Breast cancer

Breast cancer

Breast cancer represents more than one-third of all new cases of cancer in women. It is the result of a disorder of certain cells that multiply and most often form a mass called a tumor. There are different types of breast cancer, ranging from slow to very rapid.

Cancer cells can stay in the breast. The more threatening situation is when the tumor spread to other organs. This is called metastasis.

In what follows, we will go into more detail about this type of cancer.

Diseases of the breast

Breast diseases are classified into two types: benign and malignant tumors.

        1.       Benign tumors:

Benign tumors have well-defined contours, remain localized in the tissue or organ in which they originate, and are slow-growing. Therefore, they do not metastasize to other parts of the body.

The most common benign tumor is the fibroadenoma, which is composed of cells that resemble the normal cells of the tissue involved.

Other benign breast conditions are cysts, fibrocystic changes, hyperplasia, nipple discharge, and gynecomastia.

The anatomopathological examination is the only examination performed after a biopsy to verify that it is not cancer.

        2.       Malignant tumors

Malignant tumors are often poorly defined. But sometimes they are well defined and can be considered benign for a while, which can delay the diagnosis of cancer.

Cancer cells are undifferentiated cells because they have lost their original characteristics. They have various abnormalities compared to normal cells: different shapes and sizes, and irregular contours...

A distinction is made between cancers confined to ducts or lobules and invasive or infiltrating cancers.

Malignant tumors can lead to metastasis, which are cancerous cells that escape from the primary tumor and colonize another area of the body, to form a new tumor called a secondary tumor or metastasis.

It is also thanks to the anatomopathological examination of a tumor sample that we can determine whether it is cancerous or not.

Risk factors

A person with one or more risk factors may never develop cancer. Conversely, a person with no risk factors can develop cancer. We distinguish:

   ü  Personal history of diseases such as breast, ovarian, and/or endometrial cancer.

   ü  Family history of cancer.

   ü  Age.

   ü  Genetic predisposition to breast cancer.

   ü  Alcohol consumption, smoking, and being overweight.

   ü  Little or no physical activity.

   ü  Hormonal treatments for menopause.

Symptoms

The symptoms of breast cancer listed below do not mean that it is breast cancer. But if it is, it is important to detect it as soon as possible.

   ü  The most common sign of breast cancer is a lump or mass in the breast. This lump is hard, appears     "fixed" in the breast, and has irregular contours. It is usually not painful.

   ü  One or more hard nodes under the arm in the armpit sometimes means that breast cancer has spread to the axillary nodes. However, they remain painless.

   ü  A change in breast skin such as shrinkage, redness, swelling, or an orange peel appearance.

   ü  A change in the nipple or areola (the area around the nipple) such as retraction, change in color,        oozing, or discharge.

   ü  A change in the shape or size of the breast, such as redness, swelling, and warmth in the breast, can be a sign of inflammatory breast cancer.

   ü  Bone pain.

   ü  Headaches, double vision, and muscle weakness.

   ü  Shortness of breath, coughing, and fluid build-up around the lungs.

   ü  Loss of appetite, jaundice, nausea, and weight loss.

Diagnosis of breast cancer

Two types of tests must be performed to establish a diagnosis.

1.       Initial assessment examinations

The initial workup includes:

ü  A consultation, including a clinical breast examination, with a physician, who specialized in the treatment of breast cancer.

ü  A mammogram of both breasts, often combined with an ultrasound of both breasts and lymph nodes.     In certain situations (very small lesions that are not palpable or not clearly visible on ultrasound), the radiologist may use x-rays to guide the sampling to the abnormality. When the sample is taken under mammography, it is called a stereotactic biopsy. When performed under ultrasound, it is called an ultrasound-guided biopsy.

       2.       Extension assessment

After the clinical examination, the mammogram, and the anatomopathological examination of the biopsy, if the results suggest that there is metastasis, i.e. that the cancer cells have migrated to parts of the body far from the diseased breast, other imaging examinations may be performed.

These may include a chest x-ray, bone scan, CT scan, abdominal ultrasound, or MRI. A complete blood workup is performed, and other tests may be performed depending on the patient.

Treatments

Several types of treatment can be used to treat breast cancer: surgery, radiation therapy, hormone therapy, chemotherapy, and targeted therapies.

Depending on the case, treatments may have different objectives:

ü  Suppressing the tumor or metastases.

ü  Improving the patient's comfort and quality of life by treating the symptoms caused by the disease.

ü  Slowing the development of the tumor or metastases.

ü  Reducing the risk of recurrence.

The choice of treatment will depend on the following characteristics:

ü  The type of cancer you have and its location in the breast.

