Thanks to Angelina Jolie, breast cancer awareness in on the increase since news of her preventive mastectomies made headlines in mainstream press and media. Because her mother died of ovarian cancer, she decided to have herself genetically tested and learnt that she was at 65 percent risk of developing breast cancer and 50 percent risk of developing ovarian cancer as she had the BRCA mutation that translates into an increased genetic risk of developing breast cancer. She decided along with her doctors to opt for a double mastectomy followed by reconstructive surgery to eliminate her risk of developing breast cancer.
If you have family history of breast cancer in particular, but also ovarian, cancer, which means that your mother and/or one other close female blood relative had this disease, you are at greater risk of developing that cancer. So what can you do about it? Accept the additional risk as your fate? Not any longer, since there are so many preventive options that can help you as well as treatment options if you have been diagnosed. Statistics show that breast cancer incidence has tripled in 20 years. At the same time new treatment options mean that there is a 95 percent chance of survival, depending on complications, stage at which cancer has been discovered and treatment taken. However, genetic factors are only implicated in around 10 percent of breast cancer cases.
Should you get tested for gene mutations?
This may not be possible for everyone; however, doctors do advise that those who do have a family history of breast cancer, with at least two close relatives suffering from the disease, should undergo regular testing and screening to catch the cancer, if it develops, at an early and treatable stage.
Everybody may not be able to afford genetic testing for BRCA1 and BRCA2 markers – the test costs $3,000. And usually insurance does not cover the cost of the tests. However, if you have a serious family history of breast cancer, and even if your insurance does not cover it, you should give it serious consideration, more specially if there are other factors that increase your cancer risk.
Apart from genetic testing, which is usually done only by those who have risk factors for developing the disease, women ought to go for regular mammograms, which are now accompanied by ultrasound of the breasts. This is ideally done annually. However, doctors also advise a monthly self-breast examination to check for lumps. Early detection is of great help in detecting lumps and tumors, which may even be benign and not cancerous.
Those who do have genetic mutations or are at increased risk of developing breast cancer may be advised mastectomies, a serious procedure that carries with it attendant risks of surgery as well as down time and recovery time as a preventive measure much like Angelina Jolie. You can opt for reconstructive surgery that may or may not be covered by insurance and also carries with it potential problems and longer recovery times. However, doctors are divided on this option as many think that even with genetic problems there is no guarantee that the person will actually get the disease. And surgery carries with it attendant risks, which are not minimal.
But surgery is not the only option. Some doctors may advise treatment with tamoxifen or raloxifene instead of surgery as these medicines have shown to significantly reduce the risk of getting the disease, if you have the gene mutation. Tamoxifen is also given post breast cancer diagnosis and surgery as part of the treatment, and it has shown to help prevent recurrence and reduce mortality rates in those who have estrogen positive breast cancer, particularly if taken for ten years instead of the earlier recommended five.
Is treatment too aggressive?
Each person is a different individual, and each cancer is different in different people. While individualized therapy for cancer treatment has still to find its way, the fact of the matter is that depending on the patient’s age, family history, stage of cancer and other variables, even among the treatment options available there has to be degree of customization, so that the treatment tackles the disease and has a favorable outcome for the patient.
Unfortunately, it is not like all oncologists are in agreement on the best possible treatments for breast cancer patients. It is matter of luck what kind of therapy you get, so you are advised to very carefully go through many treatment options and have your research in place. If you are not happy with your doctor or the line of treatment recommended, you should certainly seek a second opinion. There are some doctors who even advise surgery or mastectomies for women who have benign lumps or very early stage problems, which may actually never even develop into cancer.
Treatment options after diagnosis
What kind of surgery?
Doctors have always been divided on the kind of surgery early stage breast cancer necessitates. At the outset they recommended complete and radical mastectomy followed by chemotherapy and/or radiotherapy even when small lumps were involved. The surgeries involved removing even the lymph nodes. Then in the 80s or thereabouts it was more usual to simply have a lumpectomy, a procedure that removed only the affected lump along with some breast tissue. This, in effect, saved the breast.
In recent years, research points out that mastectomy is a better option as breast cancer often metastasizes. Some doctors prefer very aggressive treatments to prevent the cancer from spreading, which sometime may happen after a few years of treatment. However, the jury is still out and cancer treatment also depends on the location of the cancer, at what stage it has been discovered, how far it has spread and also your own health and psychological make-up. Some women may want to conserve their breasts as far as possible, while others may want to get rid of them to reduce the risk of recurrence or metastasis.
Among the surgical possibilities for breast cancer are:
• Lumpectomy – this involves removing the lump and some surrounding tissue. Usually this is followed by chemotherapy and radiation, sometimes both.
• Quadrantectomy – as much as a quarter of the breast tissue is removed. This is a more serious surgery than a lumpectomy.
• Complete mastectomy – this removes all the breast tissue, sometimes both breasts, even if cancer is only detected in one, but leaves the lymph nodes.
• Skin-sparing mastectomy – this leaves the breast skin behind, so the woman can opt for breast reconstruction surgery along with the surgery.
• Modified radical mastectomy – the breasts and the underarm lymph nodes are removed.
• Radical mastectomy – the complete breasts along with maxillary lymph nodes and pectoral muscles on the chest wall are removed. Usually this is done when tumors are large, though this surgery is done only when absolutely unavoidable.
