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CONTENTS
q
The
Breast – Introduction
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What
Is The Breast Made Up Of?
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What
is Breast Cancer?
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How
Common Is Breast Cancer?
q
What
Are The Risk Factors?
q
How
Can We Fight Breast Cancer?
q
Does
Early Detection Save Lives?
q
How
Does Breast Cancer Present?
q
How
Is Breast Cancer Diagnosed?
q
How
Is Breast Cancer Classified?
q
How
Do We Treat Breast Cancer?
q
What
Does Locoregional Treatment Consist Of?
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What
Does Systemic Treatment Consists Of?
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Rehabilitation
After Breast Cancer Treatment
q
Support
Groups
A.
The Breast - Introduction
The biological function of the female breast is to
produce milk for the young. However,
this role is often forgotten in our modern society.
Instead the female breast is now portrayed as the symbol of
feminity and is admired for its aesthetic form.
A woman afflicted with breast cancer is thus dealt with 2
blows; one of cancer and the other of mutilation to the breast due
to the cancer and from its subsequent treatment.
B.
What Is The Breast Made Up Of?
| he female breast consists of a core made up of milk glands
(called lobules) and ducts. This
core is surrounded by a layer of fat, which in turn is covered by
the skin. Milk is
produced in the milk glands or lobules and collects in small ducts
called terminal ducts. These
terminal ducts joined together to form larger ducts, which
eventually drain, via the nipples.
|
Each female breast has about 12 to 15 breast lobules.
This understanding of breast anatomy is important because
breast lumps including cancer develop mostly within the milk ducts
and glands. (See
diagram of anatomy of breast).
|
 |
The
female breast starts to grow from puberty and is fully developed
when the woman is in her twenties.
During a woman’s reproductive period (approximately 20 to
40 years old), the breast is under the influence of oestrogens and
progesterone (female hormones) whose levels vary with the
menstrual cycle.
This influence can cause the breast to be tender, hard and
lumpy especially premenstrually.
When a woman enters her thirties, the breast undergoes
regression in which the milk glands and ducts become smaller and
are replaced by fibrous and fat tissue.
C.
What Is Breast Cancer?
Our
human body is made up of billions of cells.
Each cell reproduces by division (cell division) and this
process normally occurs in an orderly manner.
If the cells divide in an uncontrolled manner and invade
the surrounding tissues, a cancer or malignant lump is formed.
Breast cancer usually originates from the cells lining the milk
ducts and glands.
Ductal cancer (i.e. arising from the ducts) are more common
than lobular cancers (i.e. arising from the lobules).
At this early period of cancer growth, the malignant cells
are confined within the milk ducts and glands and have not invaded
into the surrounding tissue known as the stroma.
When breast cancer is detected at this stage known as
non-invasive or in-situ cancer, treatment is easier and patients
live longer.
However,
when cancer cells have broken out of the milk ducts and lobules
and invaded the surrounding stroma, the cancer is called an
invasive cancer.
In the stroma are found blood and lymphatic vessels.
Hence an invasive cancer can gain entry into the lymphatic
system and spread to the lymph glands (called nodes) in the
armpit.
Likewise, the cancer cells can enter the bloodstream and
spread to other organs in the body.
When these cells reach a new site, they may form a new
tumour, often referred to as a secondary or a metastasis.
The organs most commonly affected are the lungs, bones and
liver.
In this advanced stage breast cancer is usually incurable
and patients may only have months to live.
|
What is Lymphatic System?
This system is made up of channels known as ducts
which run alongside blood vessels and to help to drain fluid
from the body back into the blood circulation.
An important function of the lymphatic system is the
protection of the body against foreign invasion e.g.
bacteria or other micro-organism.
These foreign bodies are destroyed in lymphatic
glands (called lymph nodes) which are situated in certain
parts of the body such as the neck, armpits and groin.
|
D.
How Common Is Breast Cancer?
Breast
cancer is the commonest cancer in Singapore women and about 1000
women are diagnosed with the cancer annually.
Women of all the 3 major ethnic groups (Chinese, Malay,
Indian) are equally affected.
Significantly, the number of women diagnosed with breast cancer is
increasing at an average of 3% annually.
Women of all age groups are affected but are more common in
women above 40 years old.
The incidence rate of breast cancer in Singapore is about
one-third of that of American women and half that of European
women.
