Breast Cancer

Breast Basics

To better understand breast changes, it helps to know what the breasts and lymphatic system are made of. A woman's breast is made of connective tissue, fatty tissue and glandular tissue.

Breasts also have:

  • lobes - sections of glandular tissue
  • lobules - smaller sections of lobes where milk is made
  • ducts - thin tubes that connect the lobes and lobules; milk flows through the ducts
  • from the lobules to the nipple
  • an areola - the dark-coloured area of skin around the nipple, and
  • a nipple - the small raised area at the tip of the breast

Each breast also contains lymph vessels. These are thin tubes that carry lymph and white blood cells to small, bean-shaped glands called lymph nodes. Lymph nodes are found near the breast, under the arm, and throughout the body. They also store disease-fighting white blood cells (lymphocytes).

Lymph nodes and lymph vessels are part of the lymphatic system, which helps the body to fight disease and infection.

Breast Cancer: The Facts

What is breast cancer?2

First of all, cancer is a disease in which cells become abnormal and form more cells in an uncontrolled way. With breast cancer, the cancer begins in the breast tissue. If the cancer cells forms a mass, it's called a tumour (remember, not ALL tumours are cancer). Tissue close to the breast may also be invaded by the cancer cells and it may spread to lymph nodes and other parts of the body.

The most common types of breast cancer are:

Ductal carcinoma

  • this cancer begins in the ducts and grows into surrounding tissues
  • approximately 8/10 breast cancers are this type

Lobular carcinoma

  • this cancer begins in lobules and grows into surrounding tissues
  • approximately 1/10 breast cancers are this type

Breast Cancer in Africa

Breast cancer is the top cancer in women both in the developed and in the developing world. The incidence of breast cancer is increasing in the developing world due to increased life expectancy, increased urbanization and adoption of western lifestyles.3

Breast cancer is a growing health problem in sub-Saharan Africa, with it now having surpassed cervical cancer as the leading cause of death in many countries.4 In sub-Saharan Africa, breast cancer is responsible for one in four diagnosed cancers and one in five deaths in women.5

There is a greater proportion of breast cancers amongst premenopausal women as compared to Westernized countries.6

The problem of breast cancer in Africa is made worse by the lack of standardized diagnostic and treatment programs and that many women delay seeking treatment for symptoms, leading to a large number of cancers being diagnosed at an advanced stage with poor outcomes.7

Coupling this with the limited availability of treatment facilities and resources, it is apparent that a greater focus be placed on education and awareness, primary prevention, early detection and diagnosis.7

Breast Cancer Risk Factors8

What causes breast cancer?

It is not possible to say what causes breast cancer in an individual. However, we do know some features that are more common in women who develop breast cancer. These features are called 'risk factors'.

Doctors have tools to help estimate a woman's personal risk. Some women who get breast cancer have no known risk factors besides age. Many women with one or more risk factors never get breast cancer. So it's impossible to know who will actually get breast cancer.8

Factors that affect a woman's risk of breast cancer include:

  • Age: The strongest risk factor is age. Although breast cancer can occur at any age, risk goes up as a woman gets older. Most women who develop breast cancer are older than 50.
  • Personal history of breast cancer: Women who have had breast cancer in one breast are more likely to get it in the other breast.
  • Family history: Having a mother, sister, or daughter who has had breast cancer increases a woman's risk. The risk is higher if her family member got breast cancer before the age of 40. A woman's risk is also increased if more than one family member on either her mother or father's side has had breast cancer.
  • Inheriting certain harmful gene mutations: - Inheriting changes to certain genes, such as BRCA1 and BRCA2, greatly increases the risk of breast cancer. - Inherited genetic changes account for about 10 percent of all breast cancers.
  • Certain breast changes that are not cancer: Women who have certain types of breast changes, such as atypical hyperplasia, ductal carcinoma in situ and lobular carcinoma in situ, have a higher risk. These changes are found during breast biopsy.
  • Breast tissue that is dense on mammogram: Women whose breasts have more dense tissue than fatty tissue have a higher risk than women of about the same age who have little or no dense breast tissue.
  • Menstrual and reproductive history: You have higher risk if you: - Got your first menstrual period before age 12. - Reached menopause after age 55. - Never had children or had children after age 30.
  • Body weight: Women who are overweight or obese are at higher risk.
  • Drinking alcohol: The more alcohol a woman drinks, the greater her risk of breast cancer.
  • Breastfeeding: Women who breastfeed have a lower risk of breast cancer.
  • Physical activity: Women who are not physically active throughout life may have an increased risk of breast cancer. However, strenuous activity for more than four hours per week may help lower the risk of breast cancer.
  • Taking the hormones oestrogen and progestin: Using menopausal hormone therapy containing both estrogen and progestin for more than five years increases breast cancer risk.
  • Radiation therapy to the chest: Radiation therapy to the chest for the treatment of cancer increases the risk of breast cancer. Risk depends on the dose of radiation and the age of treatment. The risk is highest for radiation treatment used during puberty.