Which surgery is best suited for you depends on a host of factors but more especially on the extent of the cancer and your physical health, age as well as the necessity for further treatment like chemotherapy and/or radiotherapy. Sometimes chemotherapy is given before surgery to shrink the tumor and allow for less breast tissue to be removed.
Apart from different types of radiation (internal and external) and chemotherapy, breast cancer patients may be given additional therapies like hormone treatments including estrogen, tamoxifen or aromatase inhibitors. Among other promising treatments are:
• PARP inhibitors that are used for women who have cancer caused by BRCA mutations. However, this may not be very effective in the long term as studies suggest.
• Monoclonal antibodies, which are given by infusion and target substances in cancer cells that help them grow. These drugs include Trastuzumab, Pertuzumab and Ado-trastuzumab emtansine.
• Tyrosine kinase inhibitors work in a different way – they block signals that the cancer cells require to grow. Lapatinib is a tyrosine kinase inhibitor.
These drugs are only given to women who have been tested to be positive to the effects of the drugs. They are often given in combination with other therapies.
Diet and nutrition – taking care of your health
Diet, nutrition and exercise, getting enough vitamins, mineral and other micronutrients, specially from food sources helps increase immunity levels. Stress, too, plays its part and relaxation therapies or even a simple slowing down of life or doing something you love and keep your mind occupied may lead to a lowered risk of cancer. Those who eat a lot of fast and junk foods may be overweight and high fat meals also contribute towards obesity which is a risk factor in cancer. Smoking and drinking, substance abuse and even living or working in a contaminated or polluted environment also ups the risk of developing cancer.
Exercise is vital and not only for physical fitness. Exercise releases endorphins that are feel good chemicals in the brain and help keep stress levels down. A recent research study published in the Journal of Cancer Epidemiology, Biomarkers & Prevention, May 2013 issue, followed 391 women between 18 and 30 years of age. Some women led an inactive life, while others were assigned to an exercise intervention group that did 30 minutes of aerobic exercise five times a week. The study took place over 16 weeks.
The women were tested after 16 weeks and results showed that aerobic exercise had a beneficial effect because it changed estrogen metabolism in pre-menopausal women. The women who exercised had higher levels of good estrogen and lower levels of bad estrogen after 16 weeks, while the ratios of the women who did not exercise remained the same.
Exercise is so important that even after diagnosis of breast cancer and following surgery and other treatments, women are advised to incorporate exercise into their daily routine, though the exercises may be different or not as strenuous depending on their individual health.
A diagnosis of cancer is distressing in any case, whichever part of the body it occurs. But when it is breast cancer, it has an even more negative impact because breasts are associated with women’s self-esteem and body awareness. And if the breasts have to be completely removed via surgery, it is even more important to seek some psychological and emotional support.
Various studies have found that psychological support actually improves immunity levels and lowers stress levels. This has a direct impact on the physical health. Some studies have shown that psychological help can actually reduce the incidence of breast cancer recurrence. If you have been diagnosed with breast cancer or have already undergone surgery, you need to be aware of the importance of this kind of intervention, apart from having a positive mental attitude.
If you do not want one-to-one psychological counseling, you can opt for support groups in your area. When even those are not a feasible option, there are many web-based support groups and forums. It is also important to reach out to family and friends as a loving and nurturing environment will benefit you physically and emotionally.
Men and breast cancer
There are a small percentage of men who also suffer from breast cancer. It is not necessary that men have to suffer from gynecomastia or enlarged breasts to get this disease. Even men without much breast tissue can get breast cancer, though it is usually diagnosed at a later stage and often in men above 60 year of age.
Some men may be genetically predisposed towards breast cancer. Environmental factors, diseases that cause higher levels of estrogen in the body, or naturally occurring higher levels of estrogen all play a part in breast cancer in men. Survival rates of men with breast cancer are similar to those of women. Treatment for male breast cancer is similar to that of women suffering from breast cancer.
A study carried out in U.K. led by Prof Mansel, of the University Hospital Llandough, and professor of surgery at Cardiff University’s School of Medicine (Institute of Cancer and Genetics) that covered 5,000 women suffering from breast cancer showed that less invasive surgery was equally successful in preventing a recurrence. Women, who had mastectomies, but not removal of the lymph nodes, were successfully treated by radiotherapy for the lymph nodes instead of undergoing more serious surgery. Cancer occurring in the lymph nodes after radiotherapy was only one percent, which is a miniscule percentage. Radiotherapy is a less painful and more cost effective solution to breast cancer that has spread to even some lymph nodes.
But why does breast cancer occur in the first place? Apart from genetic factors that play an important role, there are others who have no family history of cancer, but still suffer from breast cancer. Often nutritional, diet and lifestyles play an important role in the lives of those affected by this disease.
A collaborative study carried out by Dr. David Gilley at the Indiana University School of Medicine, IN and Dr. Connie Eaves at the British Columbia Cancer Agency’s Terry Fox Laboratory in Vancouver, Canada that breast precursor cells have very short telomeres pointing to the fact that certain cell types have a built-in predisposition towards cancer. These luminal progenitors that show telomere malfunction point to the cellular origin on cancer. While this study, published in Stem Cell Report is peer reviewed, it helps improve understanding of cancer and may lead to various different kinds of treatment.
2) National Institutes of Health
3) National Cancer Institute