It is estimated that an American woman has a 12% chance of
developing breast cancer in her lifetime.
In Singapore this chance is lower, estimated at 4 to 5%.
E.
What Are The Risk Factor?
Research
has uncovered many of the risk factors associated with this common
cancer.
By identifying the risk factors, we are closer to finding
the cause of breast cancer and also by modifying these risk
factors, we can reduce our risk.
This is the first strategy to combat breast cancer namely
prevention or eradication of the cancer.
However, this objective is difficult to achieve as some of
the risk factors cannot be modified e.g. family history, or
lifestyle factors such as child bearing.
Despite the intensive search for the cause of breast
cancer, the exact cause of breast cancer remains unknown.
About 50% of our breast cancer patients have no
identifiable risk factors.
They can be grouped into the following: -
q
Age &
Sex
q
Family
History
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Factors
Associated with Reproductive History of a Woman
q
Dietary Risk
Factors
q
Body Weight
and Physical Activity
q
Intake of
Hormones
q
Previous
Abnormal Breast Biopsy
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Age & Sex
The
risk of breast cancer increases with age.
It is uncommon in a woman before 40 years old.
70% of all breast cancers are diagnosed in women 40 years
of age and older.
Breast cancer can also affect the male but the risk is very low
compared to the female. However,
when a breast cancer is diagnosed in a male it is often at an
advanced stage because of the small size of the male breast.
q
Family History
A
woman with this risk factor has a first degree relative (i.e.
sister, mother or maternal grandmother) with breast cancer.
Her risk is doubled (2X) when compared to a woman without
this risk factor. (See
side bar on How to Estimate one’s risk from breast cancer?)
However, family history is not a significant risk factor as
only 10% of breast cancer patients have it.
Our recommendation for woman with this risk factor is to
start breast screening at an earlier age at approximately 35 years
old.
This
risk factor comes from the inheritance of genes from our parents
and ancestors. Genes
contain encoded information and are stored in our cells and passed
on from generation to generation.
The information contained in our genes is needed for the
normal function of our cells.
When our genes are damaged, cell function become abnormal
and a cancer may be formed.
We
have identified certain genes, which may be responsible for breast
cancer. Inheritance
of abnormal forms of such genes increases
a woman’s chance of getting breast cancer.
Two such genes recently identified are BRCA1 and BRCA2
genes and inheritance of abnormal copies of either of such genes
increase a woman’s risk by several fold!
Such a woman will have a 40 to 60% of developing breast
cancer in her lifetime.
Tests
to detect such abnormal genes are at present difficult and
performed mostly in research laboratories.
If you are interested in such tests, you should
consult your doctor. There
are laboratories in Australia and America, which offer this
service.
There
is another way to identify a woman with these abnormal genes
(BRCA1 and/or BRCA2). Her
family history is more extensive and stronger with the following
features:
| § |
Many
relatives developing breast cancer at an early age
(< 40 years).
|
| § |
Woman who
develop breast cancer in both breasts at the same time (i.e.
bilateral).
|
| § |
More than
two generations of relatives with breast cancer.
|
|
§ |
Relatives
with cancer of the ovary. |
Fortunately,
such women only form a small proportion of women with breast
cancer, estimated at only 1%. A big controversy surrounds the management of such women and
most of the cancer centers at our major hospitals have special
departments to cater to them.
|
How
to estimate one’s risk from breast cancer
The
most important risk estimate is the absolute risk
i.e. the risk of developing breast cancer in one’s
lifetime. For
a Caucasian woman in America, this risk is about 12%.
As breast cancer is less common in Singapore women,
the lifetime risk is about 5% i.e. the chance of a
Singapore woman developing breast cancer in her lifetime
is about 5%.
Doctors often quote another risk estimate called the
relative risk. For
example,
a woman with a family history of breast cancer has
relative risk of 2.0 i.e. her risk is doubled compared to
a woman without this risk factor.
Her absolute risk becomes 10% (2 x 5%).
|
q
Factors
Associated with The Reproductive History
of a Woman.
Research
has identified certain aspects of a woman’s reproductive history
that can increase her risk from breast cancer.
