Importance of regular follow-up after Breast Cancer Treatment

It was quite sad to see this 68 year old lady come to the clinic yesterday. She was diagnosed with left breast cancer two years back and was treated with MRM, adjuvant chemotherapy and hormonal therapy at a private hospital. After her treatment was completed, she did not visit the oncologist again thinking that she has been cured and for the last 6 months she had been harboring this growth over the chest wall, which turned out to be a local recurrence.

Local recurrence after mastectomy

Local recurrence after mastectomy

Patients tend to think that when the treatment is over, they are cured of the disease, but that is not the case. Patients need to visit their oncologists/ doctors regularly after the completion of their treatment and this case points out the importance of correct and regular follow-up after breast cancer treatment.

The current guidelines regarding follow-up of breast cancer patients are:

  1. History & physical examination: Every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.
  2. Mammography: If mastectomy has been done, then annual mammograms of the opposite breast. If  breast conservation has been done, then B/L mammography should be done annually.
  3.  Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.
  4. Pelvic examination. If the patient is on Tamoxifen, annual gynecological check-up should be done because tamoxifen can increase the chances of uterine cancer.

One reason which deters patients from going on regular follow-ups is the fact that some doctors order unnecessary tests during these visits. One should be aware that the following tests are NOT recommended for regular follow-up care of breast cancer patients:

  • Blood tests like CBC, LFT, KFT
  • Chest x-ray
  • Bone scan
  • CT scan
  • FDG PET scan
  • Breast MRI
  • Breast cancer tumor markers – CA 15-3, CA. 27.29, CEA

Paget’s disease of the Breast

Paget’s disease of the breast or nipple is an eczematous condition involving the nipple and areolar skin, which is histologically characterized by the presence of malignant cells interspersed within the keratinocytes of the epidermis (cells of the skin). In approximately 90% of cases, the condition is associated with an in situ or invasive breast carcinoma.

Symptoms:

  • Chronic eczematous lesion involving the nipple (most common presentation) [highlighted in the image]
  • Nipple erythema or ulceration
  • Nipple inversion
  • Nipple discharge
  • Pruritus
  • As many as 40% of women have a palpable mass on presentation, and some may present with enlarged axillary lymph nodes.
Ulceration of the nipple

Ulceration of the nipple

Imaging:

90% patients who present with an underlying breast lump along with Paget’s have abnormal findings on mammography but only 50% patients who present with Paegt’s without a breast lump show mammographic abnormalities. Magnetic resonance imaging (MRI) is increasingly being used, particularly in cases without a palpable mass. MRI is particularly useful to establish extent of disease in patients in which breast-conserving surgery is being contemplated.

Pathology: The hallmark of Paget’s is the presence of neoplastic cells within the epidermis that show abundant clear cytoplasm and tend to spread individually in between the native keratinocytes (Image). They tend to display prominent nucleoli and frequent mitoses. In addition, they commonly show intracytoplasmic mucin-filled vacuoles, which are stained with a periodic-acid-Schiff or mucicarmine stain.

Paget cells seen in the epidermis

Paget cells seen in the epidermis

Paget cells are usually positive for markers of breast epithelium differentiation like:

  • Cytokeratin 7
  • CAM 5.2
  • Low-molecular-weight cytokeratins (negative for high-molecular-weight cytokeratins)
  • Vast majority of cases show strong overexpression of the HER2/neu proteinion of the gene
  • Positive for mucin
  • 18-20% of Paget’s cells express S100 protein but contrary to melanoma cells, HMB45 is consistently negative.

Toker cells are immunophenotypically similar to Paget cells, sharing expression of cytokeratin 7 and CAM 5.2, absence of high-molecular-weight cytokeratin expression, and negative S100- and HMB45-expression. They differ in the negative expression of mucin, HER2/neu, and epithelial membrane antigen. The similarities between Toker and Paget cells have suggested that the former may represent the cell that undergoes malignant transformation in the initial phases of PD. Toker cells can be present in normal patients as well.

