To honour breast cancer awareness month, we sat down with Dr. Humera Mahmood, Head of the Clinical Oncology Department at Atomic Energy Cancer Hospital (NORI) to talk at length about breast cancer, its causes, early detection and treatment.

How is breast cancer caused? Give us some general reasons.

In most patients diagnosed with breast cancer, it is difficult to find the root cause that leads to the development of cancer, but there are certain factors. These include the presence of family history of cancer from the mother or the father’s side of the family, increasing age, dietary factors; excessive intake of fatty foods and less intake of fresh fruits and vegetables, obesity, smoking, alcohol intake, increased exposure to serum estrogen, early start and late cessation of menstrual cycles, late marriage, late or no childbirth, lack of breast feeding, hormone replacement therapy with high estrogen content, lack of physical activity, diabetes and vitamin D deficiency.

What are some of the common symptoms of breast cancer?

The most common symptom of breast cancer is the appearance of swelling or a lump, which in most cases, is in breasts but at times patients can present with swelling in the armpit or the neck as well.

Fortunately, not all the lumps in breast are cancerous but 50 percent of them can be benign. One cannot determine oneself whether it is benign or malignant but should seek medical attention. Only the doctor can determine the nature of the swelling after examination and appropriate tests.

Other symptoms include change in shape or size of a breast or nipple, blood stained discharge from the nipple and skin discoloration. If these symptoms are ignored, cancer cells will spread to other parts of the body and the patient will present with features related to the organ affected.

These symptoms include headache, vomiting, loss of consciousness and power, visual impairment, fits, vertigo (brain secondary), cough, blood in sputum, breathlessness (lung secondary), jaundice, loss of appetite (liver secondary), bone pain, fracture, loss of power and sensations in lower limbs, loss of urinary and bowel control (bone secondary).

If breast cancer runs in our family, are we sure to get it?

The risk of developing breast cancer is higher in a woman with positive family history of cancer as compared to a woman with no such history. The risk is more when first-degree relatives including your sister, mother and father have cancer.

Do note that cancer is not always transmitted from the mother. If cancer runs in your father’s family, it can also increase your risk. Presence of any type of cancer in the family can increase one’s risk of getting breast cancer. Although only 10 percent of breast cancers are hereditary but if BRCA1 or BRCA2 gene is positive in any woman, her lifetime risk of suffering from breast cancer is as high as more than 90 percent.

Which age bracket is most prone to getting breast cancer?

Generally, increasing age increases the risk of developing breast cancer but it no more follows the boundary of age. The disease can affect a woman of any age. In developed countries, more women above the age of 50 fall victim to this disease while in Pakistan, most patients with breast cancer are in the age group of 40 to 50 years.

The youngest patient seen at NORI was 19 years old. More women are now presenting in the age group of 30 to 40 years. Even elderly women above 70 years can be diagnosed with breast cancer.

When should I begin screening for breast cancer?

In Pakistan, the highest incidence of breast cancer is between the age groups of 40 and 50 years. Hence, in our country, screenings including clinical breast examination and mammography should start at the age of 40.
However, breast self-examination can be easily done at home and it should start from the age of 20 and should be repeated every month on the tenth to fourteenth day of the menstrual cycle. In case of family history with breast cancer, clinical breast examination and mammography can start from the age of 35 years.

What kind of doctor should I see if I fear I have breast cancer?

You should consult a surgeon or an oncologist. There are now dedicated breast cancer clinics in most hospitals including Atomic Energy Cancer Hospital (NORI), Islamabad and other PAEC and non-PAEC cancer hospitals as well. The concerned doctor will examine and advise you accordingly.

Do men can get breast cancer too?

Men can also get breast cancer but the percentage is very low – less than one percent.

What treatment options are typically available for breast cancer?

More than 90 percent of breast cancer patients need a suitable combination of surgery, chemotherapy and radiotherapy. The extent and priority of treatment modality depends on the stage of the disease, age and performance status of the patient including co-morbidities.

Other treatment modalities used are hormonal treatment and targeted therapy – the indication of which depends on certain biological characteristics of the tumour that are determined by immunohistochemistry.

What are the possible side effects of each treatment option?

Surgical treatment: Removal of the whole breast leads to cosmetic deformity and ultimately psychosocial issues. Nowadays, conservation of breast has become more feasible and convenient due to the availability of highly effective chemotherapeutic drugs.

Detection of breast cancer at early stages can be attributed to effective cancer awareness programs and screenings. But still, the whole breast needs to be removed in an advanced stage of the disease but cosmesis can still be achieved through proper reconstructive surgery.

Chemotherapy: The most common side effect patients are scared of with the administration of chemotherapy is loss of hair. Fortunately, hair grows again within six months of chemotherapy completion in all the patients.
Other common side effects include loss of taste and appetite, darkening of skin, nails and tongue, nausea, vomiting, diarrhea, prominence of veins at the injected sites and lowering of blood cells. All these effects are transient and manageable. Patients should stick to their doctors’ advice regarding diet and use of prophylactic medicines to avoid infection.

