By Tedler D. Depaynos,MD
“Breast cancer” is simply a malignant lesion found in the breast. It could be bilateral. Patients with a cancer in one breast have a 10% chance of developing a similar lesion in the other breast. Males could also be affected but it is quite rare.
Incidence of breast Ca is found more in those in the 50s and above but it could be found in any age group from 20 to 40s. The earliest case I encountered was an 18 yrs. old girl who never informed her parents of her condition until it became fungating and foul smelling. A biopsy was done in my clinic during that time which expectedly turned malignant. She did not return for surgery but I presumed it was done somewhere else.
Females who have a family history of breast Ca or any Ca for that matter have a higher chance of developing “breast Ca”. From our textbooks, those that have menarche early (before 12 yrs old) and those that have late post menopausal syndrome have a higher chance of developing the malignant lesion. It is said that estrogen may play a role in the development of this type of Ca. Hence, those that have early menopause due to ovarian castration have a lesser incidence. Some OB-GYN no longer prescribe estrogen to menopausal patients because of this probability. Whether this is accepted worldwide, I am not aware.
Just like any Ca, early diagnosis should be done. Females are advised to do self-examination from time to time and preferably 8-10 days after menstruation because the swelling of the breasts that accompanies menstruation is expected to have subsided. It is done with the arms at the sides while standing in front of a mirror to see if there is asymmetry, dimpling or even a mass. The arms are then raised above the head and later at the hips pressing it to contract the muscles beneath the breasts (pectoralis) making the breasts protrude outwards, hence, emphasizing any abnormality. Each breast is then palpated while lying down by the opposite hand. The other hand placed over the head and preferably a pillow is placed beneath the breast being examined. The axilla should also be palpated together with the areas just above the clavicles or supraclavicular areas. In the palpation the fingers may initially slide over the breast tissues.
In general, a palpable mass that has its margins well delineated just like a marble is benign. A mass that has its edges vague is mostly malignant. It could also be adherent to the overlying skin or fixed posteriorly and may cause dimpling or nipple retractions which are positive signs of malignancy. An areolar ulcer or seemingly skin lesion which may be interpreted as allergy may actually be a sign of Paget’s disease which is a type of breast Ca. Edema and redness of the breast which may be accompanied by pain maybe signs of inflammatory type of breast Ca which in general is very malignant and metastasize early. This is due to lymphedema underneath the breast skin and may be interpreted as a sign of breast infection or mastitis. Again in general, malignant lesions are painless.
Masses or lymphnodes at the axilla and in the supraclavicular areas may be signs of metastasis.
Some masses cannot be palpated especially if they are small and the breasts are massive. Ultrasound is recommended to localize the lesion as well as to determine if the lesion is solid or cystic. Sometimes this is done before any biopsy procedure is done to guide the surgeon.
Once a lesion is detected in the breasts, a biopsy is a must for definitive diagnosis. We have numerous experiences where patients underwent simple excision but no specimen is sent to the pathologist. This is usually done in the rural areas which are quite a distance from laboratories where a pathologist is available. A specimen may grossly look benign but under the microscope and under expert eyes it maybe malignant. In some cases, especially if some doubt exists, we send the specimen to other laboratories for a second opinion. This is usually done for the sake of the patient.
Many types of biopsy procedures maybe done like aspiration or core needle biopsies but excision biopsy if feasible is recommend because the whole lesion is removed and the whole specimen could be examined by the pathologist. Besides even if it is benign, it is already removed. If the lesion is large, resection biopsy is done because the specimen removed is surely adequate. It will guide the surgeon what type of surgery he will be doing.
Once a breast Ca is diagnosed, a more extensive surgery like modified radical mastectomy is recommended. The affected breast is completely removed and the corresponding axilla is meticulously dissected to remove any metastatic nodes. In Stage I and 2 this procedure maybe curable but to make sure that microscopic cancer cells are destroyed, most surgeons recommend radiation or some chemotheraphies. In Stage 3 or 4 where there are nodal metastasis as well as to the lungs, liver and other parts of the body are already obvious, surgery is just palliation. It is just to make the patient comfortable because the cancer lesions may become huge, foul smelling and even fungating like a cauliflower. Even the chemotherapies given are just palliative and non-curable. It is very important then that early diagnosis is a must.
Some surgeons recommend removal of the opposite breast of apparently cured breast ca patients especially if abnormal masses are detected even if they are benign.**