From A-Z in Breast Cancer

*What is breast cancer?
Breast cancer is the most common type of cancer affecting females. Commonly, it affects women after developing menopause. However, breast cancer in a pre-menopausal women is also encountered but to a lesser extent.

*What is the cause of breast cancer?
There is no direct cause for breast cancer. However, there are some factors that can predispose for breast cancer development.

*How often does a female develop breast cancer?
One out of 8-9 women develop breast cancer. Certain categories of women are more prone to develop breast cancer than others

*Who is more prone to develop breast cancer?

• Age: As a woman ages, her risk of breast cancer also increases. About 75-80% of women with breast cancer are over the age 50 at the time of diagnosis. Women between the ages of 20 and 29 account for only 0.3% of breast cancer cases

• Women with positive history of breast cancer in there family, especially first degree relative (e.g. mother).

• Women who had developed breast cancer in one side are 3-4 times more prone to develop breast cancer on the opposite side.

• Women with early menarche (early age of developing menses) and/or late menopause.

• Women who didn’t give birth to children

• Women who gave birth after the age of 30

• Women who didn’t breast feed their children
  Others factors include:

• Receiving Hormone Replacement Therapy (HRT) for more than 5 years.

• Smoking and high fat diet increase the risk of developing breast cancer as well

*Is breast cancer related to stress?
Some people have strong beliefs that developing breast cancer is related to stress. As a matter of fact, many studies have discussed that matter and proved that developing breast cancer has nothing to do with exposure to stressful conditions.

*Does Hormone Replacement Therapy (HRT) put the woman at risk to develop breast cancer?
The so called HRT consists of either of oestrogen alone or oestrogen + progesterone. HRT is basically given to women who passed into menopause in order to alleviate menopausal symptoms such as hot flashes, night sweats and vaginal dryness. For more than 30 years, HRT was recommended to women to reduce the risk of osteoporosis and heart disease. But recent studies have proved that after five years of using the combination of progesterone and oestrogen in particular, women’s chances of developing breast cancer may increase. In short, HRT is highly recommended to be received for only 5 years  

*How can I suspect breast cancer?
The hallmark is ACCIDENTAL DISCOVERY OF A PAINLESS BREAST MASS
Other manifestations include:

• Nipple withdrawal

• Asymmetry in the size between the two breasts

• Bleeding from the nipple

• Discovery of a swelling in the arm pits

*Does any breast mass mean breast cancer?
By all means, NO. There is a long list of benign (non-cancerous) disorders that may lead to development of a breast mass. Women in the childbearing period (15-50 years) are highly prone to develop such benign breast masses or in other words benign breast lumps. 90% of these benign breast lumps will disappear after developing menopause due to decrease in the levels of the female sex hormone (oestrogen).

*How can I differentiate between a benign (non-cancerous) breast lump and a malignant (cancerous) one?
As a general rule, you can never confirm whether the mass is benign or malignant except after performing a biopsy. However, there are some important criteria that are highly considered when a breast mass is detected:

• Painful breast lumps in relation to menses are classically benign

• Painful breast lumps in general are commonly benign especially in menstruating women.

• Multiple lumps in both breasts are more likely to be benign rather than malignant

• Breast lumps which are hard in consistency are more likely to be malignant.

*What is meant by a tumour marker?
They are certain proteins normally circulating in the normal blood circulation. Levels of these proteins increase in the blood in case of presence of a malignant tumour inside the body. They are used to follow the course of the disease, to measure the effect of the treatment and detection of recurrence. In breast cancer, there is a specific tumour marker named CA15.3

*Does breast cancer spread to other body organs?
Breast cancer can spread to different body organs commonly bone, lung, liver and brain. Accordingly, any woman diagnosed with breast cancer is subjected to x-rays and CT scans in order to discover whether there is spread or not. In case of spread, we call it “METASTASIS”.

BREAST SELF EXAMINATION

*How can I examine myself for breast Cancer?
The method of examining your breast is very easy. Please follow the following steps guided by the illustrated diagrams (adapted from www.breastcancer.org) :

Step (1)
Look at your breasts in the mirror with
your shoulders straight and
your arms on your hips.
You should look for equality in size, shape and colour without
any distortion or swelling

Step (2)
Raise your arms and look for the same changes

Step (3)
while you're at the mirror, gently squeeze each nipple between
your fingers and thumb and check for nipple discharge

(This could be a milky or yellow fluid or blood).

 
Step (4)
Next, feel your breasts while lying down, using your right
hand to feel your left breast and then your left hand to
feel your right breast. Use a firm, smooth touch with the first
few fingers of your hand, keeping the fingers flat and together.
 Finally, feel your breast while standing using the same
 instructions mentioned earlier.

