October 8, 2008
Keeping abreast with breast cancer
Illustration by Roberto Regachuelo Jr.
Herword resident OB Gynecologist, Dr. Malu Mangubat, resumes her column this month – which is, incidentally, Breast Cancer Awareness Month. Welcome back, Dr. Malu!
There they were, tiny white specks on the mammography plate staring at me, seemingly taunting me that, again, they have claimed a victim. I looked at my best friend Gigi who was anxiously waiting for what I will say. I did what any normal person would do when faced with a life changing situation as this – I lied. I said “I don’t know.” She’s a doctor, too, so I don’t know if she believed me. I wanted the words to come from somebody else. How can you say “You have breast cancer” in a nice way? Instead, I sent a text message to her sister Maloy telling her the truth, which I hope would even out the lie I told her sister.
How do I know I have breast cancer?
 Usually, you can feel a lump on your breast either through a conscious self breast examination (SBE) or quite unexpectedly, like while bathing. Majority of those lumps are non-cancerous. Most non-cancerous lumps turn out to be fibrocystic changes which become bigger and more painful just before menstruation. If the lumps do not disappear or become smaller, then you have to go to your doctor for a clinical breast exam (CBE). Gigi came to me after feeling a lump on her left breast. Initially, I couldn’t locate it too so she had to bend forward for her breast to fall away from her chest as it was right smack at the base, nearest the muscle plane. No wonder she wasn’t able to feel it previously. Many lumps or tumors are so small and cannot be felt.
Next step – a mammogram. This is a special type of xray where your breasts are squeezed flat as a pancake while several shots are taken. The recommendation used to be for women ages 50 and over to have an annual mammogram, but that has now been lowered to 40 and above, younger still if you have a family history of breast cancer. Most hospitals and even diagnostic centers in malls have this equipment so it is readily available for everyone.
We have a very good Breast Clinic at Medical Center Manila with the latest mammography machine and top-notch radiologists dedicated just to this procedure. Gigi chose to come here even if there are mammography machines in Iloilo because she knew Grace (another best friend) and I would be here for moral support. When her official result came in – BIRADS 5, I myself needed the moral support. She even looked more composed than I. I should’ve known! Her credo, which she borrowed from another fellow doctor, Lei (who herself has breast cancer), is “Composure at all times!”
The next step depends on your BIRADS category. BIRADS or Breast Imaging Reporting And Data System was developed by the American College of Radiology to standardize reporting of mammography results – stated as BIRADS 0 - 5. BIRADS 0 means there is/are findings but you will need additional diagnostic examinations, such as a breast ultrasound or magnetic resonance imaging (MRI) to verify it. BIRADS 1 – there was nothing seen. BIRADS 2 – there is/are finding/s but definitely not cancerous. BIRADS 3 – findings are most probably not cancerous but mammography must be repeated in a short period of time (six months) to see the progress of these masses. BIRADS 4 – masses seen are suspicious for malignancy and a biopsy (fine needle apiration biopsy, core biopsy or surgical biopsy) is needed to verify this. BIRADS 5 – highly suggestive of cancer and surgery must be done soonest. An additional category of BIRADS 6 was added for a known cancer.
Why me?
These are some of the known risk factors:
• sex - about 100 times more in women than men
• family - increased when a relative has breast cancer (more likely if 1st degree)
• age - the older are more prone
• race - Asians, Hispanics, and Native Americans have lower risk
• menstruation - more common among women who started menstruating before age 12 or had menopause after 55
• hormonal therapy - higher incidence for those taking hormonal replacement
• weight - obesity increases risk especially after menopause
• alcohol intake - increasing risk with increasing alcohol consumption
• activity - exercise reduces the risk
There are emails circulating in the internet that using anti-perspirants or wearing bra increases the risk but, so far, these are just wild rumors based on unfounded claims. Other possible risk factors are having breast implants, using tobacco and working night shifts but studies linking them to breast cancer are lacking or inconclusive.
Because of the hypothesis that longer exposure to estrogens increases the risk for breast cancer, several research studies investigated this relationship using parameters like birth weight, prematurity, age of first menstruation (menarche), growth rate, weight gain, maternal age and many more. The studies showed higher risk for those who were big at birth (five times higher for those four kilos, and over), twin pregnancy (especially if the other twin is a male), had older mothers, tall at adolescence and early menarche. There was reduced risk for those who have been breastfed and whose mothers had preeclampsia (hypertension) or eclampsia. Data is inconsistent for birth length, gestational age, maternal age, weight status and weight gain in childhood.
Having many of the risk factors does not mean you will definitely have breast cancer but it means you have to be more vigilant. You should do regular SBE and report to your doctor as soon as you find something unusual. Mammogram is also done at an earlier age. Many of those with breast cancer have none or only a few of the risk factors. Gigi’s risk factors were being large at birth (10 pounds) and having maternal aunts with breast cancer.
Can breast cancer be prevented?
The short answer is NO. However, those with high risk may take measures to possibly prevent its development. Efforts must be done to change factors which can be changed (alcohol use, hormonal therapy, obesity and activity). What is more important is early diagnosis. Once you feel a lump, go see your doctor.
Recent studies seem to show that Tamoxifen (a drug that blocks the effect of estrogen on breast tissue) which is used to prevent recurrence for those with breast cancer, may lower the risk of getting cancer for those with increased risk. However, it also increases the risk for possible uterine cancer. Also being studied are raloxifene, aromatase inhibitors (anastrazole, letrozole, exemestane), non-steroidal anti-inflammatory drus (aspirin, ibuprofen), many other drugs and dietary supplements. It would be nice if any of these will give a positive result, but for now, there is still nothing that can definitely prevent breast cancer.