Symptoms of Breast Cancer9

With routine screening, breast cancer often can be found at an early stage, before a woman has any physical symptoms.

  • a lump in or near your breast or under your arm
  • thick or firm tissue in or near your breast or under your arm
  • a change in the size or shape of your breast
  • discharge from your nipple (fluid that is not breast milk)
  • nipple changes, such as a nipple that turns inward (inverted) into the breast
  • changes to the breast skin, areola, or nipple, such as itching, scaling, dimpling or puckering

Keep in mind that most breast changes are not cancer, still, if you notice a change in your breast or pain, call your doctor and schedule a visit

Don't wait until your next check up

Breast Cancer Screening10

Breast cancer screening looks for signs of cancer before a woman has symptoms, which may help find breast cancer early

Two tests are commonly used to test for breast cancer

  • Mammogram: This is a low dose x-ray of the breasts that may find changes that are too small to feel
  • Clinical breast examination (CBE): Your healthcare provider checks the breasts and under the arms for lumps or anything else that seems unusual. Ask your doctor if you need a CBE.

How to do a breast self-examination11

Breast self-examination (BSE) should be done once a month during ovulation (preferably at the same time of day).

Regular screening is the best way to find breast cancer early in most women. If you are at higher risk of breast cancer, your doctor might want to use other tests too, such as a different type of mammogram or magnetic resonance imaging (MRI).

It is important to let your doctor know if you find any changes in your breast, such as a lump or dimpling or puckering of the skin. Although research results do not support an official recommendation that all women conduct breast self-exams, knowing your body is key to pointing out any concerns to your doctor.

  1. In the mirror
    • In front of a mirror, check for any changes in the normal look and feel of your breasts, such as dimpling, size difference or nipple discharge.
    • Inspect four ways: arms at sides; arms overhead; firmly pressing hands on hips and bending forward.
  2. Lying down
    • Lie on your back with a pillow under your right shoulder and your right hand under your head.
    • With the four fingers of your left hand make small circular motions, follow an up and down pattern over the entire breast area, under the arms and up to the shoulder bone, pressing firmly.
    • Repeat using right hand on left breast.
  3. While bathing
    • With your right arm raised, check your right breast with a soapy left hand and fingers flat using the method described under step 2 ('Lying down').
    • Repeat on the other side.

Diagnosis of Breast Cancer12

If a screening mammogram or CBE shows a breast change that could be cancer, additional tests are needed to learn more.

These tests might include:

  • Diagnostic mammogram. This type of mammogram uses x-rays to take more detailed images of areas that look abnormal on a screening mammogram
  • Ultrasound exam. Sound waves help your doctor see if a lump is solid (could be cancer) or filled with fluid (a fluid-filled sac that is not cancer)
  • Magnetic resonance imaging (MRI). Radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the breast. MRI may be used if enlarged lymph nodes or lumps are found during a clinical breast exam that are not seen on a mammogram or ultrasound
  • Breast biopsy. Fluid or tissue is removed from the breast and checked for cancer cells There are many types of biopsy. A biopsy is the only test to find out if cells are cancer

Not all women who have abnormal screening test results need to have a biopsy. Sometimes, doctors can rule out cancer based on the results of follow-up tests without biopsy.

