What every Filipina should know about breast cancer

Breast cancer is the most common cancer specific to women in the Philippines. In fact, the Philippines tops the list in Asia for the most number of breast cancer in women. According to the Philippine Cancer Society, an estimated 14,000 new breast cancer cases are diagnosed each year and nearly 6,300 deaths are expected from the disease annually. That is why it is imperative that Filipino women (and men, too) should possess adequate knowledge about this dreaded disease.

This two-part series, written in support of the celebration of Breast Cancer Awareness Month this October, is meant to help in disseminating the latest facts and most recent advances about breast cancer. This week’s column will discuss the basics of the disease, and next week’s article will deal with advances in prevention, diagnosis, and treatment.

BASICS

Breasts are primarily composed of fatty and connective tissue called stroma. The muscles covering your ribs lie underneath the breast and the breast is suspended from the chest wall by ligaments. Within each breast is a network of 15 to 20 lobules. Each small lobule has a bulb. These bulbs produce milk. Thin tubes, or ducts, connect the lobes to the nipple (see illustration).

There are two main kinds of breast cancer. They are:

• Ductal, meaning it starts in the tubes, or milk ducts.

• Lobular, meaning it starts in the milk-producing glands.

There’s an early form of cancer called in situ. These cancers aren’t yet invasive and are contained in the milk ducts. However, if left alone, in situ cancers can develop into invasive cancers, which have the capability of spreading outside the breast. With noninvasive cancer (stage 0) and early-stage (stage I and II) invasive varieties, the cancer is confined to just the breast. A surgical option for early-stage breast cancer is a lumpectomy, followed by radiation treatment.

TYPES OF BREAST CANCER

Breast cancer is categorized by the appearance of the cancer cells and their cellular origin. The most common types of breast cancer are:

• Invasive ductal carcinoma (IDC). This type starts in a duct and then invades connective or fatty tissue that surrounds the duct. It can travel to the lymph nodes or enter the blood stream and spread to other parts of the body. It is the most common type of breast cancer, making up 75 percent of all invasive cancers.

• Invasive lobular carcinoma (ILC). This type starts in a milk-producing gland (lobule), and then invades the surrounding connective or fatty tissue. Like ductal carcinoma, it can spread to other parts of the body. It accounts for 15 percent of invasive breast cancers. This tumor may be more difficult to diagnose, as it can first show up as breast thickening rather than a firm mass.

• Other invasive ductal-type cancers. These less-common invasive cancers include medullary, mucinous, tubular, and papillary. Combined, these account for about 10 percent of invasive cancers.

• Ductal carcinoma in situ (DCIS). This non-invasive cancer is made up of abnormal cells in ducts that haven’t spread to the connective or fatty tissue. It’s the most common noninvasive cancer. Unchecked, it could turn into invasive cancer.

• Paget’s disease. This cancer is associated with nipple changes such as eczema, itching, and thickening of the dark circle of skin (areola) around the nipple, and can be invasive or noninvasive. About 50 percent of those with the disease have an associated cancerous lump. Paget’s disease accounts for less than five percent of all breast cancers.

• Inflammatory breast cancer. This is an aggressive cancer in which the affected breast looks inflamed, red, and feels warm. The skin can have the appearance of an orange peel, with an engorged look. It is often mistaken initially for a breast infection (mastitis). It tends to occur more often in younger women. It accounts for about two percent of all cancers.

STAGING YOUR CANCER

Tumor size, lymph node involvement, and whether the cancer has spread to other parts of your body will determine the stage of your cancer. A key part of staging breast cancer is to determine whether an invasive tumor has spread to regional lymph nodes. To accomplish this, a test called sentinel node biopsy has become the gold standard. The sentinel nodes are the lymph nodes in the underarm area that are usually the ones closest to the area of the breast involved in the cancer. Using the result of the sentinel node biopsy, doctors can determine whether additional lymph nodes need to be removed.

A surgeon may use any of several methods to locate the sentinel nodes. These include injecting a blue dye into the area of the breast where the tumor has been identified, the use of a radioactive tracer injected into the breast, or both. Once identified, the surgeon removes the sentinel nodes and a pathologist examines them for cancer cells. If no cancer is seen, then no further lymph nodes need to be removed. If the sentinel node does contain cancer, the surgeon will remove additional lymph nodes from the armpit (axillary lymph node dissection) to determine how many lymph nodes are involved as well as to remove the cancer in the area. Properly done, a sentinel node biopsy can accurately identify the lymph node involvement of the cancer 97 percent of the time.

Sentinel node biopsy has spared many women from axillary node dissection and its complications, such as arm swelling (lymphedema). Additional information important to determine treatment includes identifying the cancer’s:

• Grade. This is determined with tissue taken at the time of the core biopsy or surgical biopsy. The grade is based on how aggressive individual cancer cells appear under a microscope. There are different systems to grade cells, but a higher number typically means a more aggressive cancer.

• Stage. This refers to the cancer’s size and whether it has spread (metastasized) to lymph nodes or other parts of the body (see illustration). To further determine the stage, a history, physical exam, blood tests, and chest X-ray may be done. In select cases, other imaging techniques, such as a bone scan, computerized tomography (CT) imaging or positron emission tomography (PET) scans, may be obtained.

The various stages are:

• Stage 0: The cancer is contained within the duct — ductal carcinoma in situ (DCIS).

• Stage I: The invasive cancer is two cm. or less and is only on the breast.

• Stage II: The invasive cancer is greater than two but less than five cm. or has spread to the lymph nodes.

• Stage III: Advanced cancer that’s 5 cm. or more in size and has spread to lymph nodes or has involved the lymph channels and skin of the breast (inflammatory breast changes). It hasn’t spread beyond to the distant organs of the body.

• Stage IV: Advanced cancer that has spread to other parts of the body such as lungs, liver, bones or brain.

THE ROLE OF ESTROGEN AND GENETICS

Estrogen is the primary female hormone, and research indicates it may play a key role in the development of breast cancer. It’s known to stimulate the growth of cancer cells in hormone receptor positive tumors. Researchers have also found that the more years a body is exposed to estrogen, the greater the risk of developing breast cancer.

A woman’s genetic makeup can also play a role in developing breast cancer. Mutations or changes in the breast cancer gene (BRCA1, BRCA 2) increase the risk of developing both breast and ovarian cancers. However, such mutations account for only five to 10 percent of all breast cancers.

Male breast cancers are rare, representing less than one percent of overall cases of breast cancer. Men can develop breast cancer at any age, but it’s generally diagnosed between ages 60 and 70. Men can develop breast cancer types similar to those of women. Risk factors include exposure to radiation, having a disease related to high levels of estrogen (such as in certain liver diseases), or a family history of breast cancer, particularly with BRCA 2 gene mutation. –Tyrone M. Reyes, M.D. (The Philippine Star)

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(Next week, advances in breast cancer prevention, diagnosis, and treatment. Don’t miss it!)