Breast cancer remains the most common malignancy in women. The clinical course of breast cancer is more of a chronic nature and thus, five (or) ten years disease-free survival cannot be considered as a cure. The probability of cure is inversely proportional to the initial stage. This fact draws attention to the importance of detection of early stage breast cancer.
National statistics from USA, UK, Italy, Switzerland and other countries show a significant gradual decrease in breast cancer mortality. This trend has persisted for almost ten years1.
Whether the significant reduction in breast cancer mortality is due to earlier diagnosis secondary to systematic use of screening mammography or the improvement in combined modalities in the management of all stages of breast cancer is difficult to determine2. It is likely that both have contributed to this trend.
Early breast cancer can be classified into two types,
( 1 ) Screening detected early breast cancer, and
( 2 ) Clinically detected early breast cancer.
Mammographically diagnosed, early breast cancer is associated with excellent survival rate, exceeding 90% at 10 years, following surgical resection alone or breast conservation.
Clinically detected early breast cancer category is the group of patients who consulted doctors for suspicious breast changes, noticed on self-examination. Women are advised to do self-breast examination monthly and have been taught the proper method and the features to look for. Consultation with concerned doctors, needs to be done, whenever any abnormality/ suspicious changes are noticed. Primary care doctors, then perform clinical assessment and refer to specialist breast clinics for further action.
Early warning signs of breast cancer
Studies show, 40% of women with breast cancer, discovered by themselves. Many women often noticed early signs of breast cancer while performing daily activities. Most common sign of breast cancer is a lump in the breast or axilla.
Women should be aware of the warning signs
– Lump in breast or axilla (soft, hard or rubbery), the lump is unlikely to be visible, but can be felt.
– Dimpling or puckering on skin of the breast.
– Thickening or swelling of part of breast.
– Redness or flaky skin in nipple area
– Retraction of nipple
– Pain in nipple area
– Nipple discharge other than milk
– Any change in size and shape of breast
– Breast pain
Breast cancer screening
This is a checking of a woman’s breasts for cancer before there are signs and symptoms. Although, breast cancer screening cannot prevent cancer, it can help find breast cancer early.
Screening methods
– Clinical breast examination
– Mammogram
– Ultrasound examination of breast
– Breast MRI
Benefits and risks of screening
Benefits: finding cancer early, thus easier to treat.
Risks: 1) false positive results, over-diagnosis and over-treatment.
2) false negative results (which may delay detection).
Mammogram
X-ray of breast to look for early signs of breast cancer. Regular mammogram check-up can pick up breast cancer three years before it can be felt. Mammographically diagnosed early breast cancer is associated with excellent survival rates, exceeding 90 % at ten years, following surgical resection alone or breast conservation.
Mammographic screening has been done as a national screening program in European countries for decades and has continued for women above 50 years of age. Women under 50 years with risk factors, should undergo mammo-screening regularly to pick up breast cancer, early. High risk women should start mammographic and MRI breast screening at the age of 30 years.
Risk factors for breast cancer
– Old age: risk increases with age, most breast cancers are diagnosed after 50.
– Gene mutation : inherited changes (mutation to certain genes e.g; BRCA 1, BRCA 2, etc)
– Early menarche and late menopause ( < 12 years and > 55 years)
– Dense breasts: have more connective tissues than fatty tissues.
– Personal history of breast and certain non-cancerous diseases (atypical hyperplasia and lobular carcinoma in situ)
– Family history of breast and ovarian cancer
– Previous history of radiation therapy (e.g; Hodgkin’s lymphoma)
– Exposure to the drugs (diethyl-stilbestrol)
– HRT (hormones) for more than 5 years
– Reproductive history: first pregnancy after 30 years
– No breast feeding
– Never had full-term pregnancy
Diagnosis of breast cancer
Combination of clinical, imaging and histological examination is essential to diagnose breast cancer in the early stages. Triple assessment (clinical, radiological and pathological examination) should be done on all patients with a confirmed breast lump. It is recommended that all elements of the assessment processes are reported on a scale of 1 – 5 with increasing concern of malignancy.
Scoring system for triple assessment
1) Normal (or inadequate cytology)
2) Benign (or normal cytology)
3) Suspicious but probably benign
4) Suspicious and probably malignant
5) Malignant
In USA and European countries, The BIRADS scoring system is used for radiology.
BI-RADS classification
Breast Imaging Reporting and Datasystems, a scoring made from mammogram findings.
Pathological assessment
For early diagnosis of breast cancer, sampling of suspicious lesion can be done:
1) By imaging guided fine needle aspiration cytology
2) Imaging guided core needle biopsy (Ultrasound guided)
3) Mammographic, wire-hook localization surgical biopsy
FNAC (fine needle aspiration cytology) and core needle biopsy can be done under local anaesthetic agent or without any local injection in case of FNAC (as very fine needle of 25 – 22 guage needle is used).
