By Dr. Dineshani Hettiarachchi
Breast Cancer Awareness Month is commemorated worldwide during the month of October every year to raise public awareness and action for early detection, prompt diagnosis, treatment, and survivorship care for patients with breast cancer. To mark the event, The Sunday Morning Brunch spoke to National Cancer Control Programme Acting Consultant Community Physician Dr. E.H.K. Fernando and National Cancer Control Programme Medical Officer Dr. Dulanjani Galappaththi.
How common is breast cancer?
Breast cancer is the most common malignancy in women around the world as well as in Sri Lanka. More than 2.26 million new cases of female breast cancer were reported in 2020. The Global Cancer Observatory (GLOBOCAN) identifies breast cancer as the most common cancer in women, accounting for 25.1% of all cancers. Out of all new cancer cases detected annually, 6.9% of deaths are from breast cancer.
Breast cancer incidence in developed countries is higher, probably due to well-established early detection programmes, while relative mortality is higher in less developed countries as most cases are detected at late stages. Breast cancer incidence varies widely within regions and countries, likely due to differences in racial and ethnic makeup, health resources, and lifestyle patterns.
In Sri Lanka, breast cancer is the most common female cancer and accounts for approximately 25% of all newly diagnosed cancers detected among females in a single year. More than 4,000 breast cancer cases are reported annually in Sri Lanka. Approximately 12 new cases per day are detected and three persons die each day due to breast cancer. The increasing incidence of breast cancer has been noted over the past 25 years. According to Cancer Registry data, 4,447 new cases had been detected among females in 2019 while 113 cases had been detected among males, stated Dr. Fernando and Dr. Galappaththi.
Why is it important to detect breast cancer early?
Most patients with breast cancer have a very good prognosis if detected and treated promptly at the early stages. In addition to a high cure rate, benefits of early detection include great possibilities of conservative surgery preserving the body image, together with less aggressive treatment options which will lead to a reduction in the cost of care. Also, there is a wide range of treatment options available with better outcomes if detected at an early stage. Unfortunately, most breast cancer cases are detected at late stages, with nearly 59% of detected cases being in the first or second stages of cancer, stated Dr. Galappaththi.
What are the currently available screening methods?
Early detection of breast cancer is facilitated by many factors, emphasised Dr. Fernando. Some of these include;
- Raising public awareness on symptoms and signs of breast abnormalities (be breast aware)
- Self-Breast Examination (SBE)
- Clinical Breast Examination (CBE)
- Radio imaging (screening mammography and/or ultrasonography)
Breast awareness is a part of general body awareness and it’s a process of getting to know one’s own breasts and becoming familiar with their appearance. Being aware of the normal breast will help identify any changes as early as possible.
What are the differences between an SBE and a CBE?
An SBE is the inspection and palpation of the breast once a month by a woman herself and it helps early detection of breast cancer. It is recommended to carry out an SBE monthly, starting from the age of 20.
Clinical Breast Examination on the other hand is done by a trained healthcare worker. It is used as a screening method to detect possible cancers in asymptomatic women and it’s a component of the triple assessment in breast cancer diagnosis in symptomatic women.
A detailed history with a thorough examination provides important information. It is recommended to undergo a clinical examination every three years for women between 20-40 years and annually after 40 years of age. Clinical examination is done in a covered room with good light in the presence of a chaperone after explaining the procedure to the woman. It consists of inspection and palpation of the breast and axilla after positioning the woman properly.
What is the role of mammography?
Mammography is used for screening and diagnosis of breast cancer. In high-resource countries, mammographic screening programmes are carried out to detect breast cancer early among asymptomatic women. In limited resource settings like Sri Lanka, mammography screening programmes are not cost-effective and it is mainly used as a diagnostic test. However, it could be used as a screening tool in special situations.
How can one carry out an SBE?
An SBE should be conducted at least one week from the onset of menstruation, as some women may feel pain and lumpiness in the breast during menstruation due to hormonal changes. This examination could be carried out at any place convenient to you while lying down, sitting, or standing.
This consists of two components; inspection and palpation.
Inspection – Stand in front of a mirror exposing your chest up to the waist and look at your breasts through the mirror with your arms hanging by your side, hands pressed over the waist, and arms raised above your head.
Pay attention to the size, contour, shape, and symmetry of your breasts. Skin changes include erythema, dimpling, tethering, puckering, eczematous skin changes, or visible lumps. Observe the position of your nipple, and any inversion, retraction, erythema, ulceration, or discharge.
Palpation – This is done using the palmar surface of the middle three fingers. When examining your right breast, raise your right arm over your head and palpate using your left hand and vice versa. Continue palpating the breast in a clockwise direction from the outer circle of the breast towards the nipple using three pressure levels (superficial, intermediate, and deep). Then examine your armpits and look for lumps. Check whether there is a nipple discharge by squeezing the areola using your thumb and middle finger. Use the same techniques for both breasts.