Grades and stages
When the biopsy shows the mass to be benign, no further action is taken. When it is found to be definitely cancerous, other classifications take effect. These are the histologic tumor grade type and the stage of cancer. The histologic tumor grade tells us how aggressive the tumor is and will therefore affect if further treatment is needed after the tumor is removed. These are Grade 1 or well-differentiated, Grade 2 or moderately differentiated and Grade 3 or poorly differentiated.
The stage describes the extent of cancer in the body therefore determining prognosis (survival) and treatment options. Stage 0 or carcinoma in situ means the cancer is well contained in its original site. Stage I is for tumors two cm or less with no spread to lymph nodes or other distant sites. Stage IIA is a tumor two cm or less and has spread to at most three lymph nodes or two to five cm but has no lymph node involvement. Stage IIB is a tumor two to five cm with spread to one to three lymph nodes or larger than five cm but has not spread to lymph nodes. Stage IIIA is a tumor not more than five cm with four to nine lymph nodes or larger than five cm with spread to one to nine axillary nodes or to internal mammary nodes. In Stage IIIB, the tumor has grown into the chest wall or skin and either has not spread to lymph nodes or at most to nine lymph nodes but not to distant sites. Stage IIIC is any tumor size that has spread to more than 10 axillary lymph nodes, or to nodes of the clavicle (collar bone) or to the internal mammary nodes but no distant spread. Stage IV is any tumor size that has spread to distant organs (bone, liver, brain or lung) or to lymph nodes far from the breast.
To conserve or to remove
Most patients will have surgery. In early stages (Stages I and II), breast conserving surgery can be done. Lumpectomy removes only the lump. Partial or segmental mastectomy removes more breast tissue than a lumpectomy. However, if cancer is found at the margins of the tissue removed, a re-excision is done to remove more tissue. Total or simple mastectomy means removal of all breast tissue. When the axillary lymph nodes are also removed, this is called modified radical mastectomy (MRM). A radical mastectomy is more extensive in that even the pectoralis or chest wall muscles are removed.
Deciding between breast conserving surgery and total removal should be done with your doctor and all the facts known to you. Recent studies show that when lumpectomy is an option, the chance of survival is the same compared with mastectomy. Keep in mind though that lumpectomy always entails radiation therapy post-surgery.
There is a great psychological burden for a woman to lose her breast. This disfigurement can be remedied by reconstructive surgery with breast implants. Sometimes you can have the reconstruction at the same time as the mastectomy. When reconstruction is being considered, the plastic surgeon must be consulted prior to the mastectomy.
What’s next after surgery?
Radiation therapy is done for those who underwent lumpectomy or partial mastectomy or those who had mastectomy but their tumors are larger than five cm. External radiation is the most common form, given five days a week for six to seven months. Side effects are swelling and heaviness in the breast, sunburn-like skin changes in the target areas and fatigue. In rare cases, it may weaken ribs and damage the heart and lungs.
Chemotherapy involves treatment with cancer-killing drugs through the veins (intravenous) or by mouth. It is given in cycles – treatment period followed by recovery period of two to three weeks for thrree to six months. The length of treatment depends on the type of chemotherapy agents used. Common side effects are hair loss, mouth sores, loss of appetite, nausea and vomiting, increased chance of infections, easy bruising or bleeding and fatigue. Other side effects are premature menopause, infertility, nerve damage, heart damage, leukemia and what is called “chemobrain” (slight decrease in mental functioning).
Further treatment with hormones has become the standard to prevent recurrence. Those who tested (+) with Estrogen Receptors (ER) or Progesterone Receptors (PR) are given tamoxifen, toremifene, fulvestrant, aromatase inhibitors or megestrol. Those who are HER2-neu (+) are given trastuzumab or lapatinib.
Emotional roller coaster
Cancer wakes you up to your mortality. You have to face the fact that death is an option. There are radical changes you have to do with your life. You are not only wounded physically but socially and emotionally as well. Even those around you are affected. There are many low moments. This can even cause tension between the patient and those taking care of her. For those who cannot or find it hard to cope, there are psychiatrists and breast cancer support groups around. You don’t have to be alone.
However, that is easier said than done. I am in an emotional roller coaster and I can only imagine what my dear friend is going through. Gigi puts up a brave front and most often cries only when she’s alone. We both are undergoing what is known as the stages of death (more on this next month) and to me, it seems she has gone ahead to acceptance. I’m still in denial. I want to wake up tomorrow and find this is all a dream. I want to be as optimistic as my daughter Claire who said, “Dr. Fojas removed the cancer, didn’t he? So Ninang Gigi is OK now.” I wish I were a six-year-old again.
My brave friend said she doesn’t mind the cancer with its disfigurement and other effects of treatment but she wants to live long for her children. Her two aunts who had it lived more than 30 years since their surgery. With her positive outlook and the newer treatment options, she has a good chance of getting what she is asking for.
For further information on breast cancer, visit www.cancer.org (American Cancer Society), www.cancer.gov (US National Cancer Institute), www.philcancer.com (Philippine Cancer Society), www.pso.ph (Philippine Society of Oncology), www.psmo.com (Philippine Society of Medical Oncology), and www.thebigmagazine.com (The Big C Magazine Online).
If you have questions for Dr. Malu, you can email her at feedback@herword.com.
Ma. Luisa V. Torralba-Mangubat, M.D. is a fellow of the Philippine Obstetrical and Gynecological Society and the Philippine College of Surgeons. For personal consultations, her clinic hours are as follows:
Asian Hospital and Medical Center, Room 722
Monday, Wednesday, and Friday, 8 a.m. to 10 a.m.
Tel. (+632) 771-9340
Medical Center Manila, Room 337
Monday, Wednesday, and Thursday, 1 p.m. to 6 p.m.
Saturday, 9 a.m. to 1 p.m.
Tel. (+632) 528-1173
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