Health Awareness blog

Breast carcinoma occurs commonly in females. It doesn’t mean that it would occur in males, only rare. Frequency ratio to breast cancer in male to female is 1:125.

No other cancer is more feared by women and for a good reason too. In the United States it is estimated by the American Cancer Society that in 1996 over 185,000 new breast cancers were discovered in women and caused 44:500 deaths, making this score second to lung cancer as a cause of cancer deaths.

Breast cancer can be classified into 5 classes:
• Fibro adenoma
• Phyllodes tumor
• Papilloma
• Papillary carcinoma
• Breast carcinoma

RISK FACTORS FOR BREAST CANCER
• Geographic factors (higher n North America and Northern Europe than Asia and Africa)
• Age (>30 years old)
• Menstrual history (age at menarche <12 years old)
• Pregnancy (late first live birth)
• Genetic and family history (5%-10% of breast cancers are thought to be related to specific inherited mutations).
• Exogenous estrogens
• Oral contraceptive pills
• Obesity
• High fat diet
• Alcohol consumption
• Cigarette smoking

SYMPTOMS AND SIGNS
• Painless lump in the breast
• Nipple retraction or discharge
• Skin dimpling
• Peau d’orange
• Breast asymmetry
• Erythema over skin or nipple

SYMPTOMS OF MATASTASES
• Bone pain
• Headache
• Breathlessness
• Jaundice

INVESTIGATIONS
• Full blood count – to rule out anaemia
• Liver function tests- to look for liver metastases
• Serum calcium – this will increase in advanced disease
• Mammography – for diagnostic
• Ultrasound scan of the breast – this is less helpful inn comparison to mammography
• Fine needle aspiration cytology – this technique is very accurate
• Bone scan – to look for bone metastases
• Ultrasound scan of liver – to look for liver secondaries
• CT scan of brain

CLINICAL STAGING

Manchester classification (modified) 

 TNM classification 

MANAGEMENT & TREATMENT
There are 4 options noted:

1. Surgery
2. Radiation therapy
3. Chemotherapy
4. Hormonal therapy

The patient might be offer, either 1 option or even all 4 options depend on the stage and extend of the disease.

SURGERY

This type of treatment is suitable for early stage of breast cancer. This is consist of wide local incision, simple mastectomy (removal of breast) and modified radical mastectomy (removal of the breast, pectoralis minor muscle and the axillary contents)

Aims:
• Remove tumor
• Relieve the pain
• Correct the obstruction
• Alleviate pressure

Side effects:
• Disfigurement
• Wound seromas
• Arm oedema (swelling)
• Stiffness of the shoulder
• Losing of breast always become an issue
• Patient usually prefer less radical surgery

RADIATION THERAPY
This is use for palliative treatment. For example for fungating lesions and to localized bony metastases.

Aims:
• To destroy rapid dividing cancer cells (minimized normal cells damage)
• Shrink visible tumor (psychological lift to patient)

Side effects:
• Fatigue and weakness
• Pain
• Nausea and vomiting
• Anemia
• Diarrhea
• Dysuria (painful urination)
• Loss appetite
• Possible anorexia
• Pruritus (itchiness)

CHEMOTHERAPY
This treatment is use in patients who are unlikely to respond to hormonal treatment or who has been offered hormonal treatment but fail to respond well. If the right chemotherapy is chosen correctly, it can provide good quality palliation and prolongation of life.

Aims:
• Induce tumor regression and its metastasis adjunct to surgery and radiotherapy
• Palliative measures (relieve pain and other symptoms)

Side effects:
• Marrow suppression (anemia and leucopenia)
• Gastrointestinal tract irritation
• Nausea and vomiting
• Loss of hair
• Alopecia
• Dermatitis

HORMONAL THERAPY
This treatment is offered for patients with established metastatic disease. Women who have high level of oestrogen receptors in the tumours are likely to respond to hormonal treatments. 

OTHER THINGS THAT YOU NEED TO KNOW
Recurrent disease may be treated with radiotherapy, hormonal manipulation and chemotherapy.

Routine follow up to breast clinic is needed to monitor the progress and recurrence of the disease. Patients are encouraged to do self examination of both breast, either at the operation site or other breast that not yet affected. Minimum 5 years follow up is needed and repeat mammography to the breast is highly recommended.

Breast reconstruction might be offered to the patient but many patients are comfortable with prosthesis.