These risk factors are:
| § |
Woman
with no children or having the first child late
(after 35 years old)
|
| § |
Early
onset of menses (earlier than 11 years old)
|
| § |
Late
cessation of menses (later than 55 years old) |
These
risk factors are associated with an early and prolonged exposure
to oestrogen, which is one of the female sex hormone.
A
woman attempting to modify these risk factors to reduce her risk
from breast cancer will find it difficult to do so as it could
mean substantial alterations in her lifestyle.
There are calls in America to make changes in colleges and
the work place to facilitate a woman’s wish to have children
early.
Another measure that is being considered is to encourage
young girls to exercise more, as it is known that physical
activity can delay the onset of menses and suppress the secretion
of oestrogen.
Can breast-feeding alter this exposure of oestrogen and hence
reduce a woman’s risk?
Yes, but only if the period of breast-feeding is prolonged
(e.g > a year).
q
Dietary Risk Factors
It
has been known for a long time that eating too much red meat and
animal fat and too little fibre (vegetables & fruits) may
increase a woman’s risk of breast cancer.
Recent research has failed to prove this conclusively and
controversy still surrounds the role of diet as a risk factor.
However, Health Authorities such as the National Institute
of Health and American Cancer Society recommend limiting intake of
saturated animal fats (less than 20% daily fat allowance) and
increasing intake of fruits and vegetables (5 servings daily) to
reduce our risks from cardiovascular disease and cancer especially
breast, colon and prostate cancer.
There
is less controversy regarding alcohol as a risk factor for breast
cancer. Studies have
shown that drinking 1 to 2 glasses of alcohol daily can increase a
woman’s risk (relative risk 1.5 times)
Other
nutrients that have been identified to alter a woman’s risk from
breast cancer are:
| § |
Soy
products as in tauhoo, soya bean juice have been shown in
studies to reduce a woman’s risk from breast cancer.
This may explain why Asian women have a lower risk
from breast cancer compared to American women.
|
| § |
Omega
3 oil found in fish.
Some studies showed that it could reduce a
woman’s risk from breast cancer.
|
| § |
Other
nutrients that have been found to be protective against
breast cancer are vitamin A, selenium, vitamin C & E. |
q
Body
Weight and Physical Activity
Weight
gain especially in postmenopausal women is associated with an
increased risk from breast cancer.
This can be a combination of high calories and fat intake
as well as a lack of exercise.
Some Europeans studies have correlated physical activity to
the risk of breast cancer. Physical exercise reduces a woman’s risk of breast cancer
by lowering her body’s level of oestrogen.
A woman should engage in regular physical activities and moderate
her calories and fat intake and avoid weight gain.
Her weight should not be more than 20% above her ideal
weight.
q
Intake of Hormones
There
are 2 periods in a woman’s life that she wants to take oestrogen
(±
progesterone) supplement:
| § |
Hormone
Replacement Therapy (HRT).
A postmenopausal woman has a choice of taking HRT
or not. There
are PROS and CONS of such a choice and this is not the
forum for such a controversial topic.
Recent studies from America have shown that long
term or current users of HRT have an increased risk of
breast cancer (up by 30%) and this risk disappear 3 to 5
years after stopping HRT.
A woman should enter into a close discussion with
her doctor/doctors before making a decision.
|
| § |
Oral
Contraceptive Pill (OCP).
The Pill is a popular form of birth control and the
worry was whether it would increase a woman’s risk of
breast cancer. The
conclusion from all the many studies performed is that
there is little or no increased risk from taking the oral
contraceptive pill. Only
a small subgroup of woman may be at a higher risk –
early and prolonged usage of the OCP (i.e. late teens,
more than 10 to 15 years). |
q
Previous
Abnormal Breast Biopsy
A
woman with a previous breast cancer is at an increased risk of
developing cancer of her opposite breast.
She should be on regular reviews with her doctor.
A few types of breast biopsies are known to have an increased risk
of breast cancer, namely: atypical ductal hyperplasia, atypical
lobular hyperplasia and lobular carcinoma in-situ.
Woman with such breast biopsy reports should have regular
screening starting from her mid thirties.
What Can I Do if I Am at High Risk
From Breast Cancer?
Doctors
can now give a fairly good estimate of a woman’s risk from
breast cancer by taking a detailed family, social and medical
history.
