Breast Cancer

Inspirational Breast Cancer Celebrity

Kylie Minogue, born to an Irish father and a Welsh mother, began her career as a child actress, but found her true calling as a singer. With the release of a series of highly acclaimed music videos, the Australian has become a household name the world over.

But behind the success and the glamor is a woman of great courage and resolve. Kylie may have won legions of fans with her music, but nothing has won her more admiration and respect than her courage and dignity in the face of great adversity.

In may 2005, Kylie was diagnosed with an aggressive type of breast cancer. The news came as a shock as her doctor had initially assured her that she was fine. In an interview later, Kylie said, “You must follow our intuition and if you have any doubt, go back again”.

The second diagnosis, confirming breast cancer, occurred on the eve of one of the biggest singing tours of her career. Kylie was lucky it was early-stage breast cancer; it was confined to the breast and perhaps to the local nodes, and had not spread to other parts of the body.

With the cancellation of her singing tour and confronted by a deadly disease, Kylie slipped into depression, fearing she would never be ‘normal’ again. But despite this double whammy, she resolved to fight the depression and then her cancer.

“I had to prove i had what it takes into continue what i had done in the past.” With renewed courage and fortitude, Kylie underwent breast surgery and chemotherapy.

The battle against cancer was difficult. Kylie confessed that she was frequently weeping and begging her oncologist to get her off the treatment. The side-effects of the cancer drugs produced intense nausea and headaches, and she also went through the same hair-loss ordeal as other chemo patients (she changed her hairstyle to a short, chic look).

Thanks to her oncologist’s admonitions, she continued her treatment. And, finally, a glimpse of hope – the 6-month treatment for her breast cancer was declared a ‘success’. However, Kylie had to continue daily radiotherapy for another six months to prevent the tumors from recurring.

Fast-forward to September 2010. Despite the worst aspects of the treatment out of the way, the life-saving medication that Kylie takes continues to have side-effects. Although looking forward to being able to stop taking the medication this year, Kylie said going off the drug may make her feel insecure as she has relied o it for long time.

How did Kylie get through her treatment ordeal? She attributes this to hr work and her fans. Her profession and limelight career gave her hope. “I don’t know how other people manage, but as i went through the treatment, I tried to concentrate on the future. You lie there and you think, ‘When this is over…’.”

Within a year, she was on tour again and had released a couple of albums.

Last year, she was voted by 1,000 online participants as the most inspirational breast cancer celebrity in an event organized by the British-based mastectomy-wear specialist Amoena. The company’s spokewoman, Rhoda White, said in a statement: “Kylie inspired many women to be more direct about their own fears, encouraging them to believe they would get through their ordeal”.

Kylie’s incorrigible optimism not only helped her make a rapid recovery. but has also inspired the many women who have had to undergo a mastectomy.

She now looks forward to many more years of doing what she loves best – making music. She said in a magazine’s interview that “I’ll be the one in the old people’s home doing high-kicks in the corner. There is an inherent part of me that says, ‘This is what i do, this is who I am.’ I just can’t stop – it’s difficult to subdue a performer’s intinct”.

Treating Breast Cancer

Between 2003 and 2005, nearly 12,000 new cases of breast cancer were reported to the National Cancer Registry, making it the most common cancer among Malaysian women above age 20.

Early detection and treatment improves the likelihood of cure as well as quality of life. Once a diagnosis of breast cancer is made, the treatment options will be discussed with you and your family.

Preparation

The best treatment should take into account you physical, emotional, psychological and rehabilitation needs. A team of healthcare staff, including a surgeon, oncologist, radiotherapist, pathologist, radiologist, plastic surgeon and counsellor,  is usually involved in treating you. Treatment is divided into:

1) Local Treatment – by surgery and/or radiotherapy, to control the disease in your breast and lymph nodes.

2) Systematic treatment, by chemotherapy and hormone therapy, to control the cancer cells which may have spread to other parts of your body.

The type of treatment also depends on the cancer stage. Stages 0, 1 and 2 are considered early breast cancer and the primary treatment is surgical. Stages 3 and 4 are late breast cancer. In Stage 3, surgery is either done with or without chemotherapy. Stage 4 cancer is advanced and cure is less likely, thus treatment is systemic, ie, chemotherapy or hormonal therapy. The ulcerating breast cancer is then surgically removed.

Local treatment

Currently, the options for local treatment of breast cancer are:
Modified radical mastectomy – The breast is removed with all the lymph nodes under the armpit, but the underlying muscles are left behind and breast reconstruction is done. Radiotherapy to the chest wall is not required if the tumor is small, lymph nodes are not involved and the margins of the tumor are clear.

Breast conservation surgery – The tumor is removed with margin of normal tissue, along with the lymph nodes under the armpit. The breast is treated with radiotherapy. Only suitable for small tumors – less than 4 cm – this surgery is appealing to women because they usually don’t lose their breast.