The most accepted explanation for the development of PD is that Paget cells result from the migration of cells from the underlying adenocarcinoma through the epidermis, the so-called epidermotropic theory. This theory is supported by the existence of an underlying carcinoma in about 90% of cases of PD, which usually shares phenotypic similarities with Paget cells.

 

Differential Diagnosis:

  • Eczema – tends to be bilateral and responds to topical steroids
  • Nipple adenoma

Diagnosis: 

  • Wedge biopsy
  • Punch biopsy

Management: Management of PD depends on the underlying breast lump. Traditionally, the surgical procedure of choice has been a mastectomy but there are numerous studies which show that breast conservation surgery can be carried out in patients with PD. Prognosis in PD is largely determined by the underlying breast tumor.

 

Source: 1. Bland & Copeland – The Breast. 4th Edition 2. Michael Sabel – Essentials of Breast Surgery

AIIMS study reveals a link between OCP’s and Breast Cancer

The use of oral contraceptive pills (OCP’s) especially emergency contraceptive pills (morning after pills) is increasing rapidly among young women and this might be one of the factors responsible for the rise in the incidence of Breast Cancer in our country. Many studies conducted on this issue have failed to indicate a clear link between OCP’s and breast cancer. However, a recent study conducted by AIIMS, which was published in Indian Journal of Cancer has revealed a higher chance of breast cancer among regular users of OCP’s.

According to the study, breast cancer risk was found to be 9.5 times more in women with a history of consuming such pills regularly. The study included 640 women, out of which 320 were breast cancer patients. 11.9% breast cancer patients in the study had a history of using long term OCP’s as compared to 1.2% healthy individuals.

It is a well known fact that breast cancer is a hormone dependent cancer (mainly dependent of on estrogen) and the regular use of OCP’s leads to a disturbance in the normal hormonal status. Morning after pills (emergency contraceptive pills), which contain a higher dose of estrogen lead to a sudden surge in the levels of these hormones and are thought to be more harmful. The problem is that these pills are being consumed on a daily basis by many youngsters. The users of morning after pills were not included in this study.

Women should realize the importance of this study and more awareness needs to be created among young women regarding excessive use of emergency contraceptives. At the same point, more studies (prospective trials) are required on this issue to firmly establish a link between OCP’s and breast cancer.

download

 

Source: http://timesofindia.indiatimes.com/city/delhi/The-pill-can-kill-AIIMS-study/articleshow/28251469.cms

 

IT city (Bangalore) is also India’s Breast Cancer Capital

Bangalore is India’s breast cancer capital – Dr. Anita Khokhar’s Blog

Bangalore now has the dubious distinction of being India’s Breast Cancer Capital. In a recently concluded population based study, the IT city has registered the highest incidence of Breast Cancer cases in the country (36.6 new cases for every one lakh population). (Source: PBCR data)

This data compiled from 11 cities across India revealed Thiruvananthapuram to have the second highest incidence of Breast Cancer at 35.1 followed by Chennai (32.6) and Nagpur (32.5).

Although the study has revealed these numbers, the actual incidence of Breast Cancer in these cities is much higher. This is due to the fact that many cases go un-reported.

The reasons for such a high incidence of breast cancer in Bangalore are quite obvious:

  • Increased incidence of smoking and alcohol consumption among women
  • Early menarche (age at which menstrual periods start) due to obesity and Western lifestyle habits
  • Late marriages and children
  • Lack of breastfeeding
  • Increased use of estrogen based contraceptives
  • Late menopause and the use of hormone replacement therapy following menopause

All these factors are known risk factors for breast cancer and are quite prevalent in Bangalore.

This study should serve as an eye opener for women not only in Bangalore but also other metropolitan cities of the country.

 

Goldilocks Mastectomy – Will it have a fairy tale ending?

Goldilocks mastectomy is a relatively new procedure developed by Dr. Grace Ma and Dr. Heather Richardson. This is a single stage procedure, which gives women facing mastectomy an option that takes the best features of having and not having reconstruction and combining them into a single procedure. This procedure has been a recent topic of debate at many scientific gatherings.