ü  Whether the cancer is unifocal (single cancer) or multifocal (several cancerous tumors).

ü  The stage at the time of diagnosis and the grade of cancer.

ü  Your general health, age, personal medical and surgical history, and family history.

ü  Hormone receptor or HER2 status.

ü  Any contraindications to treatment.

ü  Your opinions and preferences.

A treatment proposal is prepared by physicians from at least three different specialties (surgeon, medical oncologist, radiation oncologist, pathologist, etc.) in a multidisciplinary consultation meeting (CPR) based on best practice recommendations. The proposed treatment is then explained to you during a consultation. Once you have agreed to the proposed treatment, the details will be laid out in a Personal Care Plan (PPS). You may also be offered to take part in a clinical trial.

The following information provides an overview of the main treatment options, depending on the stage your breast cancer is at at the time of diagnosis.

1.       Carcinoma of the breast in situ

Cancer is considered in situ if the cancer cells are present only in situ:

ü  in the ductus of the breast (CCIS for ductal carcinoma in situ).

ü  In the lobes of the breast (CLIS for lobular carcinoma in situ).

The treatment of ductal carcinoma in situ (DCIS) is mainly based on locoregional therapy:

ü  Or breast conservation surgery (lumpectomy) followed by radiation therapy. In breast conservation surgery, the tumor and a small portion of the surrounding tissue are removed, leaving most of the breast intact. In some cases, the operation may be accompanied by the removal of the sentinel lymph        node;

ü  Or non-conservative breast surgery (mastectomy), where the entire breast containing the tumor is removed. Depending on the case, the operation may or may not involve the removal of the sentinel lymph node.

Treatment of lobular carcinoma in situ (LCIS) is usually based on regular follow-up. In some cases, surgical biopsy or excision may be suggested.

2.       Non-metastatic invasive breast cancer

Infiltrating breast cancer occurs when cancer cells have spread to the tissues around the lobes or ducts where cancer originated.

Treatment of invasive breast cancer relies primarily on local treatment:

ü  Either breast conservation surgery (partial mastectomy), including lymph node surgery (sentinel node removal or lymph node dissection), supplemented by radiation therapy.

ü  Or nonconservative breast surgery (mastectomy) including lymph node surgery (sentinel lymph node removal or lymph node dissection) and, if necessary, radiation therapy.

This primary treatment may be completed depending on the presence or absence of risk factors for recurrence, i.e., features of cancer that increase the risk of recurrence after locoregional treatment. Examples of risk factors for breast cancer recurrence include:

ü  Tumor size.

ü  The number of lymph nodes and if or not lymph nodes are involved.

ü  Its class, that is, how aggressive it is.

ü  Whether the HER2 protein is overexpressed or not.

ü  Whether the tumor may or not be hormone-dependent.

If risk factors for recurrence are present, physicians consider the following additional treatments:

ü  In the case of conservative surgery:

   ü  In case of non-conservative surgery:

§  chest wall radiation therapy.

§  Irradiation of the lymph nodes.

   ü  Independent of surgery:

§  Chemotherapy, possibly combined with targeted therapy if the tumor is HER2-positive.

§  If the tumor is hormone-sensitive, hormone therapy.

In all cases, the aim is to reduce the risk of recurrence and optimize the chances of recovery.

In some cases, such as inflammatory cancer or when the tumor is too large to be operated on immediately, surgery is preceded by medical treatment (chemotherapy or hormone therapy in the case of hormone-sensitive tumors) called neoadjuvant therapy.

3.       Time between treatments

If radiotherapy is the only adjuvant treatment after surgery, the start of radiotherapy after surgery should not exceed 12 weeks.

If chemotherapy (with or without targeted therapy, depending on the HER2 status of the tumor) and radiotherapy are prescribed after surgery, chemotherapy is usually given first. This is because some chemotherapy drugs cause more serious side effects when administered after radiotherapy. To avoid these, radiotherapy is started after the chemotherapy has ended and no more than 5 weeks later. Finally, there should be no more than 6 months between surgery and the start of radiotherapy. If hormone therapy is indicated, it is started at the end of radiotherapy.

4.       Metastatic breast cancer

Metastatic breast cancer is cancer that has spread, meaning that cancer cells have separated from the original (primary) breast cancer and migrated through lymph or blood vessels to another part of the body (usually the bones, lungs, or liver) where they have taken up residence.
The main treatment for metastatic breast cancer is systemic drug therapy. These include chemotherapy, possibly targeted therapy, and/or hormone therapy if the tumor is sensitive to hormones.

In some situations, locoregional treatment, such as surgery and/or radiotherapy of the tumor or metastases, is combined with drug treatment.