Breast cancer is a kind of cancer caused by uncontrolled growth of cells in breast, normally the ducts and lobules. It occurs in both gender, but seldom in male. In United States, the breast cancer incidence in woman is 1 in 8. It happened because of mutations in the genes responsible for regulating the growth of cells. These mutated cells will then form a tumor by dividing themselves without control. About 90% of breast cancers occur as a result of genetic abnormalities that happen due to the aging process and life in general, but not heredity. There are four stages of breast cancer which refers to how far the cancer cells have spread beyond the tumor cells. Most breast cancers are discovered as painless lumps. The symptoms are breast pain, a lump in the underarm area and swelling of all or part of the breast. So what are the available treatments to treat breast cancer?
Pie Chart 1: Cancers in Malaysian Woman
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A Possible Solution
Figure 1 : Breast Cancer
Surgery is the first best method to be considered to fight with breast cancer. Most patients have surgery to remove the tumor from breast. There are several choices for surgery including the breast-conserving surgery and mastectomy.[2-13] The type of surgery to be carry on the patients depends on the size of cancer in breast, whether it has spread to any other part of body and the personal preference of the patient.
Breast-conserving surgery includes the lumpectomy and partial or segmental mastectomy ( quadrantectomy ).[2,3]
It is the removal of breast tumour and small amount of normal tissues surround it. The scar on the breast is quite small and the scar under the armpit left by removal of lymph nodes cannot be seen from the front. After lumpectomy, all the tissues removed from the breast is examined for the presence of cancer cells are in the surrounding margin of normal tissue.[2-13] Women may choose lumpectomy if :
The tumour is less than 4 cm in diameter
Have a single small tumour
Have a localized area of ductal carcinoma in situ ( DCIS )
It is the removal of a quarter of the breast surrounding the tumour. The scar left is more noticeable, so the patients may need the breast reconstruction after the surgery.
It is said to have positive margins if the cancerous cells are found at any part of the tissue removed whereas negative or clear margins means no cancer cells found at any edges of the tissue removed. The presence of positive margins indicates that some cancer cells have been left behind after surgery. In this case, the surgeon have to carry out more surgery to remove the cancerous tissue. This operation is called a re-excision which means surgically re-opening the lumpectomy site to remove a larger margin of cancer-free tissue. It is necessary to ensure that all cancerous cells are gone when cancer cells are found close to the edge of lumpectomy margin. If it is unsuccessful to clear surgical margins, a mastectomy is needed.
Figure 2: Lumpectomy's Procedure
Breast-conservation therapy has same effectiveness as mastectomy for patients in stage 1 and 2 of breast cancer. Survival rates of women are the same for both surgeries. However, it is not true for the other stages of breast cancer.[1,4] Some of the lymph nodes under the arm of the patients who undergo the breast-conserving surgery are removed for biopsy to be examined by a pathologist. This is necessary to determine whether they contain cancer. This process is called lymph node dissection.
Mastectomy involves removal of the whole breast.
It is the most appropriate treatment for those who have a large lump, a lump in middle of the breast and more than one area of cancer in breast. There are five types of mastectomy : simple or total mastectomy, modified radical mastectomy, radical mastectomy, partial mastectomy, and subcutaneous (nipple-sparing) mastectomy.[2-13]
Simple or total mastectomy
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The entire breast is removed by the surgeon, without removing the muscles from beneath the breast. It is suitable for women with large areas of ductal carcinoma in situ (DCIS) and for women who want to prevent any possibility of breast cancer occurring.
Modified radical mastectomy
It is for those patients who have invasive breast cancer as it involves removal of underarm lymph nodes. The removed lymph nodes is then used to identify whether cancer cells have spread beyond the breast.[ 2,3] Skin-sparing mastectomy can be performed as simple mastectomy or as modified radical mastectomy to provide the skin needed for immediate reconstruction. It preserves as much of the breast skin as possible. Most of the skin over the breast, except other nipple and areola is left intact during this procedure. It is not suitable for larger tumors.
