Breast Diseases

Dr. Venkatesh Sanjeeva MBBS, MS, FRCS (Edin),FRCS(Glasgow), Professor  of Surgery, AJIMS, Mangalore. He is a specialist in Breast Surgery. He did his MBBS from K.M.C, Mangalore, in the year 1987 and passed his MS in general surgery from K.M.C, Mangalore in the year 1991.   He worked as an Assistant Professor of Surgery in K.M.C, Mangalore from 1992 to 1995, before leaving to the United Kingdom for higher studies in the year 1995. During his stay in the United Kingdom, he obtained FRCS from two prestigious royal colleges of surgery – Edinburgh and Glasgow, in 1996. Later, he had higher surgical training in Gastro Intestinal and Breast Surgery from various reputed hospitals in England from 1996 -2000. He returned back to India in March, 2000 and served as Associate Professor of Surgery at K.M.C., for 5 years. In May 2005, he joined the A.J. Medical College as a Professor and Head of Unit, Department of General Surgery. He has consultation at Kamalini Building, Bunts Hostel Circle, Mangalore. In September 2001, he was awarded the "Outstanding Young Person 2001", by Jaycee, Mangalore for educating the public on "Prevention and early detection of Breast Cancer".   A health education program delivered by him, "Stanada Rogagalu" has been broadcasted in various Mangalore TV channels and aired on Akashvani, too. His articles on breast diseases had been published in noted magazines like Tharanga, Vijaya Karnataka, Hosa Digantha, Bhalaike Daaiz, Raknno, Sevak, Anupama and Mailaanj. Email id: Consultant Surgeon, Kamalini Building, Opp. Vijaya Clinic, Bunts Hostel Circle, Mangalore – 3 0091 824 2448800 (Clinic) 0091 9845080310 (Mobile)

Diseases of the Breast bring in a significant stress in women, especially when the diagnosis of breast cancer is made. Why?

The impact of this disease threatens the body image, disturbances in the form of self esteem, feminity and sexuality. Hence there is a need to understand the disease for better quality of life.
 
The magnitude of breast cancer problem is increasing in India. Breast cancer is rapidly catching up with cervical cancer as the most common type of cancer in Indian women. In England, one out of every 14 women will develop breast cancer in their lifetime, whereas in India especially in the urban areas  incident of breast cancer is increasing dramatically , not only women, sometimes men also suffer from breast cancer (one in 200).
 
Causes/ Risk factors:
 
Female sex hormones, eg. oestrogens and progesterone etc., play an important role in development and growth of the breast, changes in breast during menstrual cycle, pregnancy and lactation. Diseases of breast are mainly due to changes in hormone secretion ie., changes in duration of amount and relation between hormones. It is difficult to pinpoint the exact cause of breast cancer, but certainly we should consider some risk factors.

1. Heredity: A woman with family history of breast cancer (mother, sister or maternal aunt) has an increased risk of developing breast cancer in her lifetime.
   
2. Menstrual cycle: Girls attaining puberty at a much earlier age, pregnancies being delayed beyond 32, breast feeding shortening and late menopause are some of the major factors. So Indian, especially urban women are increasingly becoming susceptible. (Due to excessive level of estrogen in the body). Long term use of hormone replacement therapy increases the risk of breast cancer.
   
3. Lifestyle: Studies show that women who consume alcohol, eat excessive fat in diet and smoke cigarettes are susceptible to develop breast cancer. 
    

Clinical Features: Breast cancer can occur at any age. In the past 10 years, the disease has shown a dramatic increase among younger women in India.

Painless lump in the breast is the most common presentation of breast cancer. Since these lumps are painless, most women neglect it, but these lumps grow very fast and can invade skin,chest muscle & can spread to arm pit in form of glands(lymph nodes)or to other organs like liver,lungs,bone and brain. Other form of clinical presentation are:

• Blood stained nipple discharge, changes in nipple shape & size or itching around the nipple.
  
• Changes in size and shape of breast.
  
• Changes in the skin of the breast ? redness, prominent veins, dimpling or ulceration.
  
• Swelling (lymph nodes) in armpit or lower parts of neck.
  
• In late stages, these tumors can spread to the rest of the body mainly liver, lungs, bone&brain and these patients can present with symptoms attributed to those organs

DIAGNOSIS: 3 ways ? triple assessment
–         Examination of the patient
–         Radiological investigations ? mammogram and ultrasound of breast
–         Biopsy
 
Clinical Examination: Patient co-operation is vital in examination. Doctor should look for any change in size and shape of breast and nipple. If nay swelling felt, doctor should confirm the nature of the lump in form of size, hard or soft, mobility, fixed to skin or chest wall. Breast specialist can detect a breast cancer in early stages.
 