Finding out about "abnormal" breast changes can be scary. Talk to your doctor about what tests you might need and what the test results mean. If you learn that you have cancer, your doctor will help you move forward and begin treatment.

What is a triple assessment?13

A triple assessment is a combination of three tests, i.e. clinical examination, radiological imaging (mammography, ultrasonography) and pathology used to accurately diagnose all palpable breast lumps. A triple assessment means that every lump or symptoms is investigated and managed in the same rational manner.

  • Clinical examination: You doctor will spend some time examining you in order to determine if there is an abnormality. They will look at you to see if there are any breast changes you can see such as skin thickening, nipple changes, or dimples in the breast. After that your doctor will feel the breasts, in the same way as in breast selfexamination. They will feel into the axilla and all over the breast looking for lumps or pains. It is also important to look at the nipple carefully, looking for any discharges or abnormalities. Often your doctor will do a full clinical examination to check for any other changes or abnormalities, including taking your blood pressure. If you do have a lump or abnormality identified your doctor will discuss what that means. Any clinical examination is always accompanied by imaging which is the next step.
  • Radiology examination: This is imaging done by a specialist radiologist, and double read by a second radiologist to ensure nothing is missed. Normally this includes a mammogram with at least two views (but sometimes more) and an ultrasound of the breast and armpit. Often in women under 35 years the breast is often too dense to rely on mammograms to see problems so an ultrasound is done alone. Newer methods of diagnosis such as MRI scan may also be useful in some cases.
  • Pathological diagnosis: If there is a lump present, the radiologist may wish to do a core needle biopsy. This is best done by the radiologist because they use X-ray or sonar guidance. The old technique of Fine Needle Aspiration (FNA) should not normally be used because it can be inaccurate and not give enough information to the doctor. It is also rare to require a full surgical biopsy in theatre and it is often not the best method of diagnosing cancer as it affects further treatment. This sample will be sent to a pathologist who will cut the sample into small slices and stain them especially to allow easy identification of any abnormalities or cancers.

Treatment Options for Breast Cancer

Breast cancer treatment often involves more than one approach. The treatment plan suggested by your doctor will be based on several factors, e.g.:

  • the stage of cancer, based on:14 - the size of the tumour - whether the cancer has spread to nearby tissue - whether the cancer has spread to nearby lymph nodes or other parts of the body - the type of breast cancer you have
  • whether you have reached menopause14
  • your general health14

Staging15

Staging is made on clinical and laboratory findings. Staging systems are used to classify breast cancer, so that the doctor can treat the disease with a logical basis.15

The most commonly used staging system is the TNM staging system, where
T = tumour size,
N = nodal status, and
M being used to determine metastatic disease which is when cancer has spread beyond the breast and regional lymph nodes to the rest of the body.25

There are four stages of cancer:15

  • stage one and two cancers are early;
  • stage three cancers are locally advanced (large breast cancers greater than 5cm) and
  • Stage four cancers have spread to elsewhere (M+).

Management of breast cancer treatment and their side-effects

All breast cancer patients should be managed in a multidisciplinary team, ensuring that coordinated patient-centred decisions are made. International guidelines, in conjunction with multi discipline expertise ensure a high standard of individualized patient care.16

The core members of a multidisciplinary team include: breast surgeons, breast care nurses, radiologists, pathologists, oncologists (medical and radiation), plastic and reconstructive surgeons, physiotherapists and psychologists.16

Breast cancer is both a local (specific to the breast) and systemic (whole body) disease. Although in its early stages it is confined to the breast alone, it can metastasize (spread) via the lymphatic system to other parts and organs of the body.16

Survival in breast cancer is dependent on both adequately treatment the breast to ensure removal of the disease and preventing recurrence as well as predicting the risk of the cancer metastasizing and ensuring various combinations of systemic treatment.16

There are different types of treatment for patients with breast cancer. Five types of standard treatment are used17 , which fall under two main categories: local treatment and systemic treatment. Local treatment is concentrated on a specific part of the body, while systemic treatment treats the whole body.