It is the most extensive type of mastectomy where the surgeon removes the entire breast, axillary lymph nodes, and the muscles of chest wall under the breast.[ 2,4,5] As modified radical mastectomy proved to be effective and less disfiguring, so it is rarely done now.[ 3,4]
Subcutaneous ("nipple-sparing") mastectomy
It removes all the breast tissue with nipple left alone. This is followed by breast reconstruction. It is less performed than simple mastectomy because more breast tissue is left behind that could later develop cancer although it leaves less visible scars.[2-13]
Only cancerous part of breast tissue and normal tissues surround it is removed. More tissues is removed in partial mastectomy than lumpectomy although lumpectomy is a form of partial mastectomy.
Patients with early-stage cancers can choose either breast-conserving surgery or mastectomy. However, breast-conserving surgery allows to conserve most of the breast.[2-13]
Figure 3 : Mastectomy
Table 1 : Survival of Patients From Breast Cancer With or Without Surgery
Based on the diagram, the 3-year survival for the patients with clear margins who received surgery was around 35% and 37% compared with that of 17% for those who did not have surgery. It was about 17% for 5-year survival of those received surgical treatment compared to 7% for those without surgical treatment. It showed that the percentage of survival was less for those involved margins, but it was still higher than those without surgery. It can be seen clearly that with surgery, the survival is higher than that of without surgery.
Social and Economic Implications
Some people with breast cancer do not perceive themselves as at a potential risk of getting the disease. They just take the lump in their breast as a normal phenomenon, without knowing it as a symptom of breast cancer. Lack of awareness of breast cancer among these women due to low education level cause them to lose the chance to receive the treatment such as surgery as early as possible to avoid the spreading of cancer cells.
"In South Africa, only 5% of breast cancers are seen in the early phase of disease, whereas in the US, that figure is 50%."
Masilamany, J., Feb 5 2009, pg 12
This will cause the effectiveness of surgery to treat the patients to decrease. Care and help from the public and family are important for the patients with breast cancer as they tend to be suicidal, especially for those in late stages of breast cancer. This is because they feel very depressed and stressful after the treatments as side effect starts to appear. This could lead to serious social impact and would bring great distress and sadness to the people who care them.
Economically, the cost for treatments for breast cancer is extremely expensive. The quote below proves my statement.
"According to a Health Day News report from 2008, the average cost of breast cancer treatment in the US is $20,964.Â This number includes far more than the cost of surgery alone; it also covers hospital fees, chemotherapy, drugs, and any combination of treatment options.Â For the surgeries alone, an article in the American Journal of Surgery in 2001 found the average cost of breast-sparing surgeries to be $4,748 and the average cost of mastectomies to be $6,280, in a study of hospitals between 1996 and 1997."
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Other than the price for treatments such as surgery, the patients might face extra expenses for transportation to and from a treatment center and also the payments for screenings. If the patients had to take time off from work, their income will then be lower, which makes them hard to cover these daily living expenses. This would cause huge financial burden and economic impact to those who have low income or unemployed and their family. In such condition, these patients will refuse to treat themselves.[14-15]
Benefits and Risks
It is a best option for most of the patients to treat breast cancer because they can still preserve large part of their breast with all the cancer cells removed from their body. Besides, it provides hope for the patients as there is likely to be less change in the body, resulting in higher confidence. It is a less invasive surgery with its recovery time shorter and easier than with mastectomy. They do not have buy special clothes.
However, lumpectomy has its risks as it brings some side effects to the patients. The side effects include loss of sensation and the breast does not match exactly in size and shape after lumpectomy. There is usually some numbness in part of the breast depending on the size of the lump removed. Besides, the larger the part of breast removed, the more likely it is that there will be a noticeable change in the shape of the breast later. It normally makes the affected breast look smaller. There is risk of having possible local recurrence in breast too.
The benefit of mastectomy is that it removes the entire breast to get rid of all the cancer cells. It reduces the risk of the cancer cells spreading to other parts of the body more effectively. This is because all the cancerous tissues is removed and do not have to worry whether the margin removed is clear. The possibility to get the breast cancer again is low compared to other treatments.