The first question which pops to the mind is that why was this surgery named as Goldilocks mastectomy? The following is the reply given by the surgeons who developed this surgery:

“Most of us are familiar with the story of the young girl faced with uncertainty in the woods and with a big, bad wolf nearby. She had many choices to make, and each time she face a choice, she evaluated the pros and cons; risks and benefits of each one.  Most involved extremes -too hot or too cold; too hard or too soft. But there was a third choice that had attributes of both and fell somewhere in the middle. This was considered “just right”.

We chose this name because this technique embodies the simplicity of not having reconstruction and only having a single surgery with as little as possible discomfort and down time. Yet it preserves as much of the patient as possible and avoids an amputated appearance.

For those who still aren’t quite as large as they would like to be and choose to wear a prosthesis, wearing a bra is much more comfortable and the cleavage much more natural appearing.  Redundant tissue under the arm is avoided and the final result very soft and supple.

When discussing the different choices and options pre-operatively, it is easy to remember what a “Goldilocks” is and how it differs from mastectomy with and without formal reconstruction.”

Not all patients are eligible for Goldilocks mastectomy. It is mainly suitable for patients with large breasts, who have enough tissue left behind after mastectomy, which can be used to reconstruct the breast. It is NOT suitable for patients with small breasts!!

The following are the advantages of this procedure, as highlighted by the surgeons on the website (www.goldilocksmastectomy.com)

  • Can be performed on one or both breasts
  • Can be performed for prophylaxis or treatment of disease
  • No additional surgeries are required
  • No implants or artificial devices are used
  • Decreased pain and shorter recovery time when compared to formal breast reconstruction
  • Surgical removal of breast gland under the skin means:
    • No screening mammograms required
    • Most patients do not require radiation (dependent on the stage of disease)
  • Excellent option for patients who don’t want reconstruction or are otherwise poor surgical candidates for formal reconstruction
  • Patients with extremely large breasts or sagging breasts have the best outcome from this procedure

In this procedure, all the breast tissue is removed and the remaining redundant skin and tissue is mobilized and used to reconstruct the breast, which is usually much smaller than the original size and also in some cases deformed.

As it is a relatively new procedure, long term data is yet to reveal the efficacy and safety of this procedure compared to the conventional mastectomy. Another point which I could gather after reviewing the limited data available on this surgery is that cosmetic results are far INFERIOR than a regular reconstruction (whether implant based or autologous). Another reason for its limited use is that it can only be used in patients with LARGE breasts and a point which has not been highlighted by the authors is the gross disparity in size of the two breasts after the surgery (which is a source of worry to the patient).

It is still early days for this procedure and only time will tell whether it will have a fairy tale ending or not!!

6a00d8354ce17369e20133f1b1e838970b

Breast cancer cases in India to double by 2030

Currently, one in 23 Indian women develop breast cancer, but a recently concluded study states that the numbers are going to double by 2030 –Breast cancer cases to double by 2030: Study – Times Of India.

India is on the brink of a breast cancer epidemic and the question is that is it really prepared to handle this epidemic?

This study highlights some important facts:

  1. 115,000 new cases of breast cancer are diagnosed each year and this number will double by 2030.
  2. Indian breast cancer presents a decade earlier than the Western world. This means Indian women in their thirties and forties will bear the brunt of this epidemic. As screening mammograms are not very useful in this age group, it cannot be used as an effective screening modality.
  3. Increasing longevity and lifestyle changes have been attributed to this sudden rise in the number of breast cancer cases.

There are some more shocking facts about Breast Cancer in India, which have been highlighted by other studies.

  1. Lack of awareness about this disease compounded by the lack of screening guidelines in the country, leads to majority of the patients presenting with locally advanced breast cancer. A study which I published in the Journal of Royal Society of Medicine, couple of years back, highlights this problem – Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study.
  2. The above mentioned study also highlights the lack of preparedness of the medical system to tackle with this epidemic. There are very few centres in India, which are providing dedicated Breast Cancer Services. These facts should trigger a positive change in the medical system and more emphasis should be paid to develop dedicated breast cancer units across the country.

As it is extremely difficult to develop screening guidelines for breast cancer in our country, I feel increasing awareness about this disease is the first thing which we should focus on, in addition to developing a more comprehensive breast cancer service in our country.

43