The important thing is to follow a regular pattern to insure that you have
covered the entire breast. Begin at the nipple area and start moving in a
circular manner until reaching the outer edge of the breast.

*Is there a preferred timing to perform the breast self exam?
Breast self-exam is recommended every month, a few days after your period ends.

*When should I start examining myself?
About 75-80% of women with breast cancer are over age 50 at the time of diagnosis. Women between the ages of 20 and 29 account for only 0.3% of breast cancer cases. Accordingly, you can start examining yourself as early as 20 years old especially in those women with positive family history of this disease.

*Is there an organized program for early detection of breast cancer?

In Cairo Cure, we provide a highly organized program for early detection. It includes breast examination, breast imaging via a mammogram in addition to gene assay. What is meant by gene assay is detection of certain genes in your blood that indicates whether you will develop breast cancer or not. They are called BRCA-1 and BRCA-2 genes

MAMMOGRAPHY

*What if I discovered something during my self breast exam?

You should have you breast examined by a physician to confirm what you have detected in your breast and perform a mammogram.

*What is a mammogram?

A mammogram is an x-ray picture of the breast. You simply stand in front of an x-ray machine. Your breast is placed between two plastic plates to flatten it. This helps in getting a clearer picture and subsequently a more accurate diagnosis. A mammogram takes only a few seconds.

It can show cancer even before it can be felt. In general, females above forty are highly advised to have a mammogram every 1-2 years even without feeling a suspicious breast lump during monthly self exam.

*Why are women above forty advised to have a mammogram every 1-2 years?
Unfortunately, chances of getting a breast cancer are higher as we get older. Therefore, performing a mammogram on annual basis, helps in early detection of breast cancer which maximizes the possibility of cure and minimizes the need for surgery and/or other forms of therapy   . In Cairo Cure, we started already an early detection program for breast cancer. For women who have positive family history for breast cancer, it is preferred to start performing a mammogram every year at an earlier age. U/S

*Is the mammogram 100% accurate in diagnosing breast cancer?

As a matter of fact, Accuracy reaches nearly 90%. But in order to confirm
diagnosis, a biopsy has to be done.

*What is a biopsy?

A biopsy is a procedure in which a piece of tissue from an area of suspected cancer is removed from the body and examined under the microscope. There are several types of biopsies. Fine needle biopsy is the simplest and the least reliable method. It is done by removing small piece of the suspected mass. It is usually done under local anaesthesia. Core biopsy is the second type of biopsy in which a needle is inserted in the suspected mass and a bigger part is removed. This type of biopsy can be done under local anaesthesia as well. Surgical biopsy is another type in which the entire suspected mass is removed. It is usually preferred being more accurate. It can be done under both local and general anaesthesia. The tissues, then is examined by a pathologist under the microscope and then provide the oncology physician with what we call a pathology report.

*How is breast cancer treated?

There are several modalities to treat breast cancer. Surgery, chemotherapy, radiotherapy, hormonal therapy and biological therapy are all involved in management of breast cancer.

SURGERY IN BREAST CANCER AND RECONSTRUCTION

*Do breast cancer patients have to remove their entire breast?

NO. Breast removal-what we call MASTECTOMY- used to be the gold standard for management of breast cancer in the 60s and the 70s. But by the mid 80s, conservative surgery started to play a very important role without affecting the outcome in terms of cure rate and survival in general. However, it is worth mentioning that not all breast cancer patients are candidates for conservative surgery.

*What is meant by breast conservative surgery?

It means removing the area in the breast harbouring the cancer instead of the whole breast. As regards arm pits glands (axillary glands), there is a method in which the affected glands only are removed instead of removing them all –what we call sentinel node biopsy- accounting for minimizing arm oedema following surgery.   

*Who are the candidates for conservative surgery?

Criteria for conservative surgery include tumour size, number, pathology result and other criteria which have to be discussed in full details with your surgeon and oncologist.

*Are all women with breast cancer subjected to surgery?

NO. As a general rule, prior to surgery, chest x-ray, Abdomen Ultrasound and a bone scan are done to determine whether breast cancer had spread to other organs or not. If not, so surgery is mandatory. But in case of spread (METASTASIS), surgery has no role as the breast is not the only site for the disease. Accordingly, drugs are used (what we call systemic therapy) whether chemotherapy or hormonal therapy. 

*What are the hazards of surgery in breast cancer in general?

Of course psychological upset following breast removal (MASTECTOMY) is on top of the list. But classically both MASTECTOMY and conservative surgery are coupled with what we call axillary clearance. This means removal of glands situated in the arm pit (which we call axilla). The reason we remove them is that they are usually affected by cancer secondary to spread from original breast cancer. Removal of these glands causes classic arm oedema and swelling.

*How to overcome arm swelling following surgery?

- Keep the affected arm elevated as much as possible.