  • Local treatment
    • Surgery
    • Radiation therapy
  • Systemic treatment
    • Chemotherapy
    • Hormone/Endocrine therapy
    • Targeted therapies

During cancer management, the patient will have at least one local and one whole body or systemic treatment but they might require all of the different treatment methods, depending on the type of breast cancer and the advice of the specialists.18

For many women, breast cancer does not come back after treatment. For some women, breast cancer comes back after a period of time when it could not be detected. This is called recurrent breast cancer. It may return close to the location of the original tumor or in another part of the body. Treatment options depend on where the cancer returned.19

Surgery

The aim of surgery is remove all the cancer from the breast.20 Most patients with breast cancer will have surgery to remove the cancer.21

Sentinel Lymph Node Biopsy22

Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node where the cancer is likely to spread. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. After the sentinel lymph node biopsy, the surgeon removes the tumor using breast-conserving surgery or mastectomy. If cancer cells were not found in the sentinel lymph node, it may not be necessary to remove more lymph nodes. If cancer cells were found, more lymph nodes will be removed through a separate incision. This is called a lymph node dissection.

Types of surgery include:

  • Breast Conserving Surgery

    This involves removing the breast cancer and some normal tissue around it, but not the breast itself. Part of the chest wall lining may also be removed if the cancer is near it. Some lymph nodes under the arm may also be removed. This type of surgery is called lumpectomy, partial mastectomy, quandrantectomy, or breast-sparing surgery.23

    The surgeon will consider this option if the cancer is small, or because the breasts are large enough to allow a big area to be removed.24

  • Mastectomy

    Mastectomy is surgery to remove the whole breast that has cancer. Some of the lymph nodes under the arm may be removed and checked for cancer. This may be done at the same time as the breast surgery or after and is done through a separate incision.25

  • Axillary lymph node dissection

    If the cancer has spread to the glands, all of the glands under the arm will need to be removed. Most often an axillary dissection is done at the same time as the breast operation, through the same cut or a different one. If the sentinel lymph node biopsy is negative however, an axillary lymph node dissection may not be required.26

  • Reconstruction

    Breast reconstruction involves rebuilding a breast shape after breast surgery. This does not interfere with the treatment of breast cancer.27

    Breast reconstruction may be done using tissue from other parts of the body to reconstruct the breast. Surgeons may also use prostheses, made of materials such as silicon, to give shape to a breast if there has been a mastectomy.28

    Breast reconstruction is an important part of the treatment offered and helps to restore a patient's dignity and psychosexual normality. Every patient undergoing breast cancer surgery should be offered a consultation with a dedicated breast reconstructive surgeon to discuss the various options and timing for the individual patient's reconstruction irrespective of funding.29

    The timing of the reconstruction is dependent on many factors but most patients will be offered an immediate breast reconstruction (at the time the tumour is removed from the breast or the mastectomy is performed)29

Side Effects of Surgery30

  • Pain, discomfort or numbness in the breast and/or armpit while the wounds are healing.
  • Bruising or swelling around the wound in the breast (or under the arm of the lymph nodes have been removed)
  • Stiffness in the arm or shoulder
  • Tingling in the arm or shoulder if the lymph nodes have been removed
  • Seroma - where fluid may collect in or around the scar in the breast or armpit.
  • Lymphoedema - if lymph nodes have been removed from the armpit, there might be swelling in the arm, breast, hand or chest after the initial side effects of surgery are over.
  • Lymphoedema can develop a few months or years after surgery.
  • Infection or bleeding in the scar in the breast or armpit; some women may need further surgery.
  • Cellulitis - an infection of the skin caused by bacteria.