Radiotherapy: Radiotherapy is just like X-rays. The patients are radiated in a controlled environment with equipment used by qualified technologists under supervision of qualified Oncologists and medical Physicists. Only the affected areas of the body are radiated while other body parts are spared.

The patients usually experience changes in skin colour and loss of hair in the radiated areas. This settles with time. There can be desquamation, which is also transient and manageable. The patients should follow their doctors’ advice on how to minimize radiation toxicity.

What are some of the late and long-term side effects of breast cancer treatment?

Long-term and late side effects may include fatigue, headaches, pain and numbness (peripheral neuropathy), dental issues, lymphedema, musculoskeletal symptoms, bone loss and osteoporosis, heart problems, new cancers, cataracts, blood clots, absence of menstrual periods, menopausal symptoms, sexual difficulties, infertility, concerns about memory loss and cognitive function (chemo brain).

Every patient does not suffer from all the long term effects. The severity of each effect also differs. Some patients are more sensitive than others while some tolerate treatment very well.

How can I manage treatment-related side effects?

Some of the side effects can be avoided or minimized by simply modifying lifestyle and dietary habits, consuming a balanced diet, doing mild to moderate exercises and taking care of hygiene. Always ask your doctor about the possible side effects and their treatment. They may prescribe you some medicines. Always follow their advice.

Will my breast cancer treatment affect my ability to have a baby?

Some treatments for breast cancer can cause temporary infertility or make it harder for you to get pregnant after the treatment ends. Other treatments cause permanent and irreversible menopause, which means you are permanently infertile. It is likely that you will receive more than one type of breast cancer treatment – most people do. Each treatment your doctor recommends can affect your fertility.

Hormonal therapy

Medicines can cause your periods to stop or become irregular and make your ovaries stop producing eggs. Many premenopausal women are still fertile and start their periods again after the hormonal therapy treatment is done. But it is important to know that some women have problems getting pregnant even after hormonal therapy.

Ovarian shutdown

Ovarian shutdown, which can be done with medicine or surgery to remove the ovaries, is sometimes used to treat hormone-receptor-positive breast cancer or reduce the risk for women, who run a high risk of breast cancer. Medicines such as goserelin or leuprolide are used to temporarily stop the ovaries from making estrogen. These medicines cause temporary infertility. Fertility returns after you stop taking the medicine. If the ovaries are removed with surgery, infertility is permanent.

Fertility after chemotherapy

This factor depends on two things: your age and the types and doses of chemotherapy medicines you are taking.

Age

As every woman ages, her ovaries produce fewer fertile eggs. When you go into menopause, your ovaries stop making fertile eggs. Women who are treated for cancer younger than 30 years have the best chance of becoming pregnant after chemotherapy.

Overall, the younger you are, it is more likely that your ovaries will produce fertile eggs after chemotherapy. The closer you are to menopause – the average age is 51 – the more likely you will be in menopause after chemotherapy, and won’t be able to become pregnant. When women who are 40 or older get chemotherapy, they are more likely to be in menopause after chemotherapy.

Radiation treatment

This treatment for breast cancer has no effect on fertility.

What is the difference between radiation and chemotherapy?

Chemotherapy is the treatment of a cancer patient with cytotoxic drugs that are either given orally or in an injection form. These drugs reach all parts of the body through blood and can kill cancer cells anywhere.

Radiation is given to the affected part of the body while the rest of the body parts are spared of its effects through proper planning.

What are the chances of surviving breast cancer?

Survival rates can give you an idea whether the percentage of people with the same type and stage of cancer are still alive for a certain amount of time (usually 5 years) after they were diagnosed. They can’t tell you how long you would live but they may help give you a better understanding of how likely it is that your treatment will be successful.

Keep in mind that survival rates are estimates and are often based on previous outcomes of large numbers of people who had a specific cancer but they can’t predict what will happen in a particular case. These statistics can be confusing and you may have more questions. Talk to your doctor about how these numbers may apply to you, as he or she is familiar with your situation.
According to estimates, a 5-year survival for breast cancer is 90 to 95 percent when localized in a breast, 80 to 85 percent when regional lymph nodes are involved and as low as 25 to 30 percent when it has spread to distant parts of the body. These estimates speak of the importance of earlier diagnosis and timelier treatments of breast cancer.

How can I reduce my risk of breast cancer?

The risk of developing breast cancer can be reduced by changing lifestyle and dietary habits. Daily exercise, breastfeeding, increased intake of fresh fruits and vegetables, lower intake of fatty foods, avoidance of alcohol and smoking, avoidance of unsupervised intake of external estrogens, maintenance of healthy weight, controlled blood sugar and vitamin D levels are some of the measures that can be helpful in breast cancer prevention.

“Prevention is cheaper than cure.”

Breast cancer screenings help detect the disease at an earlier stage that is curable. Screenings that comprise of breast self-examination, clinical breast examination and mammography do not prevent cancer but help in an early diagnosis and timely treatment.