The surge in breast cancer worldwide, has brought a renewed effort to raise awareness on the disease as each country designs its own program to adapt to its particular needs throughout this month.
With an average of 2,500 new cases of breast cancer diagnosed each year in Sri Lanka, and evidence of a rising trend over the past quarter century, breast cancer is clearly one of the most common malignancies among Lankan women, accounting to over 27 percent of all female cancers islandwide.
“ If detected early and treated in time, unlike many other cancers, the survival rate of the patient is very high, while survivors will enjoy a better quality of life”, says Community Consultant Physician and Oncologist, National Cancer Control Unit, Health Ministry, Dr Nayana De Alwis.
Early treatment also gives them greater options, such as, the possibility of conservative surgery preserving body image, and less aggressive treatment options, she points out.
However, she notes with regret, that despite the availability of free screening facilities for two other common cancers in women such as cervical cancer and oral cancer, at the Cancer Control Unit at Narahenpita and state hospitals where clinical examination for breast cancer ( CEBC) and advice on self examination for breast cancer ( SEBC), is freely available, only a fraction of women volunteer to attend these clinics, and do so when the symptoms have advanced to a complicated stage.
Q. Although cancer, and in particular, breast cancer is a leading cause for morbidity and mortality in Sri Lanka, many are still unaware of how the disease is caused and the symptoms to look out for. Tell us briefly, what is cancer? How does it develop in our body?
A. The term cancer is used generically for more than 100 different diseases, including, malignant tumours of different sites (such as breast, cervix, prostate, stomach, colon/rectum, lung, mouth, leukaemia, sarcoma of bone, Hodgkin disease, and non-Hodgkin lymphoma).
Common to all forms of the disease is the failure of the mechanisms that regulate normal cell growth, proliferation and cell death. Ultimately, there is progression of the resulting tumour from mild to severe abnormality, with the invasion of neighbouring tissues, and eventually, spread to other areas of the body.
Cancers share several biological characteristics. One defining feature is the proliferation of abnormal cells.
The process of cell turnover is normally well controlled throughout life by basic biological mechanisms.
In cancer, however, the control mechanisms go awry. Cells in the affected part of the body grow beyond their usual boundaries, invade adjoining tissues, and may spread to secondary organs or tissues as metastases
The genetic changes that characterize cancer sometimes occur as a consequence of defective hereditary material.
However, hereditary forms of cancer are relatively rare, and more commonly, the relevant genetic changes take place as a result of an external influence.
Q. Of all these cancers, which is the commonest among Lankan women?
A. Breast cancer is the most common malignancy among the Sri Lankan females.
It accounted for 27% of all female cancers in 2010. An average of 2,500 new cases of breast cancer is diagnosed every year and there has been an increasing trend of Breast Cancer incidence over the past 25 years (Cancer Incidence data 2010).
Q. What are the risk factors for this form of cancer and who are most vulnerable?
A. When we talk about risk factors, it means anything that affects your chance of getting a disease such as cancer.
Most women who have one or more breast cancer risk factors never develop breast cancer, while many women with breast cancer have no known risk factors (other than being a woman and growing older).
Even when a woman with risk factors develops breast cancer, it’s hard to know just how much these factors might have contributed.
There are modifiable and non-modifiable risk factors for the development of breast cancer. Some risk factors can’t be changed – like a person’s age or gender. Other risk factors are lifestyle-related, such as cancer-causing factors in the environment or personal behaviours.
Non Modifiable risk factors are :
Gender
Simply being a woman is the main risk factor for developing breast cancer. Men can develop breast cancer, but it’s about 100 times more common among women than men.
This is probably because men have less breast tissue, as well as less of the female hormones oestrogen and progesterone, which can promote breast cancer cell to grow. Older women too are at risk. Over 80% of breast cancers reported in Sri Lanka are among women around 50 or 50 plus years of age.
Then, we have the genetic factor. About 5% to 10% of breast cancer cases are thought to be hereditary, meaning, they are caused by gene defects passed on from a parent.
Family history is another factor: Breast cancer risk is higher among women whose close blood relatives (maternal or paternal side) have breast cancer or ovarian cancers.
Overall, less than 15% of women with breast cancer have a family member with this disease. This means that most (85%) women who get breast cancer do not have a family history of this disease.
Personal history
A woman with cancer in one breast has an increased risk of developing a new cancer in the other breast or in another part of the same breast. (This is different from a recurrence (return) of the first cancer.) This risk is even higher if breast cancer was diagnosed at a younger age.
Benign breast conditions
Women diagnosed with certain benign breast conditions may have an increased risk of breast cancer. Some of these conditions are more closely linked to breast cancer risk than others.