In US, all lymph nodes under the armpit are usually removed because most women present with stage 2 breast cancer. Sentinel lymph node biopsy – the removal and examination of the first lymph node to which cancer is likely to spread from the primary tumor – is either not available in most centres or costly.

After breast surgery, you may experience tightness in the skin of the breast area, and your arm and shoulder muscles may be stiff. Exercising is important to regain movement and strength. You may also have numbness and tingling in the chest, underarm, shoulder and arm. Thes feeling usually go away within a few weeks or months.

Removing the lymph nodes may also give rise to swelling of the arm (lymphoedema). It is also easier for infection to occur in the arm. Therefore, you need to avoid injuries to the arm and hand on the treated side.

Systemic treatment

Systemic treatment is required to eliminate micro-metastases, which are cancer cells that spread from the breast through the bloodstream to other organs, eg, the lungs, liver and bones.

Months or years after treatment, cancers can be reactivated and grow to become obvious metastases in these organs. Tumor size, lymph node involvement and survival are all related.

Chemotherapy – (treatment with anti-cancer drugs) kills cancerous cells, but it affects normal cells as well. If administered after local treatment in early breast cancer (Stages 1 and 2 ), it is known as adjuvant chemotherapy. If administered in Stage 3 cancer – to shrink the tumor before local treatment – it i known as neo-adjuvant chemotherapy. If administered in stage 4 breast cancer – where local treatment is only for palliation ( t reduce the severity of the cancer) – it is called primary chemotherapy.

Chemotherapy consists of a combination of drugs injected through a vein, usually at 3-weekly intervals, for duration of 4-8 cycles, depending on the drug type.

Common side-effects of chemotherapy are nausea, vomiting, loss of hair, and a drop in the red and white cell count and platelets.

Hormone therapy

After surgery, tissues are sent to the lab to check whether the cancer cells are sensitive to hormones. Hormones secreted by the endocrine glands can affect the growth of breast cancer. The cell in the tumor can be hormone receptor positive, ie, they contain hormone receptors, or negative.

Tamoxifen, an anti-oestrogen drug in th form of tablets, has little side-effects, although it may cause weight gain, hot flushes and irregular periods in younger women.

In recent years, a new group of drugs called aromatase inhibitors, including exemestane, anastrozole and letrozole, has been used in post-menopausal women instead of tamoxifen. It is found to be slightly more effective in preventing the cancer from recurring.

In pre-menopausal women with advanced breast cancer, removal of the ovaries may be carried out to decrease the oestrogen levels in the blood.

Targeted therapy

Targeted therapy is a new form of treatment whereby a special drug is developed against a specific target in the breast cancer. The first targeted drug in breast cancer was developed against the HER2 proto-oncogene, which is found to be over-expressed in 20-30% of breast cancers.

This new drug, a monocional antibody against HER2 receptor, is called trastuzumab. Another anti-HER2 drug which has been shown to be effective in HER2+ breast cancer is lapatinib.

Diagnosing Breast Cancer

A friend discovered a lump in one of her breasts when she was doing her monthly breast self-examination (BSE). Her doctor confirmed the existence of a lump by performing an ultrasound examination, followed by a mammogram.

A piece of the lump was then extracted via a needle biopsy and sent to the lab for testing. Thankfully, the lump turned out to be non-cancerous. Since the discovery, my friend has been consistently checking her breasts for lumps and going for annual check-ups.

The story above illustrates the need for BSE every month or more often to familiarize yourself with your breasts and the normal changes that take place every month, so you will quickly notice if any lumps form. However, do check with your doctor if your technique is correct.

Preliminary test
Imaging and biopsy

Upon detecting a lump during BSE, you should visit your gynecologist, who will take your medical history before doing a physical examination. Your doctor will examine your breasts and feel for any enlarged lymph nodes under your arms and at the base of your neck. After the examination, you may need some tests.

Imaging tests, such as breast ultrasound scans and mammograms, are usually done. Breast ultrasound is painless and takes just a few minutes. Ultrasound uses sound waves to make a picture of the inside of the body. It is usually used for women under 35 whose breasts are too dense or solid to give a clear picture with mammograms. It is also used to see if a breast ump is solid or if it contains fluid. A fluid-filled lump is called a cyst.

A mammogram, on the other hand, is an X-ray of the breasts and is used in women above 35. A mammography is useful for finding early changes in the breast, when it may be difficult to feel a lump.

A mammography can be painful because the breasts are put between two metal plates and a little pressure is applied. But most women describe this as mild-to-moderate discomfort. It only lasts a few minutes and is not harmful to the breasts.

Next, a breast biopsy may be performed. During a biopsy, a small sample of cells or tissue from your breast is taken by your doctor and sent to the lab. At the lab, a pathologist examines the sample under a microscope to see if it contains areas of cancer. There are different ways of taking these biopsies, including needle aspiration, needle biopsy and excision biopsy.

A needle aspiration – also known as fine needle aspiration cytology (FNAC), is done in the outpatient clinic. The doctor uses a fine needle and syringe to take a sample of cells from the breast lump. This test might also be used to drain fluid from a non-cancerous cyst.

