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Today, 24 November 2009

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Yesterday, 23 November 2009

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Breast cancer is not a new disease. Even the ancient Egyptians knew that non-infective breast lumps could be dangerous and should be removed.

Who gets breast cancer?

Between 3500 and 4000 South African women are diagnosed with breast cancer every year. About 40 percent will die from the disease. A quarter of breast cancers are diagnosed before the age of 50.

The last 20 to 30 years have seen an increase in the incidence of breast cancer, even taking into account earlier diagnosis from mammography and the ageing population.

What are the risk factors for breast cancer?

Many risk factors have been identified for breast cancer. However, all these only account for about one third of the incidence. All other cases remain unexplained.

Age
Age is by far the most important risk factor and can be explained by looking at the risk in relation to age over a woman's lifetime. A 30 year old woman will have a risk of about 1:6000. This will rise to 1:600 by the age of 50. This doubles again by the age of 70 to 1:300.

Family history
Family history is a difficult relationship to interpret and the advent of potential testing for the so-called breast cancer genes, BRCA 1, BRCA 2 and BRCA 3, has led to a minefield of ethical and medicosocial issues. Risk of breast cancer is approximately doubled if there is a first degree relative with the disease. Two first degree relatives increase the risk five to six times.

Two patterns of inheritance have been identified. The first is familial in which there is some susceptibility which is then modified by various other factors.

Then there is a true genetic association, with the presence of the breast cancer genes, which were identified in 1990 at Berkley University in California. The gene BRCA 1 is thought to cause a 70 percent increase in the risk of breast cancer by the age of 70 and 87 percent by the age of 80.

Along with this is an increased risk of ovarian cancer. Men are also affected by this gene in that they will have an increased risk of prostate cancer and there is also a link with cancer of the colon.

Previous breast disease
If breast cancer has occurred in one breast then the residual breast tissue is at higher risk of developing cancer. This is estimated at between 0.5 and 1.0 percent cumulatively per year. The outcome is not worsened by a second cancer and is determined by which is the more advanced. This provides a strong incentive to have regular check ups after breast cancer is treated.

There is no connection between lumpy breasts in general and breast cancer. However, there are certain types of cell changes in the breast which are associated with an increased risk of breast cancer. This means that if a biopsy of a breast lump shows certain types of benign breast disease, this may indicate a slightly increased risk of breast cancer. These women should be followed up regularly, and if possible have regular mammograms.

Hormonal factors

• The earlier a woman starts her periods, known as menarche, the higher the risk of developing breast cancer in later life.

• Women who have not had children have a greater risk of breast cancer, as have those who have children late in life.

• If natural menopause occurs after the age of 55 this doubles the risk of breast cancer compared with a women in whom menopause occurs ten years earlier. Surgical menopause, by hysterectomy, in a woman under the age of 35 decreases the risk still further.

• Many studies have failed to show any major relationship between oral contraceptive pill use and breast cancer, except in that its use may be to delay pregnancy, which increases breast cancer risk in itself.

• The relationship between the use of hormone replacement therapy (HRT) and breast cancer is controversial. There does appear to be a slightly increased risk, 1 percent higher than that of women not on HRT. However, this risk rises if HRT is used for more than 15 years. This risk is even higher if there is a family history of breast cancer. But HRT greatly reduces the risk of cardiac disease and osteoporosis, so this must be weighed up against the risk of cancer.

Environment
Environmental factors have increasingly been looked at due to the rising incidence of the disease. Western societies have the highest incidence of breast cancer, 60 to 70 per 100 000. Asian countries such as Japan and China have an incidence of about 25 per 100 000. However, when Japanese women move to the USA or Australia the incidence rises to that of the West within two generations. This suggests an environmental influence. There may be a link between a high fat diet and breast cancer, although this has not been proven. Alcohol seems to play a part, particularly in post menopausal women on HRT.

It is important to remember that when all these risk factors are considered they only account for about 30 percent of all the known causes of breast cancer. The remaining 70 percent are unexplained.

Breast cancer screening

Every women should perform breast self examination regularly, from at least the age of 30 and younger if she has major risk factors.

The policy on mammography varies between countries, and is most aggressive in the USA. A combination of a medically aware population and the high incidence of medical litigation probably account for this, so it should not necessarily be taken as the gold standard. Most recommend regular, possibly annual, screening over the age of 50 where affordable. The presence of major risk factors will obviously modify this.

Treatment

The main focus of management of breast cancer is early detection, local control and stopping spread to other areas of the body.

If a cancerous lump is detected early then a combination of surgery, often now preserving the breast, local radiotherapy and chemo and hormonal therapy are used. The surgery removes the cancer, the local radiotherapy suppresses any remaining local disease and the chemo and hormonal therapy suppresses any distant spread.

Specific details of treatment will vary between centres and with the extent of the disease at diagnosis.

The future

Breast cancer kills women and is rising in incidence. Women are important members of the community and women's diseases should receive at least as much attention as the main cancers which affect men, particularly prostate cancer which has had so much publicity on recent years.

Education is paramount, not only of our politicians and health policy makers, but of women themselves. In breast cancer early detection is vitally important. The value of regular self examination cannot be overemphasised, and the message must be spread to the less advantaged members of our community who often present with late cancers and so have a higher mortality from the disease.