Radiation Therapy or Radiotherapy

Radiotherapy uses X-rays to destroy cancer cells that may be left in the breast, chest or armpit after breast cancer surgery. Radiotherapy is a localized treatment, which means it only treats the area of the body it is aimed at.31


There are two types of radiation therapy:32
- External radiation therapy, which uses a machine outside the body to send radiation toward the cancer
- Internal radiation therapy, which uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer

Radiotherapy to the breast is recommended after breast-conserving surgery to remove any cancer cells that may be left in the breast and reduces the risk of breast cancer coming back in the breast.33

Radiotherapy to the chest wall is sometimes recommended after mastectomy for women at high risk of breast cancer coming back in the chest wall.33

The timing of radiotherapy depends on when services are available, how quickly the woman recovers from surgery and what other treatments the woman is having. For a woman having chemotherapy, radiotherapy usually starts when the chemotherapy ends. For a woman not undergoing chemotherapy, radiotherapy will usually start after surgery.34

Side Effects of Radiotherapy35

  • Skin changes: The skin of the treated breast can become red and dry like sunburn or may become darker. These changes can begin as early as the second week of treatment and usually improves with time after treatment is over.
  • Fatigue: This is usual during the treatment and for a few weeks after treatment is over.
  • Changes in the shape or size of the breast: The breast may become smaller or larger, and may become firmer during or after treatment.
  • Tenderness or aches in the breast or chest.
  • Peeling or blistering of the skin of the breast towards the end of treatment.
  • Lymphoedema
  • Loss of hair to the treated area
  • Sore throat for women who have undergone radiotherapy to the neck area.

The following side effects are rare but can be quite serious and require consultation with the radiation oncologist:35

  • Pneumonitis: symptoms include dry cough, mild fever, shortness of breath and tiredness.
  • Pain in the ribs: this may be due to rib fracture because the bones have become weakened by treatment.

Skin Care during Radiotherapy36

Women undergoing radiotherapy should have a good skin care routine to reduce skin reactions. It may be helpful to consider the following points:

  • wash with a mild soap or cleanser and use a light moisturizing cream
  • wear sun protective clothes or use sunscreen over the treated area when in the sun
  • avoid irritants - protect the skin in the treated area from damage by abrasion (e.g. shaving with a wet razor), chemicals (e.g. perfumes, deodorants or hair dyes) and temperature extremes during the course of radiotherapy
  • keep skin folds dry

Chemotherapy

Chemotherapy is treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, or infusion, or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy, or biologic therapy.37

Chemotherapy is a systemic treatment because it treats the whole body. Other systemic treatments include hormonal therapies and targeted therapies.38

The aim of chemotherapy is to destroy any cancer cells that may have spread outside the breast or armpit to other parts of the body. It also aims to destroy cells that are left in the breast and armpit area but cannot be detected.38

Chemotherapy works by killing cells that are rapidly dividing, such as cancer cells. As well as killing cancer cells, chemotherapy also kills normal cells that are rapidly dividing, such as cells in the hair and gut. This is why patients can suffer side effects such as hair loss, or gut symptoms such as nausea, vomiting or diarrhea. However, unlike cancer cells, normal cells can repair the damage and recover.38,39

Chemotherapy can be used in addition to other treatments for breast cancer. Not all women with breast cancer will have chemotherapy. The treating doctor will consider a number of things:40

  • the risk of breast cancer coming back or spreading to other parts of the body after treatment - the higher the risk, the more likely it is that chemotherapy will be recommended.
  • whether there are hormone receptors found on the breast cancer cells and the woman is undergoing hormonal therapy - if there are no hormone receptors it is more likely that chemotherapy will be recommended.
  • if the breast cancer is HER2 receptor positive and the woman is receiving treatment with a particular targeted therapy, then it is usual that this will start while the patient is still receiving chemotherapy.
  • general health.
  • patient preference

The timing of chemotherapy will usually depend of what other treatments the patient is undergoing. Usually chemotherapy will start after breast surgery, though some women can have chemotherapy before surgery. If the patient is also undergoing radiotherapy and hormonal therapy, these treatments will not start until chemotherapy is completed.41

Side Effects of Chemotherapy

Chemotherapy drugs can affect women in different ways. Some women may experience fewer or more side effects than other women receiving the same treatment.42 The side effects of chemotherapy drugs depend on what chemotherapy drugs are used and in what combination.43 Most of the side effects of chemotherapy can be managed.42

