GENERAL INFORMATION

What is breast cancer?

It is a proliferation of malignant cells that originate in the breast, which initially has local growth which then progresses towards the lymph nodes of the closest axilla (armpit) and can finally spread through the blood to other organs. This dissemination endangers the patient’s life, as the progressive growth of new foci (known as metastases) of the tumour can cause death. If these new foci are in the liver, for example, it can be said that thePERSON dies of breast cancer and not of liver cancer. Nevertheless, breast cancer is often cured by the combination of different types of treatment. This treatment and the possibilities of a cure have improved enormously over recent years.

Is breast cancer being seen more often now than years ago?

The frequency of breast cancer has increased over recent decades, mainly because human longevity has increased. The main factor for the appearance of breast cancer is the higher life expectancy of the world’s population. Other general factors which can play aPART are changes in diet towards fried or grilled fast food with the resulting reduction in the consumption of boiled or raw foods.

EPIDEMIOLOGY

What is the frequency of breast cancer?

This varies from one country to another. It is more common in the United States and northern Europe. It is less frequent in Japan, Mexico and South America and southern Europe in general inRELATION to the type of diet. A higher consumption of calories and fried food leads to a higher frequency of cases of breast cancer.

Can men suffer from breast cancer?

Yes, although only 1 case out of every 100 breast cancers is found in men. It coincides with the fact that the mammary gland is smaller in size in men, only 1% of that of a woman.

CAUSES

What are the causes of breast cancer?

There is no single known cause for all cases apart from age, but certain factors exist that predispose to the disease. If the patient’s mother or sister has had breast cancer she is 4 to 8 times more likely to have breast cancer compared to those women who have no family history of this cancer. Other less significant causes are having started menstruation at a young age (before 12), stopping periods at an older age (after 50), not having had children, prolonged hormone treatment (oestrogens) for the symptoms of menopause, or exposure to radiation.

Is there a genetic predisposition?

Most of the time there is no predisposition. Only a small proportion of breast cancers are caused by genetic predisposition. We know that one or several of the following factors play a part: history of breast cancer in a first generation family member (mother, sister, daughter), the same but with ovarian cancer, 2 or more family members who had breast cancer when they were less than 50 years old, a family history of breast cancer in a man, altered genetic analysis with the presence of alterations in genes such as BRCA1 or BRCA2 (these are not commonly analysed, only when the family history cited is present and by very specialised centres). If there is no family history cited, having these altered genes does not predispose to cancer.

PREVENTION

Is there a way to prevent the disease?

Yes, although the best protection is still achieved with early diagnosis in the initial phases using mammograms. The disease is not prevented but it can be cured.
The preventive removal of the breast is indicated in extreme situations when there is a predisposing family history, where individuals have altered genes such as BRCA1 or BRCA2. The decision should be taken in consultation with a team of experts which includes a surgeon and oncologist.

Drugs such as tamoxifen or raloxifene have been shown to reduce the possibility of having breast cancer to around 50%. They are indicated in people with a high risk of suffering from breast cancer. The use of these treatments can be toxic over the long-term (for 5 years) and their pros andCONS should be assessed by a doctor who is an expert in the area.

Can certain lifestyle habits reduce the risk of breast cancer?

Physical exercise, a diet that is low in calories and fats, the consumption of fruit and vegetables and not consuming alcoholic drinks are factors which reduce the risk of breast cancer.

DIAGNOSIS

How can I tell that I don’t have breast cancer?

Through the clinical examination of the breasts and assessment of a mammogram by a specialist doctor. If you notice a lump in your breast when you press it with your hand flat against the ribs, see your doctor immediately. However it is preferable to visit your doctor once a year even though you have not noted anything in the breast. Timely diagnosis of breast cancer increases the possibilities of being cured by 25-30%.

When should I have a mammogram?

When a lump appears in the breast that was not there before.

When there are no lumps or family risk factors, once a year from 40 years old or from the age of 50 if you live in a country with a lowRATE of breast cancer.
If there is a high risk, a mammogram should be taken from 25 years old or 5 years before the family member who had breast cancer at a younger age. For example, from 35 years old if the direct family member had breast cancer at 40.

What the term “stage” mean in breast cancer?

