Diagnosis of breast cancer
The diagnosis of breast cancer is ultimately dependent on having a definitive tissue diagnosis. That means a pathologist must be able to identify and determine the exact type of breast cancer from tissue taken from the patient. The triple test is the standard way of determining whether a breast lump is cancerous or not. The three components of the triple test are:
- Clinical examination by experienced person treating breast cancer.
- Imaging - This is a mammogram combined with an ultrasound investigation of the breast. A mammogram is a specialised x-ray taken of the breast, and an ultrasound investigation is an imaging tool using ultrasonic waves to detect abnormalities in the breast tissue.
- Fine needle aspiration cytology -This is a process where cells are taken from the breast for the pathologist to examine. It involves putting a needle into the breast lump and is not much different from taking a blood sample.
In some patients, all three of the elements of the triple test will point to the same diagnosis, and this will be a conclusive diagnosis with a 99% accuracy.
In the small group of patients where the triple test is inconclusive, an open biopsy or core biopsy is required to get to a definitive diagnosis.
What is a breast biopsy?
A breast biopsy is a surgical procedure that removes a portion of breast tissue for testing in a laboratory. It is a method of assessing a suspicious area in your breast to identify or exclude breast cancer. The two main types of breast biopsies are a core biopsy and an excision biopsy. A core biopsy is generally done under local anaesthetic and involves using a specialised needle that removes a small core of tissue from a breast lump for examination by a pathologist. This differs from a fine needle aspiration cytology. With fine needle aspiration cytology, only single cells are removed from the breast tissue. A core biopsy produces a small core of intact breast tissue for the pathologist to examine. An excision biopsy is the surgical removal of a lump typically done under general anaesthetic. An excisional biopsy is seldomly required and is usually reserved when all other less invasive tests cannot provide a conclusive diagnosis.
What is breast cancer treatment?
The main aim of treatment of breast cancer is to cure the patient. The treatment is divided into two main groups:
- Systemic treatment
This is aimed at reducing the risk of having spread the cancer to other organs. This can involve hormonal treatment, chemotherapy, or observation only. - Regional treatment
is mainly aimed at controlling the primary tumour in the breast and lymph nodes. Regional treatment usually requires surgery.
Regional treatment
- Breast cancer surgery:
- Lumpectomy or Breast-conserving surgery - The surgeon eliminates the tumour and a small amount of good tissue surrounding it during a lumpectomy, also known as breast-conserving surgery or wide local excision. Breast-conserving surgery always requires post-operative radiation to the remaining breast tissue to reduce the risk of local recurrence. Patients will be offered breast-conserving surgery if the predictable outcome is equivalent to a mastectomy. In other words, you will not be offered breast-conserving surgery if you are not perfectly suited for it. The main advantage of breast-conserving surgery is the obvious cosmetic benefits. The main downside to breast-conserving surgery is the need for radiation.
- Mastectomy - A mastectomy is a procedure in which all of the breast tissue on the affected side is removed. The lobules, ducts, fatty tissue, and some skin, including the nipple and areola, are removed during a mastectomy. (total or simple mastectomy). The main advantage of a mastectomy over breast-conserving surgery is that in most cases, radiation is not needed. The main downside of a mastectomy is the obvious cosmetic disadvantage. I usually advise delayed reconstruction for patients that choose to have a mastectomy and reconstruction. In selected cases, we do immediate reconstruction in conjunction with the plastic surgeon.
- Sentinel node biopsy - Your surgeon will discuss the role of removing the lymph nodes that receive the lymph drainage from your tumour with you to assess whether cancer has progressed to your lymph nodes. All patients with invasive breast cancer and no obvious lymph node involvement need to have a sentinel node biopsy to determine the possible spread of malignant cells to the lymph nodes in the axilla. It is important to understand that the sentinel lymph node biopsy does not influence whether a patient needs a mastectomy or is suitable for breast-conserving surgery. The lymph node involvement is key to whether systemic therapy is necessary or not.
A sentinel node biopsy involves injecting a radioactive substance into the breast the day before surgery and doing sequential imaging to detect the sentinel node. In our practice, this will be done by the nuclear medicine facility in George.
The actual images created by the sentinel node scanning provides no information on lymph node involvement but only helps us to identify the lymph node most likely to be involved with cancer.
On the day of surgery, during the surgical procedure under general anaesthetic, the sentinel lymph node is identified with a radioactive sensor and removed. In theatre, while the operation is underway, the pathologist examines the lymph node and determine whether it is involved with cancer not. If the lymph node is not involved, in other words, negative for malignancy, no further attempt at removing lymph nodes is made. If the lymph node is involved with the cancer and axillary lymph node dissection is done. - Axillary Lymph node dissection: This is offered to all patients with cancer in the lymph nodes in the axilla. In some patients, if there is obviously lymph node involvement preoperatively, one will plan to do an axillary lymph node dissection. In most patients, the decision of whether a lymph node dissection is needed or not will only be made during the operation, depending on the outcome of the sentinel node biopsy.
- Removing both breasts: (bilateral prophylactic mastectomy). Some patients have a very high risk of cancer in the other breast due to a genetic predisposition or a strong family history. Some women with cancer in one breast may choose to have their second (healthy) breast removed (contralateral prophylactic mastectomy). The discussion around removing a normal healthy breast is individual and will not be discussed on this platform. Generally, bilateral mastectomies are reserved for specific indications.
- Radiation therapy - To treat possible remaining cancer cells, radiation therapy uses high-powered energy beams such as X-rays and protons. This is usually done as part of breast-conserving surgery, but sometimes it is necessary, even in patients treated with a mastectomy, to improve the outcome if the tumour was close to the chest wall or surgical margins.
Systemic treatment
All patients treated in my practice for breast cancer will be cared for by a multidisciplinary team involving myself and an oncologist. Sometimes the help of a plastic surgeon is also required. The initial treatment is very often surgical, and most patients will be referred to an oncologist after the surgery. There are, however, certain circumstances where an oncology consultation or oncological treatment is advised before surgery. Preoperative consultation with the plastic surgeon will also be arranged if appropriate.
- Chemotherapy - Chemotherapy is a type of treatment that uses medications to kill fast-growing cells, such as cancer cells. The need for or advantage of chemotherapy to breast cancer patients can often only be determined once all the information and tumour biology and lymph node involvement are available. There is also a small group of patients that will benefit from preoperative chemotherapy. Chemotherapy is administered and monitored by an oncologist. Dr Bruwer works in close association with a team of oncologists.
- Hormone therapy - Hormone treatment, also known as hormone-blocking therapy, treats hormonally sensitive breast cancers. Often underestimated, the hormone treatment of early hormone-sensitive breast cancer as an adjuvant to surgery has greatly improved the outcome of patients suffering from breast cancer.
- Targeted therapy and immunotherapy are specific therapies aimed at defects in cancer cells and is appropriate and effective in selected individuals.