Mastectomy also carries several risks. It can cause delayed wound healing. The blood vessels that supply breast tissue are cut during mastectomy can present problems when the body tries to heal the incision site. Small areas of skin may wither when there is not enough blood flow to the incision. In addition, nerves removed can cause numbness and tenderness of the skin and the touch sensitivity within area of surgery. There is also potential loss of confidence in the patients.
"Cancer cell growth is unwieldy and uncontrolled-these cells just don't have their act together like normal cells do. When normal cells are damaged by radiation, they are like a big city with a fire and police department and trained emergency squads to come and 'put out the fire.' Damaged cancer cells are more like a disorganized mob with a bucket. "
Marisa Weiss M.D. , http://www.breastcancer.org/treatment/radiation/how_works.jsp
It is a treatment that uses high-energy beam or other types of radiation such as light and x-rays to kill or stop the growth of cancer cells. It is an option for those unable go through surgery. Mutation in DNA which codes for body's processes and characteristics causes the cells grow in uncontrolled way which is cancerous. These high-energy beams works by causing severe damage to a cell's DNA, which is used in cell division. Growing and multiplying of cancer cells can be inhibited by radiation damage. As cancer cells are less organised than healthy cells, it's more difficult for them to recover from the damage. Therefore, cancer cells are more easily destroyed by radiation, whereas normal cells are able to repair themselves and survive the treatment.
There are two types of radiation therapy[22-24]:
External radiation : a machine called linear accelerator delivers radiation to the tumour from outside the body.
Internal radiation : a radioactive substance called implant sealed in needles, seeds, wires, or catheters placed directly into or near the cancer.
Radiation can damage a rib or a lung, discolor the breast and thicken the breast skin. It is carcinogenic as it can cause another cancer.
Figure 4 : How does Radiotherapy Works
It uses strong drugs to treat breast cancer, either by killing the cells or slowing the cancer's growth. These drugs can affect normal cells, too. But most normal cells can repair themselves. The way it differs from surgery or radiation is that it is a systemic treatment which means the drugs travel throughout the body wherever the cancer cells may have spread. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body. When chemo is placed directly into the spine, chest or abdomen, the drugs mainly affect cancer cells in those areas. As chemo drugs affect the whole body, it is normally used to treat advanced-stage breast cancer by destroying the cancer cells as much as possible. Research has shown that newer chemotherapy medicines, such as Taxol, Adriamycin and Ellence help patients with advanced-stage breast cancer live longer. Sometimes more than one chemotherapy medicines are given at the same time to work together to kill the cancer cells. This is called combination chemotherapy. Fatigue is a common side effect of chemotherapy.[17-21]
" In advanced breast cancer, chemotherapy regimens make the cancer shrink or disappear in about 30-60% of people treated."
Figure 5 : Common Agents of Chemotherapy
Evaluation of Sources
I have found the source: www.breastcancer.org to be very reliable and gives factual and valid information related to breast cancer. Breastcancer.org is a non-profit organization and managed by more than 70 medical professionals from all over the world in breast cancer-related fields. These experts are also the members of Professional Advisory Board, who constantly updated the information on the web, making sure that the facts are true from time to time. The information I retrieved from this website was on the treatments and side effects as stated on page 3-8 and 12-13 from http://www.breastcancer.org/treatment/
Another source that came up with the same information is http://www.cancer.org/Treatment/TreatmentsandSideEffects/TreatmentTypes/index
The other source is a book named Breast Cancer Guide by Dr Foster, which provides the information on pros and cons of lumpectomy and mastectomy as stated on page 12-13. Dr Foster is an independent organization which brings together academics, healthcare experts and media professionals to produce a book with fundamental knowledge on
breast cancer. This book was produced in consultation with Breast Cancer Care, which means that the information in this book should be accurate and up-to-date. It is free of political correctitude and does not patronize the reader. The same information about advantages and disadvantages of lumpectomy and mastectomy can also be found at http://www.breastcancer.org/treatment/surgery/mast_vs_lump.jsp