Women who are at high risk from breast cancer will be offered
counselling as to how to cope with this knowledge:
| q |
They
are offered breast screening at an earlier age
|
| q |
They
are advised on means to alter their lifestyle and diet to
reduce their risk.
|
| q |
A
recent study from America has shown that tamoxifen, an
important anticancer drug can significantly reduce the risk
of breast cancer in these women.
|
| q |
These
women can consider preventive prophylactic mastectomies as a
means to reduce their risk from breast cancer.
A recent study from America has shown that high-risk
women who underwent bilateral mastectomies have a 90%
reduction in their risk.
After removal of the breast, it is reconstructed
using a woman’s own body tissue or an implant.
Because of the psychological consequence and
extensive nature of the surgery involved, a woman must
consider very carefully this option before deciding on it.
|
F.
How Can We Fight Breast Cancer?
There
are 3 methods of controlling breast cancer.
| q |
Prevention
is possible only by elimination of known risk factors and
this is a difficult and long term goal, e.g. change of diet
and lifestyle habits.
|
| q |
Early
Detection is currently the most promising method to fight
breast cancer. The
main advantages are (a) improved survival (b) less
mutilating surgery (c) less toxic drug therapy.
This method is easier to implement and yield results
faster than prevention.
|
| q |
Better
Treatment is an expensive method to fight breast cancer as
it involves development of tertiary medical services.
New drugs and surgical technique usually take time
and effort to develop. |
G.
Does Early Detection Save Lives?
What
is the Aim of Early Detection Or Breast Screening?
The
aim of Breast Screening is to detect breast cancer early
so that with effective treatment women can live longer.
How
Does It Work?
When
breast cancer develops it goes through a stage whereby its cancer
cells are confined within the breast ducts.
This is known as the non-invasive stage.
If we can detect breast cancer at this stage we know that
the cancer cells have most likely not spread to the armpit lymph
nodes or elsewhere in the body.
What
are The Advantages of Early Detection?
When
a breast cancer is detected and treated at an early stage there
are several advantages.
| q |
Most
important of course is the fact that such women can live
longer
|
| q |
These
tumours are often small (less than1 cm diameter) and are
suitable for less mutilating surgery e.g. Lumpectomy as
compared to Mastectomy.
|
| q |
There
is also a higher chance of avoiding Chemotherapy after
surgery
|
| q |
If
no cancer is detected by Breast Screening, a woman can
feel more reassured.
|
What
Are The Methods Of Early Detection?
The
only effective and proven method to detect breast cancer early is
an X-ray of the breasts called Mammogram.
Mammogram is able to detect microcalcifications (calcium
dots), which is an early sign of non-invasive duct cancer, and
also breast cancers that are too small to be detected by clinical
examination (less than 1 cm diameter).
Other methods such as Breast Self Examination, Clinical
Examination, Ultrasound Scan (Breasts) have not been proven to be
effective.
Is
Mammogram Painful?
A
certain amount of compression of the breast is required to obtain
a clear image on the mammogram.
This may be uncomfortable and painful.
However in a survey in UK, only 10% of women said it was
painful.
Is
Mammogram Harmful?
The
common belief is that since mammogram is a form of X-ray it is
harmful to our body. However
the radiation dose from mammograms is quite low and hence the risk
to our health remains low. The
risk is comparable to smoking 3 cigarettes!
Is
There Any Proof That Breast Screening Works?
YES.
Studies in US and Europe have shown that regular breast
screening in women aged 40 years and above can reduce the risk of
death from breast cancer by up to 50%.
This translates into lives saved.
Is
Breast Screening Effective In All Women?
Studies
have shown that Breast Screening is most effective in women 50 to
70 years old. The
effectiveness of breast screening for women in her seventies
remains unproven.
Where
Can I Go For Breast Screening?
Breast
Screening is available as part of a general health check in Well
Women Clinics found in most government outpatient clinics and
Singapore Cancer Society. Breast
screening involves a clinical breast examination performed by the
doctor followed by a mammogram.
Facilities for mammogram and X-rays are available in most
hospitals.
The
Ministry of Health has just launched a nationwide campaign to
screen women above 40 years for breast cancer.
The cost of mammogram is heavily subsidized.
What
Happens If A Woman’s Mammogram Is Abnormal?
This
does not mean that the woman has breast cancer. A large proportion of the abnormalities found on mammogram
are not due to cancer. The
woman will be recalled by the doctor for further tests such as
magnification views of the mammograms and ultrasound scans.