  • nausea and vomiting42
  • fatigue42
  • hair loss42
  • diarrhoea or constipation42
  • weight gain or weight loss42
  • depression or anxiety42
  • menopausal symptoms (temporary or permanent)42
  • sexual difficulties42
  • mouth ulcers42
  • skin or nail changes or reactions42
  • muscle aches and pains42
  • numbness and tingling in the fingers and toes42
  • swelling in the arms and legs42
  • feeling 'vague' or 'in a fog'42

The following side effects are rare but can be quite serious and require consultation with the oncologist:42

  • infection due to low levels of white blood cells
  • bleeding or bruising
  • kidney or bladder problems
  • heart problems (with anthracycline drugs only)42
  • bone marrow problems42
  • allergic reactions42

Hormone or Endocrine Therapy

Certain hormones, such as oestrogen, can causes certain types of breast cancer to grow.44 Hormone therapy is cancer treatment which removes hormones or blocks their actions and, in so doing, stops cancer cells from growing.45

Breast cancer cells which have hormone receptors on them are said to be 'hormonereceptor positive'. Hormone therapies lower the levels of female hormones in the body, or change the way that the body responds to female hormones, to stop hormone receptorpositive breast cancer cells from growing.46

There are two types of hormone receptors:46

  • oestrogen receptors (ER); and
  • progesterone receptors (PR)

About two thirds of women with breast cancer have hormone receptor-positive breast cancer.46

Hormone therapies reduce the risk of breast cancer coming back (in the breast and other parts of the body) and some hormone therapies have been shown to increase the chance of survival for women with breast cancer. These include hormone therapies such as selective oestrogen receptor modulators, some aromatase inhibitors and removal of the ovaries by surgery.46

Hormone therapies may be used in addition to surgery, radiotherapy or chemotherapy, or on their own.47

There are different treatments used in hormone therapy. The type of treatment used will depend on whether the patient has reached menopause.48

  • Anti-oestrogens
  • Anti-oestrogens work by preventing oestrogen from attaching to oestrogen receptors on cancer cells, slowing the growth of tumours and killing tumour cells.49 Anti-oestrogens that can be used in both pre- and post-menopausal women.49

  • Aromatase Inhibitors
  • Aromatase inhibitors work by stopping the body from making oestrogen after menopause. These drugs block the action of an enzyme that converts androgens in the body into oestrogen.51

    Aromatase inhibitors are only effective for postmenopausal women.52

  • Oestrogen blockers53
  • Oestrogen blockers target oestrogen receptors and work by binding to these oestrogen receptors and blocking the effect oestrogen has on cancer cells. This binding causes the oestrogen receptor to change shape and not work as well, resulting in a decrease in the number of oestrogen receptors in breast cells, so there are fewer receptors available for the oestrogen to act on.

    Certain oestrogen blockers are used to treat hormone receptor-positive metastatic breast cancer in postmenopausal women whose disease has spread after treatment with antioestrogen medicine.

  • Ovarian treatments54
  • Ovarian treatments work by stopping the ovaries from making oestrogen. Gonadotropinreleasing hormone analogues temporarily stop the ovaries from making oestrogen. They only work while a woman is taking the drug. This is called ovarian suppression.

    Oestrogen production can be stopped permanently by removing the ovaries (oophorectomy) or giving radiotherapy to the ovaries.

    Ovarian treatments are only suitable for women who have not yet reached menopause.