It refers to the degree of spread of the tumour in the human body and helps doctors decide upon the treatment and know the percentage possibility that it will be cured.

Stage 1 means it is localised, and is highly likely to be cured with less intensive treatments. Stage II is localised and has a good prognosis although it requires more intensive treatments. Stage III means locally advanced. It can be cured but always with the combination of chemotherapy, surgery and, on occasions, radiotherapy and hormone treatment. Stage IV means that the cancer has spread through the blood to other organs. These days doctors are starting to be able to cure some cases in stage IV, but what has most improved is that the patients in this phase of the disease manage to live several years. All of this information is very sophisticated and requires consultation with a specialist doctor.

The TNM classification is also used, according to the size of the tumour (T), the presence or not of axillary lymph nodes invaded by the tumour (N), and the presence or not of distant metastasis (M).

TREATMENT

Which is the best treatment?

In general, the combination of surgery, chemotherapy, radiotherapy and hormone treatment. However there are enormous possible variations depending on how locally advanced or disseminated the breast cancer is.

When is it necessary to perform surgery?

In localised or locally advanced cancer (stages I, II or III), always. At times it is necessary to perform a mastectomy in the disseminated stage or stage IV, especially if there is a good response to hormones or chemotherapy and a long life-span is expected, as the original tumour which is the source of the metastasis will be eradicated.

When should we perform conservative surgery, removing only the tumour?

When the tumour is small in size, especially if it is less than 3 centimetres and does not have multiple foci, it is usually better to perform extirpation of the tumour alone or of a quadrant of the breast (quadrantectomy. It is always accompanied by radiotherapy on the rest of the breast after surgery to prevent recurrences.

When is radiotherapy indicated?

To prevent local recurrences after conservative surgery, or in other words when only the tumour or the quadrant of the breast which includes the tumour (quadrantectomy) is removed.

To prevent recurrences of the tumour when more than 3 lymph nodes of the axilla are detected with invasion of malignant cells after surgery (the doctors usually call this “more than 3 positive lymph nodes”)
Before surgery, to reduce the size of a large tumour and thereby make it more easily operable. In this case it is usually combined with chemotherapy.

In the event of distant metastasis, to reduce tumoral foci and thereby improve symptoms and prolong life.

When is chemotherapy indicated?

Chemotherapy is used in almost all patients with breast cancer, but with very different intents depending on the phase or stage of the disease: A) Palliative intent, in disseminated tumours, or stage IV, to lengthen life by several years. (In some cases a cure is achieved). B) Curative intent (this prevents the recurrence of the tumour), to improve the possibilities of a definitive cure which is obtained with surgery. When administered before surgery it is called a “neoadjuvant” and also serves to reduce the size of the tumour and make it more easily operable (it is usually used in stages III). If it is administered after surgery, it is called an “adjuvant”. Four to 6 cycles are usually administered and this manages to increase the possibilities of a cure, especially if the axillary lymph nodes that were removed were invaded by malignant cells. If 4 or more lymph nodes were affected it is essential that we use adriamycin or 4-epiadriamycin (they are very similar). These drugs are unpopular as they cause totalHAIR LOSS for the 4 or 6 months of the course of chemotherapy, but when the treatment is finished the hair regrows with even more vitality than before. This drug is usually combined with another drug called cyclophosphamide and a third, 5-fluorouracil (doctors call this regimen CAF due to the initials of the drugs). If 1 to 3 axillary lymph nodes are affected, some oncologists prefer to change adriamycin for another drug, methotrexate. There is less hair loss with this drug whilst maintaining efficacy (this regimen is known as CMF). When the axilla is free of affected lymph nodes, the advantage of this preventive chemotherapy is less, but it can still have some advantages if it is carried out. In this case the pros and cons should be discussed with your doctor.
The treatments described previously are considered standard, but can benefit from research that is taking place with new drugs or new forms of administering the drug which appear to improve the results.
This field of preventive or adjuvant chemotherapy is being intensely researched and in forthcoming years it is possible that other drugs such as paclitaxel, docetaxel, and the anti-oncogene antibodies Trastuzumab (commercial names Taxol, Taxotere and Herceptin respectively) will be commonly used.

When is preventive or adjuvant chemotherapy not indicated?