Only in a small proportion of women, an abnormality
suspicious of cancer is confirmed by these further tests.
These women are offered a surgical biopsy to rule out a
cancer.
What
Is A Surgical Biopsy?
This
is a small operation to remove the abnormality in the breast for
laboratory examination to rule out a cancer.
This operation is usually performed under general
anaesthesia as a day surgery procedure.
What
Are The Disadvantages of Breast Screening?
| q |
I
have mentioned earlier that mammogram is painful to some
women and there is a small risk from radiation exposure
|
| q |
Unfortunately
no diagnostic tests including mammogram are 100 percent
accurate and some normal women may have mammograms showing
an abnormal result. They have to undergo further tests and surgical biopsy to
rule out a cancer. This
can be costly and inconvenient to these women.
Such women may also be subjected to unnecessary
mental stress.
|
| q |
On
the other hand, some women with breast cancer may have a
normal mammogram i.e. the cancer was missed by the tests.
Such women may be falsely assured. |
What
Are Our Government’s Guidelines For Breast Screening?
|
|
|
40
years and below
|
Monthly
Breast Self Examination
|
|
|
Clinical
Breast Examination every 3 years
|
|
|
|
40
to 49 years
|
Monthly
Breast Self Examination
|
|
Clinical
Breast Examination yearly
|
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Mammogram
yearly
|
|
|
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50
years and above
|
Monthly
Breast Self Examination
|
|
Clinical
Breast Examination yearly
|
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Mammogram
every 2 years
|
|
|
H.
How Does Breast Cancer Present?
The
commonest presentations of a breast cancer in decreasing order of
frequency are:
q
Breast
lump
q
Bloody
nipple discharge
q
Skin
changes
q
Itchy
rash of the nipple
q
Breast
pain
Are all breast lumps cancerous?
The
answer is no. In fact
8 out of 10 breast lumps are benign or non cancerous.
The type of breast lump depends on the woman’s age.
|
Twenties |
The
commonest type of breast lump in this age group is a
fibroadenoma. It
also known as a breast mouse as it is mobile i.e. it can be
moved within the breast.
This lump is non cancerous.
|
| Thirties |
The
commonest type of lump in this age group is known as fibroadenosis
or
fibrocystic disease.
It is often a painful hard area in the outer guardant
of the breast and is associated with the female sex hormone,
oestrogen. It
is non cancerous.
|
| Forties and beyond |
Two types of
breast lumps are common in older women.
One is a breast cyst which is a lump filled with
fluid. Breast
cyst can be diagnosed by an ultrasound scan and is treated
by needle puncture to extract the fluid.
Breast cancer is the other
type of breast lump to consider in older women.
This lump is usually hard irregular and fixed inside
the breast. Changes of skin over the cancer may be seen (thickening,
redness depression, skin sore). |
I.
How Is Breast Cancer Diagnosed?
The
doctor depends on three tests to help to diagnose a breast cancer:
| q |
Clinical
Examination. Depending
on his experience, a doctor can suspect whether a breast
lump is cancerous or not by performing a clinical breast
examination. Breast
lumps or cancers smaller than 1.5cm diameter or situated
deep in the breast cannot be detected by clinical palpation. Accuracy of this diagnostic method is approximately 60 to
70%.
|
| q |
X-ray
Mammogram. This
is an x-ray examination of the breast and a cancer can
appear as an irregular mass, clustered microcalcifications
or distortion of the breast tissue.
Mammogram can detect breast cancer when it is small
and not clinically palpable and hence is very useful in
early detection of breast cancer.
See section on Breast Screening for more details on
this test.
|
| q |
Breast
Ultrasound Scan. This
method which uses sound waves to generate an image of the
breast is useful in detecting breast lumps in the younger
women (less than 35 years) in whom the breast is often lumpy
and hence difficult to palpate and whose mammograms are
difficult to interpret.
Presently ultrasound scan is especially useful to
differentiate between a solid lump and a cyst.
A breast cancer appears as an irregular tall mass
with indistinct margins on the ultrasound scan. The role of breast ultrasound is to complement x-ray
mammogram. |
Based
on these three tests, a doctor is able to suspect whether a lump
is present and whether it is cancerous.
Very
often, a doctor will recommend a BIOPSY of a breast lump detected
by any of the three tests in order to exclude a malignancy.