- Minimize salt in food to avoid water retention and consequently more arm oedema 

*Is there a role for breast reconstruction after breast removal?

YES. Women who had undergone complete removal of their breasts can stand a chance for breast reconstruction. In Cairo Cure, we prefer to proceed for reconstruction following the end of therapy. Currently, we have an organized program for breast reconstruction supervised and directed by Dr. Omar Zakaria, MD.

*Why reconstruct the breast?
Breast reconstruction is designed to reduce as far as possible any degree of disfigurement breast cancer may cause. Breast cancer surgery can change the patient’s appearance to some extent and also may have a profound effect on her sense of femininity. Every attempt is made to reconstruct breast symmetry and, after a certain time, gives the patient a sense of recognising the reconstructed breasts as an integral part of her own body.

*What are the techniques of breast reconstruction?
There are several techniques in order to perform reconstruction. The most famous and known by women is prosthesis using silicon. Physiological saline is also used as prosthesis instead of silicone. Other methods of reconstruction include reconstruction using FLAPS. The method involves part of the patient’s tissue which is "transferred" from the abdomen or the back to the breast.
With the abdomen, the small-medium excess of "fat" that almost everyone has under the belly may be used for breast reconstruction. This has the advantage that it is possible to reconstruct a breast very similar to the other normal breast without using any prosthesis. In cases where the use of abdominal tissue is neither desirable nor possible, and especially in patients with a small breast where larger volumes are not necessary, the large dorsal muscle may be used. This can be transferred to the breast region for reconstruction. A scar on the back will be present and an elliptical shape of skin from the back is transferred to the breast so as to recreate the missing skin. Sometimes it is necessary to integrate the volume with prosthesis

*Does breast reconstruction put women at risk of developing cancer?
As a matter of fact, reconstruction using FLAPS is certainly the most natural way of reconstruction. It changes along with the physique of the patient and needs no further attention or prosthesis-changing, unlike traditional reconstructions. As regards silicone prosthesis, it is important to clarify that studies have proved that there is no link between silicone prostheses and developing cancer

RADIOTHERAPY IN BREAST CANCER

*What is radiotherapy?
These are high energy radiation beams which are carefully focused on the tumour to kill the cancer cells. They are similar to x-rays used in diagnostic imaging but are administered at much greater doses. Before starting, you will have marks on your skin to determine to exact area that will receive radiotherapy. Accordingly, you will be asked not to wash this area or apply any creams as will be mentioned later.     

*Do all women with breast cancer have to receive radiotherapy?
In general, women that have undergone conservative surgery are almost always candidates for radiotherapy. On the other hand, women who performed complete removal of their breast may be subjected to radiotherapy and may be not according to various factors including original tumour size and number of lymph nodes involved (arm pit glands).  

*How to cope with radiotherapy?

- Avoid excess effort:
You may find that you feel tired during your radiotherapy. If so, allow yourself extra time to rest, perhaps by taking a nap in the afternoons.
- Healthy diet:
As always during treatment of any kind, it is important to maintain a healthy diet and drink plenty of fluids. At times you probably won't feel like eating, or you may find that your eating habits change. It may be easier to have small snacks throughout the day rather than large meals. Loosing weight as a result of radiotherapy is really unusual but it can happen as a result of inadequate diet.
- Skin care:
Some people develop a skin reaction, similar to sunburn, while having external radiotherapy. This normally happens after three to four weeks. People with pale skin may find that the skin in the treatment area becomes red and sore or itchy. People with darker skin may find that their skin becomes darker and can have a blue or black tinge. The amount of the reaction depends on the area being treated and the individual person's skin. Some people have no skin problems at all. If the skin reaction is severe, your treatment may have to be delayed for a short time to allow the area to recover. Soaps, talcs, deodorants and perfumes may also make your skin sore and should not be used. After your treatment, simple soap and simple moisturisers are often recommended. It is very important that any marks put on your skin to mark the treatment area are not removed. If the marks do fade or disappear, do not try to replace them yourself but let the radiotherapy staff know. These restrictions apply only to the treatment area, and the rest of your skin can be treated normally. Skin reactions usually settle down two to four weeks after the treatment has finished, but the skin area may remain slightly darker than the surrounding skin.
- Clothing
Loose-fitting clothes, preferably in natural fibres rather than man-made materials, are more comfortable and less irritating to the skin

*Where can I receive my radiotherapy sessions?
Radiotherapy is administrated in the form of sessions. Usually women with breast cancer are subjected to 25 sessions of radiotherapy. Radiotherapy is received under our supervision in SALAM and INTERNATIONAL MILITARY CENTER

CHEMOTHERAPY IN BREAST CANCER

*What is chemotherapy?
Chemotherapy is the application of chemical drugs to stop further growth of cancer cells as well as destroying them. They are almost always administrated in the form of a cycle. This is a process in which chemotherapy is given followed by a period of rest during which the body is allowed to recover.