PROGNOSIS
• Stage I : 80% 5-Year survival
• Stage II: 50% 5-year survival
• Stage III: 15% 5-year survival
• Stage IV: 5% 5-year survival

SUMMARY
Breast carcinoma is so far the most common malignancy in female. Annually, about 13 000 women die in UK for this disease. Surprisingly, the incidence appears to be rising. The cause still remains a mystery. Although the 5-year survival rate had increased, the overall mortality has changed very little in the past 25 years.

I am seriously recommending routine self examination at home. Breast screening is very important based on the fact that early detection can improve the prognosis.

Reference:
1. Clinical medicine by Kumar and Clark. 4th edition. 1998.
2. Churchill’s Pocketbook of Surgery by Andrew T Raftery. 2nd edition. 2001.
3. British medical journal 1997.
4. European Journal of Cancer 1997.
5. Journal of Clinical Oncology 1998.
6. Primary management of breast cancer alternatives to mastectomy. 1st edition. Edward Arnold Ltd.
7. Early breast cancer, its history ad results of treatment. 1st ed. Basel: S Karger, 1976.
8. Basic Pathology. 6th ed. Bangalore: Prism Books PVT Ltd, 1997.

Menorrhagia is defined as bleeding of more than 80ml per cycle or a menstrual cycle that lasted longer than 7 days over several consecutive cycles. However, in clinical practice, where actual measurement is not possible, management deals with those women whose significant menstrual loss interferes with their normal life.

During normal menses, the amount of blood loss is an average of 40 + 20 ml over a period of between 2 and 6 days in cycles of 21 to 35 days. In reality, menorrhagia is suggested by the presence of clots, flooding (gushing flow that soaks pads and undergarments), increased duration of bleeding and number of pads used per day.

The initial diagnosis is often based on subjective evaluation of blood loss.

  CAUSES   The most likely cause changes with age. Benign pathology is generally more common in younger women and those with regular cycles. The chances of malignancy are very low in these groups. For example, pregnancy and dysfunctional uterine bleeding is more common seen in girls. Causes of menorrhagia also can be divided using following categories. 

• Gynaecological (e.g., fibroids, polyps, adenomyosis, cancer)
• Medical (i.e., bleeding disorders. Systemic bleeding disorders account for 7 – 20 percent of women of all ages who present with menorrhagia. This should be considered in all adolescents with early onset menorrhagia.)
• Drugs like heparin and warfarin
• Intrauterine devices
• Dysfunctional uterine bleeding (DUB) – is diagnosed when no obvious cause can be established. It is associated with anovulatory cycles, so DUB is common at the extremes of reproductive life. This is the diagnosis by exclusion.

   TESTS   None may be needed. But sometimes, we need to run some investigations that will help with the diagnosis and management. 

• Full blood count – look for haemoglobin. Patient with low haemoglobin content will need blood transfusion.
• Thyroid function test – menorrhagia can be present in hypothyroidism
• Ultrasound or laparoscopy – if we suspect of pelvic pathology
• Dilatation and curettage – usually done in perimenopausal women to rule out endometrial cancer

   TREATMENT  

Treat the underlying cause is the mainstay of treatment. However, if the bleeding is mild or recent onset – just observe. No need for any medical intervention yet. In dysfunctional uterine bleeding, the treatment will depend on age and the wish of the patients. Reassurance will help.

  Those with unacceptable loss should be offered treatment: 

• Hematinics to combat anemia
• Weight reduction in obese patients as excess weigh increased the risk of irregular menses
• Tranexamic acid 1gm thrice daily or 4 times daily over 3 to 5 days.
• NSAIDs (e.g., mefenamic acid 500mg thrice daily for 3-5 days)
• Oral contraceptives (containing 30mcg estrogen) either monthly or a tricyclic regimen (taking active pills continuously for 3 cycles before taking a week break). For maximum effectiveness, tranexamic or NSAIDs should be started at the first sign of menstruation.

  Other treatments if first line agents fail: 

• Progestogen (oral or indictable, implants)
• Mirena
• Danazol
• Gonadotrophin-releasing hormone agonist

  If medical treatment fails, surgery is the next option: 

• Operative hysteroscopy – least invasive method. Involve the insertion of a loop via the vagina to remove any fibroids, polyps or the endometrium.
• Endometrial ablation is the current option used to destroy thickened endometrial lining.
• Hysterectomy – this is the last resort or if the patient presented with other pelvic pathology

Reference:

1. Overview of gynaecology in primary care, medical tribune 1-15 march 2008, page 20-21.
2. Oxford handbook of clinical specialties, 5^th edition.