A biopsy is an invasive technique in which some tissue is
obtained from the lump for laboratory tests to determine its exact
nature.
The
common biopsy techniques are:
| q |
Fine
Needle Aspiration (FNA).
A small needle is introduced into the breast lump to
sample it. The
aspirate is smeared onto a glass side and analysed in the
laboratory. An
experienced pathologist is able to tell whether the cells in
the aspirate are cancerous after studying them under the
microscope. Even
though it is simple and easy to perform, FNA is not as
accurate as the other biopsy techniques for several reasons
(a) inadequate number of cells sampled (b) inexperienced
pathologist (c) inability to diagnose a noninvasive breast
cancer (which requires a piece of the breast cancer for
diagnosis)
|
| q |
Core
Needle Biopsy. The
core needle is a slightly bigger needle and is able to
obtain slices of a breast lump for analysis.
Core needle biopsy is more accurate as it is based on
analysis of a piece of the breast lump under the microscope
(i.e. histological diagnosis).
It can also diagnose noninvasive breast cancer.
Automated core needle biopsy systems have been
invented in which many slices of a breast lump can be
obtained via one small skin puncture.
|
| q |
Excision
Biopsy. A
doctor may recommend that the whole breast lump be removed
(i.e. excised) for histology.
This procedure can be performed under local
anaesthesia or more often general anaesthesia.
The advantage of excision is that the lump is wholly
removed from the woman’s breast.
|
| q |
Frozen
Section. This
is a technique to prepare tissue for histological
examination quickly (duration 15 to 30 mins).
With frozen section, a breast cancer can be diagnosed
with the patient under general anaesthesia and the proper
cancer operation carried out.
This saves the patient having to undergo two
hospitalizations, one for the excision biopsy and the other
for the cancer surgery. |
J.
How Is Breast Cancer Classified?
For
practical purposes, breast cancer can be classified according to
the stage (extent of spread), grade (index of
aggressiveness of the cancer cells) and oestrogen receptor
status (ER). These
information are vital and help to predict survival and determine
the treatment.
Staging
is determined based on the following:
| q |
Information
regarding the tumour size and invasion of the lymph glands
in the armpit based on microscopic examination of the tumour
and operated specimen.
|
| q |
Diagnostic
Imaging Studies to study the extent of spread within the
body, which includes chest x-ray, ultrasound scan of liver
and bone scan.
|
| Stage |
|
Average Survival (%) |
| 0 |
Non
invasive cancer |
90 |
| 1 |
Small
invasive cancer
|
75 |
| 2 |
Invasive
cancer > 2 cm with lymph gland invasion
|
60 |
| 3 |
Large
invasive cancer > 5cm with invasion of skin
|
50 |
| 4 |
Widespread
or metastatic cancer |
50 |
Grade
is determined by examining the cancer cells under the microscope
and labeling the cancer cells as grade 1 (well differentiated),
least aggressive; grade 2 (moderately differentiated), moderately
aggressive and grade 3 (poorly differentiated), most aggressive.
Estrogen
receptors
are markers found on the surface of breast cancer cells and their
presence is determined by tests on the breast cancer.
If present, the breast cancer is labeled estrogen receptor
positive (ER+) and if absent; the breast cancer is labeled
estrogen receptor negative (ER-). This has an important bearing on determining the type of
systemic treatment for the patient (see treatment).
K.
How Do We Treat Breast Cancer?
Broadly
speaking, treatment consists of two parts:
| q |
Locoregional
Treatment which is the use of Surgery together with
Radiotherapy to eliminate the cancer from the breast and
armpit lymph nodes (also called axillary lymph nodes)
|
| q |
Systemic
Treatment which is the use of Chemotherapy or Hormonal drugs
e.g. tamoxifen
to
eliminate cancer cells in the body.
Modern research has shown that clumps of cancer cells
called micrometastases may be circulating in the body of a
woman with breast cancer. |
L.
What Does Locoregional Treatment Consist Of?
| q |
Local
control of the cancer. The two techniques are Mastectomy, which is the removal of
the whole breast including the nipple or Lumpectomy, which
is also known as Wide Excision.
The newer technique is Wide Excision, which is
removal of the tumour with a margin of normal breast tissue.
The rest of the breas | | 
