Breast cancer can be classified by the stage of cancer at diagnosis and their biological characteristics. These will determine treatment recommendations as it has prognostic (most likely outcome of the disease) implications and treatment implications.
Understanding the stage of the cancer is important to understand the prognosis and the treatment recommendation.
Cancers treated in earlier stages have better outcomes, more advanced cancers will need more aggressive treatment.
Cancer stage is based on:
The TNM staging system is based on:T: Size of the tumourN: Lymph node involvementM: Metastasis when cancer has spread to other organs like the lung, liver and bones. Different T, N and M in combination will determine the stage of the cancer.
Stage 0 or Ductal Carcinoma in Situ (DCIS) is a common non-invasive breast cancer, where cancer cells are still within the ducts and have not grown out to breach the duct linings into the surrounding normal breast tissue.
DCIS, also known as Stage 0 breast cancer, unlike invasive breast cancer, is not life-threatening, but it can increase the risk of developing an invasive breast cancer.
lnvasive breast cancer occurs when cancer cells spread beyond the ducts or lobules resulting in invasive ductal and invasive lobular breast cancer, the two most common subtypes of breast cancer.
Metastatic breast cancer refers to the stage when the cancer has spread beyond the breast to distant organs such as the lungs, liver or bones.
Breast cancers are also differentiated by the presence of special receptors on the surface of the cancer cells, such as the:
This is associated with the aggressiveness of the cancer and affects the prognosis of the patient.
More importantly, there are drugs to target these changes, and hence directed treatment for them will improve the outcome.
The histopathological (microscopic appearance) subtype of the cancer also helps to determine the prognosis, and nature of breast cancer overall.
The grade (assessment of how abnormal the cancer cells look) also determines the aggressiveness and hence, treatment recommendations.
The most common subtype is the invasive carcinoma of no special type (NST). Specific subtypes include invasive lobular, tubular, cribriform, metaplastic, apocrine, mucinous, papillary and micropapillary carcinoma, as well as carcinoma with medullary and neuroendocrine (WHO classification 2012).
If there is an unusual lump or changes in the breasts, seek medical attention. Try to pinpoint the area accurately as this will assist the doctor with the examination. Tests will be recommended to obtain a definite diagnosis.
Tests to diagnose Breast Cancer include:
1. Imaging
2. Biopsy
Mammography is a low-powered X-ray technique that gives a picture of the internal structure of the breast. Usual screening mammograms involve taking X-ray images of the breast compressed between two plates with two views taken — cranial caudal or horizontal and mediolateral oblique or diagonal.
Additional angles and magnified views may be taken if there are areas of concern. It can detect the presence and position of the abnormalities and help in the diagnosis of breast problems, including cancer.
Any previous mammograms (and reports if available) should be brought along when seeing a doctor.
Sometimes a lump that can be felt is not seen on a mammogram. Other tests may be necessary to determine if the lump is cancerous.
What to expect when you go for a mammogram.
Breast ultrasound is the use of high-frequency sound waves to produce an image of breast tissue.
The sound waves are transmitted from the probe through the gel into the body. The transducer collects the sounds that bounce back and a computer then uses those sound waves to create an image.
This uses a combination of magnetism and radio waves to build up a picture consisting of detailed cross-sections of pictures of the breasts.
The test involves lying on the stomach on a padded platform, with cushioned openings for the breasts, that passes through a tunnel-like structure (which forms a very large magnet). It may take up to one hour to complete, but is completely painless.
Magnetic Resonance lmaging (MRI) is useful when mammograms are not suitable, e.g. in young women with dense breast tissue or when findings on mammograms and ultrasound are not conclusive to achieve a diagnosis.
It is used as a screening tool for young women with high-risk factors like BRCA gene carriers or those with a very strong family history of breast cancer.
This involves taking multiple X-rays of each breast from many angles. The breast is positioned the same way as in a conventional mammogram, but only a little pressure is applied, just enough to keep the breast in a stable position during the procedure.
An X-ray tube moves in an arc around the breast while images are taken. Information is sent to a computer, where it is assembled to produce clear, highly-focussed 3-dimensional images throughout the breast.
This is a minimally invasive method that obtains a few tiny strips of tissue from an area of abnormality with a wide bore needle. Local anaesthetic is injected to numb the breast area, followed by a small incision in the skin to allow easy insertion of the needle.
If the abnormality is non-palpable (not detectable by clinical examination) and visible on the ultrasound, ultrasound guidance is used to obtain the tissue. Usually 2 to 6 cores of tissue will be obtained for examination.
A nurse will apply compression to the breast to stop any bleeding. The wound is closed by a steristrip and the dressing applied. Strenuous activity is to be avoided for 2 days after the biopsy.
Vacuum-assisted biopsy (VAB) devices use a larger bore needle with a vacuum component to obtain tissue samples from non-palpable lesions.
Like the usual core biopsy, this minimally invasive procedure is also performed under local anaesthesia, which is injected to numb the breast area, followed by a small incision in the skin to allow easy insertion of the needle. It is used for lesions seen by mammography (stereotactic-guided biopsy), ultrasound or MRI.
The surgeon or radiologist places the probe into the suspicious area of the breast accurately. A vacuum then draws the tissue into the probe, a cutting device removes the tissue sample and then carries it through the probe into a collection area.
More tissue is usually obtained using the Vacuum-assisted biopsy (VAB) than the usual core needle biopsy and the number of strips removed is dependent on the area that needs to be examined.
A small titanium clip (microclip) may be placed at the biopsy site as a location marker for future treatment. This clip is very small (2 mm), is harmless, and will not cause any problems when left inside the breast. An X-ray is taken post-biopsy to ensure proper clip placement. New biodegradable markers are also available now.
A nurse will apply compression to the breast to stop any bleeding, the wound is closed by a steristrip and the dressing applied. Strenuous activity is to be avoided for 2 days after the biopsy.
This procedure is minimally invasive as compared to an open surgical biopsy. It is performed as a day surgery procedure. lt has the ability to sample tiny abnormalities called microcalcifications, making early diagnosis of breast cancer possible.
Under local anaesthesia, it takes about 30 to 45 minutes to complete. The procedure is usually not painful but you may experience some discomfort.
A syringe with a very fine needle is used to withdraw fluid or cells from a breast lump. This is a simple procedure and can be uncomfortable but is usually tolerable enough for it to be done in the clinic.
If the lump is just a cyst, withdrawing fluid in this manner will usually make the cyst disappear.
However, if the lump is solid, your doctor may use this procedure to withdraw some cells from it. The cells will then be sent to a laboratory for examination.
An excision biopsy is the removal of a lump or sample of suspicious tissue by surgery for examination under a microscope to give a definite diagnosis.
For lesions that are small or not palpable, accurate marking of the area for surgery is necessary. These include using ultrasound during surgery, or with procedures done just before surgery to mark the area to be operated.
Ultrasound, mammogram or MRI can be used to insert a small thin wire to the abnormal spot in the breast.
This wire is used to guide the surgeon to remove the area accurately. This technique is known as Hook Wire Localisation (HWL) Biopsy.
Excision biopsies are often performed under general anaesthesia, depending on the size and position of the lump, but local anaesthesia may be used for small lesions close to the skin.
As a minor day surgery procedure, patients can return home after surgery. Strenuous activity is to be avoided for the first few days; immediate ability for usual light activities of daily living is expected.
Post-operative advice may differ between individuals depending on their needs and circumstances. In general, most will be able to return to work in a week.
