description

Breast cancer is the common term for a set of breast tumor subtypes with distinct molecular and cellular origins and clinical behaviour. The most common histology is Ductal Carcinoma. Sarcomas and lymphomas may also affect the breast. Breast cancer can also occur in men.

 

Clinical Features

SIGNS AND SYMPTOMS

Early breast cancers may be asymptomatic, and pain and discomfort are typically not present. If a lump is discovered, the following may indicate the possible presence of breast cancer:

  • Change in breast size or shape
  • Skin dimpling or skin changes
  • Recent nipple inversion or skin change, or nipple abnormalities
  • Single-duct discharge, particularly if blood-stained
  • Axillary lump

INVESTIGATIONS

  • It is advisable for women above age 20 years to do Self Breast Examination (SBE) monthly for potential masses.
  • Mammography and breast USS is recommended for women between 50 – 75 years.
  • Definitive diagnosis is through histology of the breast mass and ipsilateral axillary lymph nodes. This is more superior to cytology which should be understood as a preliminary diagnostic test.
  • Cytology should be considered for suspicious lymph nodes.

 

Treatment 

  • Treatment for breast cancer is multimodality.

NON-PHARMACOLOGICAL 

Surgery

  • Modified radical mastectomy and axillary lymph node clearance of level I and II nodes.

Note: Lumpectomy or breast conserving surgery in state hospitals should be reserved until radiotherapy facilities are available.

PHARMACOLOGICAL

Chemotherapy

  • This may be given as neo- adjuvant (before surgery) or adjuvant (after surgery). The first option has advantage of down-staging to make difficult to operate tumors resectable. Protocols include:
    • TAC, AC +/-Taxane, TC, CMF, FEC-75
    • HER 2 +: Add Trastuzumab
  • Patients on Doxorubicin or Epirubicin should have cardiac assessments (ECHO) before and during treatment
  • For Metastatic disease consideration of chemotherapy for younger patients or Tamoxifen in elderly patients who may not tolerate chemotherapy

Hormonal treatment: 

  • If ER/PR positive, Tamoxifen 20mg PO daily +/- Goserelin 3.6mg SC every 28 days or Ovarian Ablation if premenopausal.
  • If postmenopausal, consider Anastrazole 1 mg daily PO or Letrozole 2.5 mg PO.

Radiotherapy 

  • Adjuvant post-surgery to minimize recurrence and improves survival from breast cancer
  • Palliation to breast or chest wall for pain, bleeding as well as in brain metastases and bone metastases with or without spinal cord compression
  • Bone Disease: Palliation should include Denosumab 60 mg sc 6 monthly or Zoledronic Acid 3.3 to 4 mg 1 to 3 monthly. Pathological fractures should be discussed with Orthopedic team