Once the examination is completed, note down the changes identified during inspection and palpation. As mentioned above, focus on the changes in skin, colour, shape, orange peel appearance of the breast, ulceration, nipple discharge, inverted nipple, breast lump with the position, and lumps in the armpit or around the neck, stated Dr. Fernando.
What should you do if you detect a lump?
If any abnormality is detected during an SBE, it is necessary to consult a doctor even though all changes you detect may not be due to breast cancer.
Once a lump is identified, a triple assessment is conducted to confirm the diagnosis of breast cancer. Triple assessment includes a clinical assessment with history and CBE, radiological assessment with mammogram or ultrasound, and if necessary, MRI. It also includes a pathological assessment with non-excision biopsy, Fine Needle Aspiration Cytology (FNAC), or core biopsy.
Following these procedures, a definitive diagnosis can be made to conclude whether it is a breast cancer or a benign lesion like a fibroadenoma, cystic breast disease, etc. Treatment modalities depend on the type and spread of the cancer and grading and staging of the cancer are very important.
Treatment for breast cancer is essentially multimodal. Local disease is treated with surgery or radiotherapy or a combination of both. Systemic disease is treated with chemotherapy, endocrine therapy, targeted therapy, or combinations.
What are the risk factors and how can one minimise them?
A risk factor is any factor that increases your risk of developing a specific disease. Most of the important risk factors for breast cancer are beyond our control and they are called non-modifiable risk factors. These are female sex, age, and family history of the disease.
Risk factors which could be somewhat controlled are called modifiable risk factors. These include lifestyle factors such as obesity, unhealthy diet, lack of physical exercise, and use of tobacco and alcohol. Women who are obese have a higher risk of developing breast cancer.
Major risk factors include being a female (although males can also develop breast cancer, it is about 100 times more common among females), increasing age (over 80% of all female cancers occur among females over 50 years with a peak incidence of breast cancer in Sri Lanka between 50-60 years), family history of breast cancer (women who have first degree relatives with breast cancer have two-to-three-fold higher risk of getting the disease), genetic factors (BRCA 1, BRCA 2 genetic mutations), and familial syndrome (If relatives from the maternal or paternal side have breast or ovarian cancers, the risk of developing breast cancer is high).
Minor risk factors include exposure to oestrogen and progesterone for longer periods during one’s lifetime, early menarche (before 11 years) and late menopause (after 55 years), and nulliparity (never having a child) or having the first child after 30 years. Exogenous oestrogen and exposure to ionising radiation are considered risk factors for breast carcinoma. Fibrocystic diseases and epithelial hyperplasia are benign entities in the breast which are known to be associated with a minor risk of getting breast cancer. Studies have shown that breast augmentation surgery also increases the risk of developing breast cancer.
Consuming a healthy diet and getting more exercise to maintain an ideal Body Mass Index (BMI) may help you to lower the risk of developing breast cancer. In addition, research shows that even those with ideal body weight could further lower the risk of breast cancer by engaging in regular physical exercise. Breastfeeding is also considered a protective factor against breast cancer.
What are the facilities available in Sri Lanka for the early detection of breast cancer?
Breast cancer prevention and control begins with health promotion and involves multiple disciplines. There are several services available in Sri Lanka that facilitate the process of breast cancer prevention, control diagnosis, treatment, and palliative care.
Early detection of breast cancer by screening and diagnosis is provided at Cancer Early Detection Centres (CEDC), Healthy Lifestyle Clinics (HLC), and Well Woman Clinics (WWC) at the ground level. Designated breast clinics/surgical clinics available in teaching hospitals, provincial and district general hospitals, base hospitals, and a few private hospitals in the country also cater to these patients. Some breast cancer screening services are provided by Non-Government Organisations, community-based organisations, workplace settings, and general practitioners.
The CEDC of the National Cancer Control Programme is situated in Narahenpita, Colombo 5 and there are three more centres established in Jaffna, Matara, and Rathnapura. These centres function as walk-in clinics where any person can attend the clinic with or without a referral and obtain services on weekdays from 8.30 a.m. to 3.30 p.m. CBE, ultrasound scans, and mammogram facilities for high-risk categories are available free of charge at the CEDC and health education is also imparted at an individual level by a trained healthcare worker.
There are more than 1,000 functioning HLCs, mainly located at primary-level hospitals, and approximately 900 WWCs conducted by Medical Officers of Health all over the country providing screening services for breast cancers.
There are 22 breast clinics attached to teaching and provincial or district general hospitals in Sri Lanka conducted by a general surgeon or an oncological surgeon. These breast clinics function on certain clinic dates scheduled by the hospital and patients can be referred to these clinics with a referral from a doctor or a trained healthcare officer.
There are 24 oncology units in the country which deliver specialised care to patients with breast cancer. Furthermore, there are nine centres of excellence for cancer in each province which provide all screening, diagnostic, treatment, and palliative care services for breast cancer patients.
What is your take-home message?
Early detection saves lives! Hence, be alert, do your SBE, and consult a doctor if you detect any changes in your breast. Early detection leads to prompt treatment, resulting in a complete cure, concluded Dr. Fernando and Dr. Galappaththi.