Side effects of Hormone Therapies:

Some side effects are common to all hormonal therapies and some only happen with certain therapies. Everyone is different in how they respond to treatment. A medical professional should be consulted if the patient has any concerns. Some of the side effects that a patient may experience with the various hormone therapy options are listed below.55

  • Side effects of anti-oestrogens56
    • hot flashes
    • night sweats
    • vaginal dryness

    More significant side effects include:

    • blood clots
    • uterine cancer
    • stroke
    • cataracts
  • Side effects of aromatase inhibitors57
    • hot flashes
    • night sweats
    • vaginal dryness
    • joint and muscle pain
    • increased risk of bone thinning (osteoporosis)
  • Side effects of oestrogen blockers58
    • injection site reactions
    • increased liver enzymes
    • nausea
    • hot flashes
    • headache
    • vomiting
    • diarrhoea
    • anorexia
    • rash
    • urinary tract infections
    • allergic reactions
  • Side effects of ovarian treatments59

    Surgery to remove the ovaries, or radiotherapy to the ovaries, causes permanent menopause. Women who have these treatments can no longer have children naturally. Drugs that stop the ovaries from working also cause menopause, but this usually only lasts while the woman is taking the drugs. However the effect of these drugs may be permanent if close to natural menopause when starting treatment.

Targeted Therapies

Targeted therapies (sometimes called biological therapies) are drugs used to treat certain types of cancer cells and are only effective for people with certain types of cancer cells.60

A common targeted therapy for early breast cancer belongs to a group of drugs called monoclonal antibodies. This is used to treat HER2-positive breast cancer. In HER2-positive breast cancer, the breast cancer cells have higher than normal levels of a protein called HER2.60

The targeted therapy attaches to the HER2 receptors on the surface of the breast cancer cells and stops them from dividing and growing.61

Side effects of targeted therapies:62

  • heart problems - it is not recommended for women with pre-existing heart problems
  • chills
  • fever

Breast Cancer Follow Up and Care63

Follow-up care after treatment is an important part of surviving breast cancer. Regular follow-up is recommended after treatment for early breast cancer.

Women who have been diagnosed and treated for early breast cancer have an increased risk of breast cancer coming back or developing in the other breast. Regular follow up means that if breast cancer does come back or if a new breast cancer develops, it can be treated promptly.

Follow-up also allows doctors to check for any side effects from treatment and to see how long-term treatments, such as hormonal therapies, are going. It also provides an opportunity for the patient to talk about how they are feeling.

Follow up treatment for breast cancer involved regular physical examinations and imaging tests such as mammograms and/or ultrasounds.

Appropriate follow-up does not involve chest X-rays, bone scans or blood tests unless there are symptoms which suggest that the cancer has spread outside the breast or armpit area or there is a high risk of the breast cancer coming back. Studies have shown that having more tests does not improve the length or quality of life for women who have been treated for breast cancer.

If a patient is receiving a hormonal therapy such as tamoxifen or an aromatase inhibitor, they will have follow-up tests while taking these therapies.

For most women, no changes are found during follow-up appointments. However, if the mammogram or ultrasound shows an abnormal area, or if there is a lump being identified during the physical examination, further tests will be conducted. This may include more imaging tests and a biopsy.

Lymphoedema64

Lymphoedema after breast cancer is a persistent swelling of the arm or breast that occurs due to a build-up of fluid.

During treatment for breast cancer, lymph nodes may be removed from the armpit or breast region by surgery or may be damaged by radiotherapy. This can cause lymph fluid to build up in the arm or breast, causing the arm or breast to swell.

Lymphoedema usually develops gradually. It can develop months or even years after treatment for breast cancer. The risk seems to be higher for people who have undergone both surgery and radiotherapy to the armpit. However, many people who have lymph nodes removed and radiotherapy to the armpit do not develop the condition.

Lymphoedema is not the same as swelling in the breast, armpit or arm that immediately follows surgery or radiotherapy to the breast or armpit.

Signs and symptoms of lynphoedema64

Early signs can include:

  • a feeling of heaviness, tightness or fullness in the arm or breast
  • swelling of the arm, breast or hand
  • aching, pain or tension in the arm, hand, chest or breast area

Management of lymphedema64

The aim of management is to reduce and control swelling, improve the range of movement of the affected area and prevent infections.