It is rarely not indicated. Only in tumours with negative lymph nodes of a very small size (less than 1 cm), and with favourable prognostic factors such as positive hormone receptors.

When is hormonotherapy indicated?

The tumour is analysed in the laboratory and it is observed whether it reacts to treatment with hormones (positive receptors) or does not react (negative receptors).

As a palliative treatment in disseminated cancer when the hormonal receptors are positive.

As a preventive treatment of a tumoral recurrence after curative surgery. If the hormone receptors are positive, tamoxifen is administered for 5 years consecutively. The possibilities of a definitive cure can therefore increase to 30% (this depends on several factors).

As a preventive treatment of a second tumour in the contralateral breast. With tamoxifen this risk is reduced to 50% compared with patients who have not taken it, and it even works in patients with negative hormone receptors.

I have heard that it is possible to prevent clearing the lymph nodes of the axilla.

The so-called “sentinel lymph node” can be detected using a contrast technique. If this lymph node is not present it is possible to prevent axillar clearance when operating on the breast and preventing disturbance from oedema of the upper arm. However the efficacy of this technique is about 95%, which means that 5% of patients could be left with tumoral lymph nodes in their axilla if it is not cleared by surgery. Until a technique is perfected which ensures a 100% successRATE, all patients with breast cancer should be operated on including clearance of the axilla to ensure a definitive cure.

Why do doctors sometimes administer hormones, sometimes chemotherapy and at times both?

After curative surgery, if the tumour had positive hormone receptors or if they are unknown but it is a woman who is older than 50, treatment with tamoxifen for 5 years increases the possibilities of a definitive cure and furthermore reduces the risk of suffering from a second tumour in the contralateral breast.

If chemotherapy is also indicated, the advantages of both treatments can be added. It is more appropriate not to give chemotherapy and hormonotherapy at the same time. Tamoxifen is therefore started at the end of chemotherapy.

Why do some women not lose their hair with chemotherapy?

Because they are taking certain cytostatics which only weakly attack the hair such as chemotherapy with CMF (cyclophosphamide, methotrexate, fluorouracil).

Patients who receive regular doses of adriamycin practically always have total or almost totalHAIR LOSS.

Can hair loss by chemotherapy be prevented?

Hair protections such as a bag of ice or an elastic band next to the scalp do not usually prevent all hair loss and do not protect the skin underneath the hair which is dangerous due to the possibility that the tumour will reproduce in that area.

If there is a risk of total hair loss this usually starts 3 weeks after the first doses of chemotherapy. There is sufficient time to go to a specialist hairdresser to order a wig. The hair should be cut totally or almost totally at 3 weeks and the best wig possible fitted according to the financial situation of each patient and her family. The best wigs are made of natural hair, are made to measure and fixed (they are held in place with a substance that stops them from moving). There are also fixed wigs that are made to measure but made of artificial hair making them somewhat cheaper. The cheapest wigs can be bought ready-made but it is also worth noting that they are not made of natural hair. It is generally preferable to wearing a headscarf if patients live in an area where it is not common to wear one.

Can vomiting be prevented during chemotherapy?

Yes, but taking suitable drugs against vomiting and preferably as a preventive measure before the first doses of chemotherapy. If the patient vomits the first time, it is more difficult to control the vomiting afterwards.
When the chemotherapy causes a great deal of vomiting, the best modern treatment against vomiting is the combination of two antivomiting agents. In general ondansetron, granisetron or tropisetron are combined with corticoids such as dexamethasone or prednisolone.

My neighbour is undergoing chemotherapy and she looks so well you can hardly believe it. Why?

She is probably taking a suitable antivomiting treatment and is wearing a good quality wig to disguise the hair loss. This prevents her from suffering from depression. Many doctors prescribe antidepressives and anxiolytics which boost this feeling of wellbeing.

It can be achieved whilst receiving a course of treatment of chemotherapy and other people cannot tell what is happening.

Are bone marrow transplants made for breast cancer?

