Malignant breast lumps
A malignant breast lump means it is a cancerous tumor that can spread to other tissues. If your doctor suspects a malignant lump, he/she will perform a biopsy to be certain it is malignant. Rarely, some tissues in the breast can be similar to malignancy tissues, but only a biopsy will confirm this for certain.
There are various types of malignant lumps.
Invasive ductal carcinoma
Invasive ductal carcinoma is a common type of malignancy arising in the ducts of the breasts. It is called invasive because it starts small and grows and spreads into the tissue. If the malignancy is not treated it will continue to spread to other parts of the body like the lymphatic system, axillary, liver, lung or bone.
The importance of early detection for better cosmetic outcome and cure
It is very important to diagnose invasive ductal carcinoma at an early stage because of the tumor’s ability to spread throughout the body. The Women’s Health and Breast Center at the Khalidi Hospital advises women from the age of 40 years to have an annual mammogram. Women should also perform breast self-examination regularly.
Some tumors grow quickly, within a few months; others take three years to grow to a palpable size. Usually, when you feel a lump it is about 1 cm in size. You will not feel any lump below this size; hence, the benefit of screening mammograms. They can detect tumors that are very small.
When the tumors are small they do not spread to other sites of your body, so they are highly curable and treatment is easier. Treatment after early diagnosis is only with surgery. You will not need chemotherapy or radiotherapy.
Your doctor at The Women’s Health and Breast Center at the Khalidi Hospital advises women, whenever you feel a lump, do the test. If you have a benign lump you do not need to worry. If it is malignant you will have a much better chance if it is detected early.
Invasive lobular carcinoma
Invasive lobular breast cancer is similar to invasive ductal carcinoma. It starts in the cells surrounding the lobular (milk ducts) and spreads to other tissues.
There are some differences. Invasive lobular malignancy does not usually come as a lump and is not clearly diagnosed, as it invades the breast without clear signs at the beginning.
Diagnosis of invasive lobular breast cancer
There are also a few differences in the management of the tumor. Your doctor will perform various examinations. First your doctor will examine your breasts and check for swollen lymph nodes under your arms or neck.
Then you will be asked to do a mammogram, an ultrasound and as a final confirmation, a biopsy. A biopsy is when a small sample of cells or tissue is taken for examination at the lab. It is either taken out by a needle or by surgery.
Treatment of invasive lobular breast cancer
Treatment is the similar to invasive ductal carcinoma. If your tumor is detected early, treatment may be only surgical.
After surgery, your doctor may suggest radiotherapy, chemotherapy or a combination of treatments, depending on the stage of the tumor.
DCIS- ductal carcinoma in situ
We call DCIS cancer but it is probably a misnomer: DCIS is a non-invasive breast cancer that arises in the milk ducts and stays there. At the beginning you cannot feel it. The lump only shows up on a mammogram as some breast changes. DCIS is the most common type of non-invasive breast cancer
Treatment of DCIS – no chemotherapy needed
The treatment is usually simple. It does not need chemotherapy even if you catch it late because the tumor stays in the duct and does not spread to other areas of your body.
Your doctor will remove the tumor through surgery and he/she will decide if you also need radiation or hormone therapy, or a combination of both in addition to the surgery.
Lumpectomy: Your doctor will remove the tumor completely through surgery. Most of the breast is saved. Sometimes radiation therapy accompanies this surgery.
Mastectomy: Your doctor may remove all your breast if he/she detects the tumor is located in multiple areas of the breast or if the tumor is large in size.
In general DCIS is not a lethal disease, but there is a better outcome for cure if it is detected early. Chemotherapy is generally not needed even if in rare instances the cancer cells have migrated to other parts of your body. Your doctor may suggest hormone treatment after your surgery.
Your doctor at the Women’s Health and Breast Center at the Al-Khalidi Hospital will consult with you to decide the best course of treatment for you, as each individual case is different.
Hormone receptors are proteins found in breast cells. They are sensitive to estrogen and progesterone hormone signals telling them to grow. Breast tumors have receptors to these as well. If your pathology report shows evidence of hormone receptors, it means your doctor can give you hormone treatment to make sure the tumor does not come back.
HER2 is a protein found on the surface of normal breast cells and they respond to guided treatment with Herceptin. HER2 can affect the growth of some malignant cells. Some breast cancer cells have a high number of HER2 receptors that stimulate the malignant cells to grow and divide. The higher the level, the quicker the cells will divide.
HER2 differs from region to region. If the tumor has receptors for HER2, it is a little worse in terms of outcome than if it has only the hormonal receptors to estrogen and progesterone.
Treatments known as targeted therapy have been developed to treat HER2.
Some tumors have none of these receptors. For example, the two hormonal receptors for estrogen and progesterone are negative and the HER2 is negative. This is considered the most difficult type of cancer to treat.
Triple negative is probably more common in the Middle East because there is a genetic component and family intermarriage is common. Some women with triple negative breast cancer have a faulty BRCA1 gene.