  • Skin care: daily attention to the skin is essential as the skin provides a barrier against infection.
  • Exercise: studies suggest that gentle exercise can help to reduce the symptoms of lymphedema by helping lymph to flow through the lymphatic vessels. Exercise can also help maintain a healthy body weight. This is important as excess body weight may slow the flow of lymph.
  • Elevation: raising the limb, for example by supporting the arm on several pillows, can help reduce the symptoms of lymphoedema in the early stages of the condition.
  • Compression sleeve: this is a tightly fitting elastic sleeve worn on the affected arm and can help to reduce the swelling associated with lymphedema. The sleeve stops fluid from building up and moves excess fluid out of the affected area. This may be combined with other forms of treatment, such as manual lymphatic drainage. Compression sleeves should be fitted professionally and should be replaced when they lose their elasticity.
  • Manual lymphatic drainage or decongestive physiotherapy: this is a special form of massage to the affected area. The aim is to improve the way in which the lymphatic vessels are working are reduce the build-up of fluid.
  • Compression bandaging: this is usually done in combination with manual lymphatic drainage to reduce swelling in the breast or to reduce severe swelling in the arm before a compression garment is fitted. It may also be used if the skin is very fragile or damaged. Compression bandages should be replaced daily.

Breast cancer, menopause and fertility65

About two thirds of women who are younger than 50 years of age when their breast cancer is diagnosed will go through menopause because of treatment. This is a common side effect of hormonal therapy and some chemotherapy drugs. Sometimes the menopause is permanent and sometimes it is temporary.

Symptoms of menopause65

  • hot flushes
  • mood changes
  • sleep disturbance
  • vaginal dryness and/or discharge
  • a decrease in libido (sex drive)
  • irregular or no menstrual periods

The closer the woman is to the age of natural menopause, the more likely it is that the menopause will be permanent.

Treatment and infertility65

Some treatments for breast cancer can affect a woman's ability to become pregnant. Some treatments have this effect during the treatment period only, while others have a permanent effect.

This issue should be discussed with your healthcare professional.

Contraception during and after breast cancer treatment65

Treatments for breast cancer may reduce fertility, temporarily or permanently. However, this does not mean that it is impossible to become pregnant during or after treatment.

There is no evidence about whether or not it is safe to take the oral contraceptive or use implants during or after treatment for breast cancer. Women should be encouraged to use non-hormonal forms of contraception such as condoms, diaphragms, intrauterine contraceptive devices or male or female sterilization.

Advanced or Metastatic Breast Cancer

Metastatic breast cancer, also known as Stage IV breast cancer, is a form of advanced breast cancer. When breast cancer metastasizes, it spreads beyond the breast to other parts of the body.66 This usually includes the lungs, liver, bones or brain. 67

The symptoms may vary, depending on how far the cancer has spread and the type of tissue it has invaded.68

Some symptoms commonly associated with breast cancer metastasis may include:

  • Metastasis in the bone:69
    • severe, progressive pain
    • swelling
    • bones that are more easily fractured or broken
  • Metastasis to the brain:69
    • persistent, progressively worsening headache or pressure to the head
    • visual disturbances
    • seizures
    • vomiting or nausea
    • behavioural or personality changes
  • Metastasis to the liver:69
    • jaundice
    • itchy skin or rash
    • abnormally high enzymes in the liver
    • abdominal pain, appetite loss, nausea and vomiting
  • Metastasis to the lungs:69
    • chronic cough or inability to get a full breath
    • abnormal chest x-ray
    • chest pain

Other non-specific symptoms of metastatic breast cancer may include fatigue, weight loss, and poor appetite, however it is important to remember that these can also be caused by medication or depression.69 Speak to your healthcare professional if concerned.

Multidisciplinary Team Approach

The treatment and supportive care of patients with breast cancer involves a number of different medical and allied healthcare professionals, ensuring coordinated, patient-centred decisions.70,71

International guidelines, in conjunction with cross-discipline expertise ensure a high standard of individualized patient care.71

The core members of the multidisciplinary team must include breast surgeons, breast care nurses, radiologists, pathologists, oncologists (medical and radiation), plastic and reconstructive surgeons, physiotherapists and psychologists.71

Evidence indicates that a team approach to cancer care, in which healthcare professionals together consider all treatment options and develop an individual treatment plan for each patient, can reduce mortality and improve quality of life for the patient.70

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