Menstruation
Women who have had more menstrual cycles (periods) because they started menstruating early (before age 12) have a slightly higher risk of breast cancer. The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone.
Menopause
Women who have had more menstrual cycles because they went through menopause later (after age 55) have a slightly higher risk of breast cancer.
The increase in risk may be due to a longer lifetime exposure to the hormones oestrogen and progesterone.
Chest radiation
Women who as children or young adults, were treated with radiation therapy to the chest area for another cancer have an increased breast cancer risk. The risk is highest if the radiation was given during adolescence when the breasts were still developing.
If detected and treated early, unlike many other cancers, the five-year survival rate of breast cancer is very high.
Moreover, early treatment would result in greater possibilities of conservative surgery preserving body image and less aggressive and clinical examination facilities for breast cancer as well as for three other cancer treatment options, leading to a better quality of life of survivors.
Q. So what are the modifiable risk factors you referred to?
A. .Modifiable (Lifestyle-related) risk factors for breast cancer include the following:
Obese
Being overweight or obese after menopause increases breast cancer risk, the reason being, after menopause (when the ovaries stop making oestrogen), most of a woman’s oestrogen comes from fat tissue. Having more fat tissue after menopause, can increase the chance of getting breast cancer by raising oestrogen levels.
Pregnancies
Women who have not had children have a slightly higher breast cancer risk overall, while having many pregnancies and becoming pregnant at an early age reduces breast cancer risk. Still, the effect of pregnancy is different for different types of breast cancer.
Breast feeding
Breast feeding is a protective factor for breast cancer development. The reason for this possible effect may be that breastfeeding reduces a woman’s total number of lifetime menstrual cycle.
Hormone pills
Taking hormone (Oestrogen, progesterone) containing drugs for long periods without medical advice has slightly increased the risk of developing breast cancer.
Alcohol
Drinking alcohol is clearly linked to an increased risk of breast cancer. The risk increases with the amount of alcohol consumed.
Physical activity
Evidence is growing that physical activity in the form of exercise reduces breast cancer risk.
Q. How can breast cancer be detected early?
A. In order to detect breast cancers early a woman should be aware about her breast.
Q. What is Breast Awareness?
A. It is a process of getting to know your own breasts and becoming familiar with their appearance. You can become familiar with your breast tissue by looking and feeling. Being breast aware and knowing what is normal for you will help you to be aware of any changes from normal.
Before menopause, normal breasts feel different at different times of the month. The milk-producing tissue in the breast becomes active in the days before a period starts. In some women, the breasts at this time feel tender and lumpy, especially, near the armpits.
After menopause, activity in the milk-producing tissue stops so that normal breasts feel soft, less firm and not lumpy.
Q. What are the changes or signs to look for?
A. Let’s begin with Appearance. Any change in the outline or shape of the breast, especially, those caused by arm movements, or by lifting the breasts. Any puckering or dimpling of the skin.
Next, we come to feelings such as, discomfort or pain in one breast that is different from normal, particularly, if new and persistent.
Thirdly, watch out for lumps. Any lumps, thickening or bumpy areas in one breast or armpit which seem to be different from the same part of the other breast and armpit.
This is very important if new. A change in the nipple too is significant, e.g if you have a nipple discharge and it is a new symptom and not milky, don’t ignore it. Also, if there is bleeding or moist reddish areas which don’t heal easily. Any change in nipple position – pulled in or pointing differently, or a nipple rash on or around the nipple, is equally significant.
Q. What should we do if we find such changes?
A. First, don’t panic. There can be many reasons for changes in the breast. Most of them are harmless, but all of them need to be checked as there is a small chance they could be the first sign of cancer. If there is any change in the breasts from what is normal, it needs urgent attention.
Q. Are there simple guidelines we can follow?
A. Follow the Breast Awareness for Point Code :
• Know what is normal for you .
• Look and feel
• Know what changes to look for . Report any changes without delay
Q. What is the Health Ministry doing with regard to prevention and early detection of the disease?
A. As in the rest of the world, during this month our objective will be to increase public awareness and initiate action for early detection and prompt treatment of breast cancers.
Early detection of breast cancer is encouraged by increasing public awareness on breast cancer, ‘Be Breast Aware’ Breast Self-Examination (BSE) and Clinical Breast Examination (CBE).
Q. Have you had a good response to these awareness raising programs.?
A. Yes and No. More people are coming forward to be screened and not feeling embarrassed to undergo clinical examination. But unfortunately, there still seem to be a gap that needs to be filled in knowledge and awareness .
Lack of awareness among the general public with regard to the importance of breast awareness, BSE and CBE still contribute significantly to the underutilization of free health services available for early detection. This has resulted in a considerable proportion of cases of breast cancer detected in late stages.