By Tedler D. Depaynos, MD
“Breast cancer” (Ca) 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 the 50s and above but it could be found in any age group from 20 to 40s. The earliest case we encountered was an 18 yrs. old girl from the lowlands who never informed her parents of her condition until the lesion became fungating and foul smelling. A biopsy was done which expectedly was 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 believed 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. Actually, some OB-GYN practitioners no longer prescribe estrogen to menopausal patients because of this probability. Anti-estrogen medications may also be a part of chemotheraphy.
Just like any Ca, early diagnosis is a must. 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 axillas should also be palpated together with the areas just above the clavicles called supraclavicular areas. In the palpation, slide the fingers initially 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 vague edges 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.
A lady executive who was a physical fitness buff because she regularly went to a nearby gym thought initially that the enlarging mass in her right breast was part and parcel of her developing muscles. She neglected it for some time because she felt that she was getting fit even when she felt another “enlarging muscle” in her right axilla. It was only when she noticed the obvious asymmetry that prompted her to seek consultation. True enough the masses turned out to be fast growing malignancy which appeared initially as “muscular enlargement”.
Once a breast mass is palpated, immediate consultation is advised.
Some masses cannot be palpated especially if they are small and the breasts are massive. Routine bilateral breasts ultrasound is then recommended and in fact some companies make this a part of the yearly routine check-up of their 35 yrs. old and above female employees. In almost all cases this procedure is done before any surgical biopsy. Non-palpable masses may be seen.
Once a lesion is detected in the breasts, a biopsy is a must for definitive diagnosis. We have encountered numerous patients who underwent simple excision but no specimen is sent to the pathologist. This is mostly observed in rural area clinics which maybe distant from laboratories where a pathologist is available. In our local hospitals, it is a policy that all tissues or specimens are sent to the laboratories for examination. 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, the specimen is sent to other laboratories for second opinion or even third opinion. This is done definitely, for the sake of the patient.
Many types of biopsy procedures are 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 recommended to make sure that the specimen removed is adequate. It will eventually guide the surgeon what type of surgery he will be doing.
Once a breast Ca is diagnosed, a more extensive surgery mostly modified radical mastectomy is recommended. The affected breast is completely removed and the corresponding axilla is meticulously dissected to remove any metastatic nodes. Based on the biopsy results and work-up of the patient, further treatment may be prescribed by our young Oncologists like chemotheraphy or radiation.
It is very important then that early diagnosis is a must and it starts with self examination!**