Radiological imaging: 

Mammogram: Soft tissue X-ray of the breast, mammogram is useful only after the age of 35 years. Under the age of 35 the breasts are denser, it is difficult to detect cancer. By mammogram, we can detect tiny breast lumps which are not palpable.

Ultrasound: Useful in young ladies less than 35years,  we can diagnose non-cancerous as well as cancerous lumps, cysts & under ultrasound we can aspirate cysts.

Biopsy: Fine needle aspiration cytology; A needle is inserted into the affected lump and cells extracted & examined under microscope. Sometimes we have to make a cut into breast and remove the suspicious lump for biopsy.
 
TREATMENT: Successful treatment depends on various factors, such as age of the patient, menopausal status, size of breast, size of lump, pathological type, hormone receptor status of cancer, stage of cancer, etc.

Cancer Stages

Initial stage (Stage 1 & 2): Lump is less than 5 cm in size and movable lymph nodes (glands) in armpit. At an early stage, if there is small lump in a large breast , then no need to remove whole breast, we can do removal of lump only (wide local excision). In other cases we have to remove the entire breast (mastectomy), same time we also remove the glands from the armpit. Following the surgery, depending upon the histopathology report and hormonal status of the tumour, Radiotherapy, chemotherapy or hormone therapy is given to control the spread of the tumor to other parts of the body. Women who undergo excision of breast in early breast cancer, we can reconstruct an artificial breast.
 
Stage 3: Here breast lump is large in size and fixed to the skin, chest wall and fixed glands in the arm pit. In these cases, first we give chemotherapy to decrease the size of lump, then surgery and finally radiotherapy and hormone treatment.
 
Stage 4: Features of tumor spread to liver, lungs, bone and brain. We cannot cure it, we can offer only palliation in the form of pain management, removing fluid from abdomen, chest to make patient life comfortable, some time we give palliative chemotherapy or surgery or radiotherapy or hormone treatment.
 
SELF EXAMINATION: Breast self examination is the key to early detection of breast cancer if detected earlier we can cure it with modern  treatment.

Body hormones have constant influence in the day to day changes in the breast, breasts are lumpy, swollen and the painful just before the menstrual period, best time to examine the breasts is 4 to 5 days after the periods.

Looking should be done in the front of a mirror, check for any change in size and shape of breast, changes in skin, nipple size and shape.

Feeling (palpation) is done in lying down position. Feel right breast, raise your right hand behind the head, use the pads of left hand to feel for any lump or mass under the skin, and also gently squeeze the nipple for any discharge and finally check arm pits for any glands. Same examination is repeated in the left breast using right hand. Remember, any change in the breast should not be ignored. It merits a visit to the specialist to set your mind at rest. Never wait and worry.
 
NON CANCEROUS CONDITIONS OF BREAST:

Fibro adenoma: These are non cancerous tumors which appear in young women, in between the age group of 15-25 years.  Most of these lumps are 1-2 cm in size & rarely do they grow beyond 5cm. These are firm, smooth to feel & very mobile (movement) inside breast tissue. If a breast specialist rules out cancer by clinical examination, ultrasound scan & biopsy, no need for excision of the tumor.

Breast pain: This is a common symptom affecting 70% of women, usually it occurs 1-2 days before the menstrual period, and it is due to hormonal changes in the body. Sometimes it is related to chest muscle or rib cage. Once breast specialist rules out cancer these can be managed by medicines.

Nipple discharge: This can present at any age. It may be watery, greenish, and blackish or blood. Blood stained  discharge from the nipple may be an early sign of breast cancer, it is always better to take the opinion of a breast specialist.

Breast Abscess: Commonly seen during lactation (breast feeding). Patient can have fever, swelling, redness etc. in initial stages the infection settles down with antibiotics but a well formed abscess needs and operation. In non lactating woman, breast abscess may be sign of breast cancer. It is advisable to take the opinion of breast specialist in these cases.

KEY POINTS

1. Breast cancer is the second most common cancer in Indian women and magnitude of the problem is increasing in India.
   
2. By self examination of the breast, cancer can be detected in early stages and can get cured by modern treatment.
   
3. If a woman notices any change/problem in the breast, without any hesitation should contact a breast specialist.
   
4. Any lump in the breast need not be a cancer. Never wait and worry, always take the opinion of a breast specialist.

Author: Dr. Venkatesh Sanjeeva- Mangalore