Whether you or a loved one is worried about developing breast cancer, has just been diagnosed, is taking breast cancer treatment, or is trying to stay well after treatment, this detailed information can help you to find the answers you are looking for.
We spoke to National Cancer Control Programme Director and Consultant Community Physician Dr. Janaki Vidanapathirana and National Cancer Control Programme Consultant Community Physician Dr. Upuli Perera to create awareness around breast cancer during the month of October and beyond.
Breast cancer is the commonest malignancy among females in Sri Lanka and the world. It accounts for 27% of all female cancers. An average of 4,000-4,500 new cases of breast cancer patients are diagnosed every year, and there is an increasing trend of breast cancer incidence over the past 25 years in Sri Lanka. If detected and treated early, breast cancer can be cured with minimal complications with a high five-year survival rate. Early treatment would result in greater possibilities of conservative surgery preserving body image and less aggressive treatment options, leading to better quality of life of survivors.
Risk factors for breast cancer
The specific cause for breast cancer is unknown and there are known risk factors. A risk factor is anything that affects the chance of getting a disease, but not a definitive cause for a disease. Most women who have one or more breast cancer risk factors never develop breast cancer, while many women with breast cancer have no known risk factors. Concerning the development of breast cancer, there are modifiable and non-modifiable risk factors.
Non-modifiable risk factors
Sex: Being a woman is the main risk factor for developing breast cancer. Men can develop breast cancers, but it’s about 100 times more common among women than men. This is probably because men have less breast tissue, as well as less of the female hormones oestrogen and progesterone, which can promote breast cancer cell growth.
Age: Risk of developing breast cancer is higher when someone gets older. Over 80% of breast cancers reported in Sri Lanka are among women of around 50 or 50-plus years of age.
Inheriting some genetic variants: About 5-10% of breast cancer cases are thought to be hereditary, meaning that they are caused by gene defects passed on from a parent.
Family history of breast cancer: Breast cancer risk is higher among women whose close blood relatives (maternal or paternal) have breast cancer or ovarian cancers. Overall, less than 15% of women with breast cancer have a family member with this disease. This means that most (85%) women who get breast cancer do not have a family history.
Personal history of breast cancer: A woman with cancer in one breast has an increased risk of developing a new cancer in the other breast or in another part of the same breast.
Modifiable risk factors
These are lifestyle-related factors.
Being overweight or obese: Being overweight or obese increases breast cancer risk. After menopause (when the ovaries stop making oestrogen), most of a woman’s oestrogen comes from fat tissue. Having more fat tissue after menopause can increase the chance of getting breast cancer by raising oestrogen levels.
Alcohol consumption: Drinking alcohol is clearly linked to an increased risk of breast cancer. The risk increases with the amount of alcohol consumed.
Tobacco use: Smoking tobacco increases the risk of getting breast cancer.
In addition, another modifiable risk factor, which is less risky than the above, is prolonged lifetime exposure to hormones (oestrogen and progesterone), which slightly increases the risk of developing breast cancer. Starting menstruation before the age of 12 and going through menopause after the age of 55 also increases the risk. Taking hormone (oestrogen and/or progesterone)-containing drugs for a long period without medical advice results in a slightly increased risk of developing breast cancer.
Women who have not had children have a somewhat higher breast cancer risk overall. Having had multiple pregnancies and becoming pregnant at an early age reduces breast cancer risk.
There are protective factors as well. Evidence is growing that physical activity in the form of exercise reduces breast cancer risk. Breastfeeding is a protective factor for breast cancer development. The reason for this possible effect may be that breastfeeding reduces a woman’s total number of lifetime menstrual cycles.
Prevention and early detection
Even in most developed countries, breast cancer is the commonest cancer among females. As the cause of breast cancer is multifactorial, prevention may be difficult, and therefore risk-reduction is essential. Therefore, early detection is the main control strategy for breast cancer globally. A number of early detection strategies are implemented in order to identify patients with early stages of cancer.
As one such strategy, “World Breast Cancer Awareness Month” is commemorated during the month of October every year in many countries. Programmes which support early detection, treatment, as well as supportive care for breast cancer survivors are conducted during this month with the objective of increasing public awareness and action for early detection and prompt treatment of breast cancers.
Early detection of breast cancer is encouraged by increasing public awareness on breast cancer, breast self-examination (BSE), and clinical breast examination (CBE).
Breast self-examination
BSE is the inspection and palpation of the breast by the woman herself. Engaging in BSE on a selected date every month is very important for early detection of breast cancer of all women over the age of 20 years. It is better to conduct BSE one week after the beginning of menstruation, as some women feel their breasts are painful and lumpy during menstruation. If not menstruating, a convenient fixed date should be selected. This procedure takes little time and can be incorporated into routine life activity. It can be carried out in any place that is comfortable, ensures privacy, and has a mirror.
Steps of BSE
There are two components in a BSE: Inspection (preferably in standing position) and palpation (either lying down, sitting, or standing).
- Inspection: Stand in front of the mirror exposing the chest until the waist. Look at the breasts in the mirror, while keeping the arms in positions (see Figure 1).