*Do women with breast cancer have to receive chemotherapy?
In general, there is no rule that is applied for all women with breast cancer. The decision whether to receive chemotherapy or not depends on age, pathology result, size of the tumour, lymph node involvement and whether the tumour is hormonal sensitive or not.

*Do I have to be hospitalized to receive chemotherapy?
The vast majority of breast cancer chemotherapy protocols don’t require hospitalization. However, there are some protocols that will be given over night that will require hospital admission

*What are the side effects of chemotherapy?

NAUSEA & VOMITING: These are the most common side effects associated with administration of chemotherapy. Usually, patients start to feel nauseated eight hours after receiving therapy. This may last for 24 hours. The treating physician should set the patient on anti-nausea and vomiting drugs to control such side effects.
HAIR LOSS: One of the most well known side effects of chemotherapy. However, it is worth mentioning that not all chemotherapy drugs cause hair loss. Hair loss doesn't only apply to scalp hair but also face, body and extremities. Hair loss is not permanent. Hair starts to grow gradually after two to three weeks following completion of therapy. During receiving chemo, you will be offered a cask to be placed on your head to minimize hair loss. We always advise to have your hair cut short and to have a hairpiece or a wig before you lose a lot of hair so you can match your natural colour and current hair style if you wish
ANAEMIA & FATIGUE: Due to suppression of the bone marrow by chemotherapy. The bone marrow is the place where blood cells are formed including the red blood cells which carry oxygen to various body organs. When the bone marrow is suppressed, the number of red blood cells decreases leading to decreased tissue oxygenation and this is what we call ANAEMIA. Anaemia causes fatigue, weakness, headaches and sometimes shortness of breath. Blood transfusion is usually done if the red blood cells are markedly decreased.
INFECTION: Due to decreased white blood cells as a result of bone marrow suppression as mentioned before. White blood cells are the bacteria fighting cells. When they decrease, the body become more prone to infection. Infection may occur in the mouth, skin, lungs, and even in the genital and urinary systems. If you developed any sort of fever, you should contact your physician to set you on a suitable antibiotic. DIARRHOEA & CONSTIPATION: Some chemotherapy drugs cause diarrhoea while others cause constipation. Anti diarrhoea drugs as well laxatives (anti-constipation drugs) are usually prescribed to avoid such side effects.
MOUTH INFECTION: Good oral care is important during cancer treatment. Chemotherapy can cause sores in the mouth and throat. They can also make these tissues dry or cause them to bleed. Eating soft and soothing food as well as avoiding spicy and salty food is advisable.

*How long is the period of treatment with chemotherapy?
A minimum of 6 cycles is given for women diagnosed with breast cancer. Before each cycle, a blood picture is done to make sure that blood components are adequate in order to administer the chemotherapy safely. In those patients with spread to other body organs other than the breast (METASTASIS), an image is usually done to the site of the disease following the 2^nd or 3^rd cycle to assess response to treatment. 

*What about dietary habits during chemotherapy?
Good nutrition is vital for your body especially during receiving these drugs. Patients on chemotherapy can easily get infected. A Good and adequate diet helps your immunity in fighting these infections. Fruits, vegetables in general are recommended. Animal proteins as chicken and fish are also needed in considerable amounts.

*Is it possible to get pregnant after receiving chemotherapy?
YES. In fact, women who still get there period and suffer breast cancer are almost always offered chemotherapy as a main line of therapy. Following chemo, some of them continue to have their period but other suffer what we call “early menopause”. For those who still get their period, there is no problem getting pregnant and giving birth as long as she is off therapy. 

*Where can I receive my treatment?
Minority of chemotherapy drugs are available in an oral form. The majority of drugs are given in an intravenous form. Accordingly, you can receive your chemo either in Cairo Cure if your chemo protocol doesn’t require overnight stay. If it is given over 24 hour’s injection, you will be admitted to our inpatient section in SHEROUK hospital to receive it

HORMONAL THERAPY IN BREAST CANCER

*What is meant by hormonal therapy?
Hormonal therapy means the use of certain drugs that act on specific receptors on the breast. They act by blocking the effect of oestrogen on the breast. It is an easy form of therapy that is classically administrated in the form of pills.

*Can all women with breast caner receive hormonal therapy?
Not all women with breast cancer can receive hormonal therapy. After performing a biopsy or surgery, the cancerous breast tissue is examined for what we call ”hormonal receptor status”. If the hormonal receptor status is positive, this means that the tumour can respond to hormonal therapy. But if negative, it won’t respond.
In short, hormonal therapy is only possible for those patients with positive hormonal status.

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