Needle biopsy – is also called ‘core biopsy’ and uses a slightly bigger needle than the one used for aspiration. A local anesthetic is used to numb the area and allows the doctor to take biopsy – a core of tissue from the lump. This type of biopsy is useful because the pathologist can see the cells in place within the piece of breast tissue that has been removed, so it is possible to differentiate between a non-invasive and invasive from the breast cancer.

Excision biopsy -  is also called a surgical biopsy. A minor operation is done to remove the whole lump under general anesthetic. The lump is sent to the lab for examination.

When breast cancer is diagnosed

If the tests confirm breast cancer, your doctor may want to do further tests to check the cancer size and whether it has spread to the lymph nodes or other parts of the body. These tests will confirm what stage the cancer has reached and will help your doctor determine which treatment is best.

The staging system normally used in breast cancer is called TNM, which stands for tumor, node and metastasis. Thus, TNM staging takes into account the size of the tumor, whether the lymph nodes are affected and whether the cancer has spread to other parts of the body (metastasis).

The T stages are numbered 1-4 and describe the size of the tumor. The N stages are numbered 0-3 and describe which lymph nodes are affected, if any. The M stages are M0 (no sign of cancer spread) and M1 (cancer has spread to another part of the body apart from the lymph modes under the arm).

Your doctor will these three stages together to give you your overall stage. For example, you may see a tumour described as T2 N0 M0. This would be a single tumour 2-5 cm across, with no evidence of spread to any lymph nodes and no evidence of spread beyond the breast.

Breast Cancer Causes

A cancer, or tumor, is a group of cells that has lost its ability to ‘die’. The process of programmed cell death – also known as apoptosis – is what keeps cell growth in check. When a cell mutates and loses its ability to die, it will keep replicating without end. The result is a mass of tissue we call a cancerous tumor. Breast cancer is the most common cancer in women – in US and the rest of the world. Locally, it is also the top cause of cancer deaths among women.

The many causes

Although the causes of most cancers may be similar, it is important to list them out and to understand why these factors contribute to the disease.

Genetics

Also known as ‘family history’, the risk is increased if one has an immediate family member with breast cancer. Women who have mothers, sister or daughters who develop breast cancer before the age of 50 should get themselves checked.

Age

Our genetic blueprint gathers damage and errors as we age due to the constant replication that takes place. These errors build up and if it happens in the wrong place, it results in a cell that doesn’t die. This is the genesis of a tumour.

Early menstruation (before age 12) or late menopause (after age 55).
Such women are exposed to the effects of oestrogen and progesterone for a longer period compared to the average woman.

Being woman

This might sound silly, but men do get breast cancer as well. Having said that, women are still about 100 times more likely to get breast cancer.

Dense breast tissue

Dense breasts have more gland tissue, which increases the risk of a women developing breast cancer. This trait also makes it harder for doctors to spot irregularities when a mammogram is performed.

Race

Different races have different cancer profiles and risks. In US, white woman are most likely to develop breast cancer, followed by black women. Their lifetime risks are 1-in-6 , 1-in-17 and 1-in-28, respectively.

Alcohol

Drink away, but don’t say you’ve not been forewarned – alcohol has been associated with an increased risk of breast cancer. According to the American Cancer Society, women who 2-5 glasses of alcoholic drinks a day have 1.5 times the risk of developing breast cancer than those who do not drink.

Obesity

Although the medical fraternity may seem biased against fat people, the facts are irrefutable. Not only are they more likely to get a hear attack, develop diabetes and not fit into a bikini, obese and overweight women run a higher risk of developing breast cancer.

Not breastfeeding

The benefits of breast feeding are not only protective for the infant, but for the mother, too. The protection could possibly be because a woman does not have menses when she breastfeeds – the regulatory hormones prevent a woman from going into the reproductive cycle again when providing nutrition for her child.

The list goes on. Suffice to say. if you meet one or a few of the criteria above, the best thing to prevent breast cancer is to visit your doctor/ gynaecologist regularly.

The Case of The Aggressive Breast Cancer

While many women survive breast cancer, there are also quite a number who succumb to the disease at a young age. This is because some forms of breast cancer are so aggressive that the prognosis is extremely poor upon diagnosis.  One such form is HER2 positive (+) breast cancer.

HER2+ is more aggressive than other types of breast cancer. This is due to a mutation of the genes in the protein HER2 ( human epidermal growth factor receptor 2) which promotes the rapid growth of cancer cells. It is believed that about 1-in-5 women with breast cancer will have the HER2+ form.

HER2+ breast cancer is less responsive to treatment, besides causing tumors to spread quickly to other parts of the body. There is also a higher chance of relapse years later. However, with optimal treatment, which includes chemo and anti-HER2 therapy, the chances of survival today have improved.

Therefore, its is extremely important to know the status of your HER2 (besides hormone) upon a diagnosis of breast cancer. Early detection and accurate diagnosis are crucial for successful breast cancer treatment. Speak to your doctor about HER2 testing.