Note any:
- Changes of the breast skin
- Colour changes of the breasts
- Change in shape of the breasts
- Orange peel/peau d’orange appearance of the breast
- Ulceration on the breast
- Late occurrence of breast asymmetry (most women may have asymmetry in normal circumstances. Therefore, long-standing breast asymmetry is not a sign of a cancer)
- Nipple changes, discharges other than breast milk/inverted nipple (having inverted nipples from birth is not a sign of a cancer)
- Breast lump, change in the texture, thickening of the breast skin
- Lumps in the armpit or around the neck
- Palpation of the breasts
Palpate the breast using the three centre fingers to identify thickened areas and/or lumps. Use the palmar surfaces of the fingers (flat surface of the three middle fingers). Palpation of the breast can be done in sitting or lying down positions. When examining the right breast, raise the right arm over the head and palpate the right breast using the left hand. While examining the left breast, raise the left arm and palpate the left breast using the right hand (see Figure 2). If palpating in a lying down position, to palpate the right breast, keep the right palm beneath the head and palpate the breast using the left hand; for the palpation of the left breast, keep the left palm under the head and palpate with the right hand.
Continue palpating the breast in a clockwise direction from the outer circle of the breast towards the nipple using three pressure levels. Start with applying “minimal” pressure as indicated (to feel the area just beneath the skin) and then gradually increase the pressure (to feel the tissue deeper within) (see Figure 3).
At the end of the breast palpation, find out whether there is nipple discharge by squeezing the areola using the thumb and middle finger (Figure 4). Then examine the armpit and look for lumps. Use the same technique to examine the other breast.
If any abnormality is detected during a breast self-examination, it is necessary to consult a doctor even though all the changes may not be due to breast cancer.
Efforts towards accelerating screening and early diagnosis
The National Cancer Control Programme is the national focal point for cancer prevention and control and has identified prevention and early detection as one of the key strategies to control cancer in the National Strategic Plan on Prevention and Control of Cancer.
The early detection of breast cancer has two components: Screening and early diagnosis. The screening consists of testing healthy individuals to identify those having cancers before any symptoms appear, and early diagnosis focuses on detecting symptomatic patients as early as possible.
Well Women Clinics and Healthy Lifestyle Clinics provide services for breast cancer screening, health education, and clinical breast examination. In addition, breast clinics are situated in hospitals, from government base hospitals to gynaecological and surgical clinics of other hospitals, providing opportunistic screening for breast cancers. A decision has been taken to expand these services.
There are many reasons that contribute to late-stage diagnoses. One is the late presentation of patients, as some of the age groups were not covered through the national screening programmes and also due to a delay in the referral of patients with signs and symptoms suggestive of cancer from the first contact point up to diagnosis and treatment.
Considering these important facts, the National Strategic Plan (2020-2024) of the National Cancer Control Programme, Sri Lanka included the establishment of islandwide Cancer Early Detection Centres (CEDCs) in all provincial hospitals, aiming to avoid some of the delays for all age groups, as a separate activity under the early detection strategy. This decision was further approved at the National Advisory Committee on Cancer Prevention and Control. The objective of CEDCs is to improve early detection of cancers and early referral or required treatment to a dedicated centre with modern diagnostic facilities. The concept of the CEDC was initiated in 2004 by the National Cancer Control Programme (NCCP) of the Ministry of Health.
The first-ever CEDC in Sri Lanka, established with the partnership of the Rotary Club of Colombo, is situated in Narahenpita. It showed many positive results and detected early cancers in the thousands, saving many lives during this period. The idea is to establish a one-stop CEDC in each province with required infrastructure and diagnostics to detect, confirm, and refer, without a long referral pathway.
Any person who wishes to get educated on or screened for cancer can walk into a CEDC, even without being referred. Here, the referral treatment centre would be the same as at provincial hospitals and thus priority would be given to referred individuals. The CEDC facilitates clients to consult a doctor to discuss cancer-related issues including clinical history-taking to identify the risk of cancer, education on risk factors, to obtain guidance on the need to screen and prevent common and preventable cancers, and for individual counselling for risk factor reduction and post diagnosis. Furthermore, it facilitates screening for breast cancer which includes clinical breast examination, ultrasound scanning, and a mammography, depending on the clinical assessment. A demonstration on the correct technique of BSE is provided for female clients.
A CEDC has been established in the Jaffna Teaching Hospital and the establishment of a CEDC in the Ratnapura Teaching Hospital has also been initiated. In addition, another CDEC will be opened in Matara in collaboration with the Palliative Care Trust of Sri Lanka. The establishment of CEDCs in other provincial hospitals is under discussion.
The islandwide establishment of CEDCs at the provincial level would provide equitable cancer early detection services for all Sri Lankans, by minimising the prolonged waiting lists and increasing accessibility to the relevant healthcare services. The establishment of CEDCs is one of the fast-track strategies for early detection of cancers including breast cancer.
The National Cancer Control Programme has initiated many programmes to empower the public. Two live model videos for the public and a clinical breast examination video for healthcare workers were released during this month on breast self-examinations. In addition to that, breast cancer management guidelines were released with partnership of the College of Oncologists and other relevant professional colleges to ensure equal and quality treatment services for all breast cancer patients. Many skills training programmes have been initiated to empower healthcare providers. This is targeted at both public health and clinical healthcare providers for early detection of breast cancers. Additionally, an islandwide virtual training programme for healthcare providers has been conducted jointly by the National Cancer Control Programme and Associations of Breast Surgeons.