This is still an experimental treatment. It is being tested in large hospitals in women who are without evidence of tumours after conventional surgery and chemotherapy but have a high risk that the tumour will recur. This happens in women in whom 10 or more axillary lymph nodes affected by the tumour have been discovered after curative surgery (in some centres this is also being tested with women who have had 4 to 9 affected lymph nodes), or who had a locally advanced cancer (stage III) in which chemotherapy was firstly administered and surgery performed afterwards, and where one or more affected lymph nodes were still discovered in the axilla, or in the special case of inflammatory breast cancer after conventional treatment.

Why give chemotherapy before surgery if the tumour can already be removed as it measures 4 or 5 centimetres?

When a breast tumour is large in size, in general more than 3 centimetres in diameter, chemotherapy can be given before surgery for two reasons:

(A) on one hand to improve the possibilities of cure as from the very beginning we are treating possible foci of metastasis which cannot be seen but may exist;

(B) and also to perform conservative surgery, or in other words, remove just the tumour and give radiotherapy afterwards on the rest of the breast. Mastectomy can therefore be avoided as the tumour is reduced with chemotherapy, as otherwise it would be necessary if the tumour measures more than 4 centimetres. (There is no fixed limit of 3 or 4 centimetres to perform conservative surgery as this would depend on the total size of the breast).

After the operation, the surgeon says the patient should avoid moving her arm and the oncologist says the opposite. Why?

The surgeon is concerned that the scar or stitches will split. However it is necessary to move the shoulder carefully but continually from the day after the operation to prevent ankylosis of the shoulder due to pain (something that happens if the shoulder is not moved).

When should doctors do breast reconstruction surgery?

This can be done at any time other than when explicitly contraindicated by the doctor. In the past patients waited one, two or several years before reconstruction, but improvements in the technique and prognosis makes it unnecessary to wait for years to enjoy the psychological effect of reconstructing the self-image that has been lost through mastectomy.

Which is the best way to reconstruct the breast, with silicone or abdominal muscle?

Reconstruction with muscle from the abdomen or back would be better if it was not for scarring and these are more complicated operations.
The new silicone prostheses filled with serum pose little risk and give rise to few problems, although some cases of chronic inflammatory reactions have been seen. As they do not containFREE silicone they can be removed again if problems occur.

 PROGNOSIS

Will I be cured? When can I consider that I have been cured?

The overall percentage of patients cured of breast cancer that is diagnosed on time is 70%. This figure has improved over recent years. Breast cancer can recur (although rarely) 5 years after treatment with curative intent. Therefore doctors usually wait for 10 years of monitoring with sporadic controls to be able to ensure that the patient has been cured definitively. Nevertheless, we have to remember that as they get older women have a higher risk of suffering from a second cancer of the contralateral breast meaning that it is advisable to follow controls once a year for the rest of their lives.

MONITORING

What kind of checkups do I need to have? Would it be better to have more regular checkups?

In most health centres around the world it is recommended that after the initial treatment checkups are made every 3 to 6 months for the first 3 years, every 6 to 12 months for the next two years and once a year when 5 years have passed. The checkups should be complemented by breast self-examination once a month by the patient. The medical checkups should be simple, with a physical examination, questions on symptoms and an annual mammogram. Performing more checkups or complicating matters with new imaging tests and sophisticated blood analysis has not shown that a higher number of patients are cured due to an earlier diagnosis of the recurrences of the tumour.
Whatever the situation, the doctor’s experience is very important when choosing tests which will be of use.

Can I pass on any disease to my husband?

Absolutely not. No type of cancer can be spread even by the most intimateCONTACT, as there is always an incompatibility of cells between two people. People’s immunity makes this impossible.

Can I pass on the predisposition to cancer to my daughters?

Yes, especially if you suffered from cancer before the age of 50 years old and have other risk factors (see previous). In these cases younger daughters should have checkups with mammograms before the age of 40.

Can I have children after chemotherapy?

Yes, but not always as sometimes chemotherapy brings forward the menopause, menstruation disappears and fertility is lost. Something similar occurs when homonotherapy such as tamoxifen is taken for 5 years. On the other hand, if menstruation continues then it is perfectly possible to get pregnant. A complicated situation is when a woman has not menstruated due to chemotherapy or taking tamoxifen, as this can be a period when she can still ovulate. In this situation it is better to take other precautions as if a woman gets pregnant during treatment with chemotherapy (but not after) this can lead to malformations in the foetus.