The sensitivity and specificity of both FNAC and core needle biopsy is high. But review of published series has shown that core biopsy with histology is more sensitive and specific than fine needle aspiration in diagnosing most impalpable radiological lesions3. In symptomatic breast disease, FNAC, together with clinical and radiological assessment allows rapid, in-expensive and accurate diagnosis4.
Mammographic, wire-hook localization surgical biopsy is a form of histological assessment of clinically occult breast lesion. Hooked wire is placed under stereotactic or ultrasound guidance, to the micro-calcified lesion in the breast and excision of the lesion was done by the surgeon. Accurate wire placement is essential and ideally the shortest possible length of the wire within the breast tissue.
Fig 1– Wire localization
Fig 2- Mammographic wire localization (a & b) and post-excision recheck mammography of specimen (c)
Fig 3- MRI breast imaging technique
Pathology of early breast cancer
Carcinoma in situ, is the earliest histological change of breast cancer within the terminal duct or lobular unit, that precedes invasion. This earliest lesion of breast cancer can be either DCIS (ductal carcinoma in situ) or LCIS (lobular carcinoma in situ). DCIS is much more common than LCIS. Both lesions are the initial changes of the normal breast structure and are regarded as pre-malignant changes. Histologically, the basement membrane remains intact.
DCIS is usually uni-centric and characteristically shows micro-calcification which can be recognized in mammogram. LCIS tends to be multi-centric and thus most likely to affect both breasts (bilateral breast lesion is one of the characteristic pictures). LCIS do not have calcification, and are likely to be missed on screening mammogram.
Invasive ductal carcinoma develops, once the basement membrane is invaded and can spread locally and has the potential for systemic spread. The possibility of lymph node metastasis and systemic distant spread can be predicted by careful examination of lympho-vascular invasion in histology. The pathologist plays a major role in diagnosing early breast cancer and nodal status of the breast cancer patients, which is the main determining factor in the prognosis. Nodal positivity and negativity is critical and a key factor in detecting early breast cancer, and makes a difference in the clinical course and management.
Sentinel node biopsy is thus the most important issue in the management of breast cancer. Histological grading is one of the important determining factors of the natural course. The grade of tumour reflects its degree of differentiation and proliferation capacity. There is a highly significant correlation between histological grading and long-term prognosis. Patients with grade 1 carcinoma breast have a 93 % of 10 years survival, which decline to 70 % if the grade is 3.
IHC (Immuno-histo-cytochemistry) is another prognosticator in the pathological assessment of the breast cancer patients. Oestrogen receptor (ER), progesterone receptor (PR) and human epithelial growth factor two (HER-2) estimation can be done on core biopsy specimens. Assessment of receptor status on core biopsy sample also gives the advantage of early treatment planning.
Curability of early breast cancer
The use of adjuvant tamoxifen following primary surgery for ER (+) early breast cancer has been associated with prolonged disease-free survival and 20 % to 30 % reduction in mortality rate. An overview analysis of the major treatment among nearly 30,000 women with early breast cancers demonstrated a 47 % reduction in the incidence of contralateral breast cancer with 5 years of adjuvant tamoxifen5. At present, studies show that continuing for a further five years of tamoxifen has no value in patients responding to the five years tamoxifen therapy. The recommendation now is to switch over to aromatase inhibitor (e.g; letroz) for another 5 years if the response to tamoxifen is satisfactory. The alternative regime is aromatase inhibitor (e.g; letroz) for 10 years straight.
Conclusion
Early berast cancer, if diagnosed and treated at the earliest stage can give a normal life span especially in postmenopausal women suffering from early breast cancer with positive receptor status.
References
1. DM. Parkin, P Pisani, J Ferlay, (1999) “Global cancer stasitstics, CA Cancer” J Clin, Jan – Feb: 49 (1): P 33 – 64.
2. K.Kerlikowske, D Grady, SM. Rubin, et al: (1995) “A metaanalysis on efficacy of screening mammography”, JAMA, 213 (2), P 149 – 154.
3. PD.Britton,(1999) “Fine Needle Aspiration or Core biopsy”, The Breast, Vol.8, Issue 1, Feb, P 1-4.
4. ID Bulety, DC Roskel, (2000) “Fine Needle Aspiration Cytology in tumour diagnosis: Uses and limitations”, Clin Oncol (R Coll Radial),12 (3), P 166 – 171.
5. Tamoxifen for early breast cancer: an overview of the randomized trials, 1998, Vol. 351, Issue 9114, P 1451 – 1467.
Author Information
Win Myint
Professor, Department of General Surgery, Pun Hlaing Hospital