This is the worse type of cancer if they don’t have these receptors. In our region this might be more common because there is a genetic component and we have intermarriage.
Treatment is usually a combination of surgery (lumpectomy or mastectomy), radiotherapy, and chemotherapy. Your doctor at the Women’s Health and Breast Center at the Al-Khalidi Hospital will discuss the options of treatment with you including the option of breast reconstructive surgery.
Advances in surgery
The trend over the years has been to do less
In surgery, the trend over the last 150 years has been to do less. More than a century ago, doctors performed aggressive, mutilating surgery. They would remove the breast, skin, and lymph nodes. After the 1950s, the started becoming more conservative.
Today we know we do not have to remove all of the breast; just the cancer and surrounding tissue. Some women, however, feel more reassured when the entire breast is removed.
The outcome will not be better. It has no impact on the cancer. The treatment for the cancer is the same whether you remove the whole breast or not, so why do a mutilating surgery? And the flip side, some women think if doctors remove only the tumor it means it is a better tumor. But this is not always so. Sometimes doctors need to remove the whole breast for technical reasons.
The main aim for any treatment plan is that all evidence of the tumor in the breast is removed.
Sentinel lymph node biopsy
Just over 20 years ago, the lymph nodes were removed routinely in surgery for breast cancer. Tumors spread to the lymph nodes in 40% of women with breast cancer. But in doing that surgery doctors are operating on 60% of women who do not have tumors in their axilla. In addition, there are complications with removal of the lymph nodes: it causes arm pain and swelling.
Since 20 years or more doctors perform a sentinel lymph node biopsy. During surgery your doctor will inject a dye that migrates to the lymph nodes. Then he/she will make a small opening in the axilla, and take 1-3 lymph nodes that get colored. This will tell your doctor if the tumor has spread to the lymph nodes or not. This is done at the time of surgery. If the pathology report indicates no evidence or tumor, your doctor will not remove your lymph nodes. This is much easier for your doctor, less pain and less complication for you in the long term.
Developments in treatment
Surgery is the main treatment if the tumor is localized, as it is the only chance for cure. If the tumor is spread surgery is usually not indicated. The main aim is to remove the tumor and not leave anything behind.
All treatments and medications applied to help prevent breast cancer spread is called adjuvant therapy.
The aim of radiotherapy is to clear the area so the tumor does not come back.
The aim of chemotherapy is to clear the body so the malignant cells do not return. It takes between 4 and 8 cycles, over 3 and 5 months.
Hormone and targeted therapy have the same target– to kill these cells. The hormonal therapy is taken as a tablet during a period of between 5-10 years. Sometimes you need a combination of all treatments, or part of them. This depends on many factors including the type of cancer, the stage and what is the best outcome.
Developments in chemotherapy and in targeted treatment are evolving. New medications have emerged that add a little to the improvement of the outcome of breast cancer. There is no breakthrough for chemotherapy so far, aside from targeted therapy.
The development in radiotherapy for the breast concerns the aim of reducing the side effects or complications of radiotherapy and at the same time improving the outcome of radiotherapy. The aim of radiotherapy now is to clear the rest of the breast, cleaning the area of these cells. But radiotherapy has side effects, causing redness and pain and changes in feeling of the breast and if it is deep it can affect the heart and lung.
Recent research is looking to administer radiotherapy only to the tumor and surrounding area without affecting the whole breast. It is easier to administer and takes a shorter time, within 1-2 weeks,(usually radiotherapy takes 5-6 weeks). But research needs more time to make sure this treatment is effective and helpful.
Can I do a cancer marker test instead of mammogram?
The short answer is No.
Many people request cancer marker tests from their lab, and a number of doctors use it as a diagnosis for cancer. Some tumors secrete these markers, but not all of them. The more tumor you have the higher the level of these markers. Once the marker is at a high level, it means the breast cancer is advanced or has spread to other parts of body.
It is possible to have early detection by doing a scan or examining the breast. So why wait till you see results in a cancer marker? Your doctor needs a test that diagnoses the tumor at an early stage, before it comes apparent on examination or mammogram. Your cancer marker will always be normal when the tumor is very small.
Your doctor often uses the markers after diagnosis and with treatment to test if tumor has spread. If it rises your doctor will suspect the tumor has come back somewhere in the body.
This test is misleading. There could be a sizeable tumor, but not cancer markers; or there could be nothing, but there is a high cancer marker reading. People could spend days worrying, testing, investigation and spending a lot of money. Most of the time it is not helpful to do cancer markers for the purpose of diagnosis.
Diet for breast cancer patients
Paying attention to your diet is one additional detail you can add as a breast cancer patient. The general advice from the Women’s Health and Breast Center at the Khalidi Hospital is to eat plenty of fiber in the form of fruits and vegetables, exercise regularly and decrease your fat and red meat consumption.
Fat and red meat are related to breast cancer. Keeping your weight within a healthy range will also help you recover. The risk of cancer is higher in overweight. Smoking is related to breast cancer, but it is not a strong factor.