Need to understand breast carcinoma
Dr Faisal Ali
Breast cancer is one of the haunting melancholia that has not been minimized and curtailed by the perfumes of pharmacological, surgical, and radiological advancements even in the present age. It is the second most common reason for death after lung cancer that develops in women with mutations in the BRCA1 gene, located on Chromosome 17, BRCA2 gene located on Chromosome 13, Ataxia-telangiectasia mutation (ATM), BARD1, CHEK2, PALB2, RAD51D and mutation of the tumor suppressor gene P53. Early menarche, late natural menopause, alcohol consumption, high dietary intake of fat, lack of exercise and combined oral contraceptive pills are believed to be some of the risk factors for breast carcinoma.
Histologically, breast carcinoma is divided into four types i-e Infiltrating Ductal Carcinoma (IDC, 80-90%), Invasive Lobular Carcinoma (ILC, 6-8%), Non-Invasive (4-6%) and Rare Cancers (<1%). The subtypes of IDC are Medullary, Colloid (Mucinous), Tubular and Papillary while the subvarieties of Non-Invasive Carcinoma are Intra-Ductal Carcinoma and Lobular in Situ Carcinoma.
The special clinical forms of breast cancer are Paget’s disease, Inflammatory Breast Carcinoma, Angiosarcoma and Phyllodes Tumor. Phyllodes tumor may be benign or may be malignant.
The clinical manifestation of breast cancer among 70% of patients is the presence of lump. The other sign and symptoms are breast pain, nipple discharge, erosion, retraction, enlargement and itching of the nipple, redness, peau d’orange, generalized hardness, enlargement or shrinking of the breast, an axillary mass or swelling of the arm, back or bone pain, jaundice and cachexia.
Very small (1-2mm) erosions of the nipple epithelium may be the only manifestation of Paget’s disease of the breast. The investigative techniques for proper diagnosis are mammography, ultrasound, MRI and needle biopsy/cytology. The various procedures/methods of needle biopsy are Trucut or Corecut Biopsy device and Fine Needle Aspiration (FNAC), the troika of clinical assessment, radiological imaging and histopathology is called Triple Assessment Strategy.
Furthermore, the assessment of embonpoints is also done via biomarkers and gene expression profiling like that of HER2 Gene profile, ER profile, PR Profile, Immunohistochemical stain for Ki67 and Genomic assays i.e. ONCOTYPE DX and Mamma Print etc. All these markers may be obtained on core biopsy and surgical specimen. In general, tumors that lack expression of HER2, ER and PR (Triple Negative) have high risk of early recurrence and metastasis and are associated with a worse survival compared to other types.
In therapeutic amphitheater, surgical resection along with sentinel node biopsy and radiation therapy are the primary ministrations of choice. The Neo-adjuvant and Adjuvant polychemotherapies are also inserted into curative arena but the timing and cycle of duration for chemotherapies in both spheres are different. The adjuvant polychemotherapy includes Anthracycline and Cyclophosphamide containing regimens and Taxanes.
The ideal duration of adjuvant chemotherapy is 3-6 months. The targeted therapies in adjuvant domain include HER2-Targeted therapy & Endocrine therapy. HER2-Targeted therapy includes monoclonal antibodies whose appellations are Transtuzumab and Pertuzumab plus HER1 and HER2 Tyrosine Kinase Inhibitor by the name of Neratinib.
Endocrine therapies include Tamoxifen and Aromatase inhibitors. The regimens approved for Neoadjuvant Therapy of HER2-Positive breast cancer include the 6 cycles of TCHP {Docetaxel (T), Cyclophosphamide (C), Transtuzumab (H) & Pertuzumab (P)} and 3 cycles of 5-Fluorouracil, Epirubicin and Cyclophosphamide (FEC) preoperatively as well as postoperatively again (neoadjuvant + adjuvant). In residual disease, the standard of care is to give 14 cycles of Transtuzumab emtansine.
Women with carcinoma of caparisoned parts can also experience anxiety and depression. Anxiety includes feelings of fear, dread, unease, or even tight muscles. Some of these symptoms can contribute to physical pain during breast cancer treatment. Therefore, the initiation of anxiolytic and antidepressant medicines plus psychotherapy becomes an indispensable part of management plan.
Tricyclic Antidepressants, Paroxetine, Fluoxetine, Bupropion, Duloxetine and Sertraline must be avoided during breast neoplasm because they interfere with a liver enzyme called CYP2D6 that converts Tamoxifen into its active form i.e. Endoxifen. Psychiatrists always make an organic whole of a patient before initiating any drug to these downtrodden patients. The only endorsed anti-anxiety and anti-depressants during breast cancer are Citalopram, Desvenlafaxine, Escitalopram, Milnacipran and Venlafaxine. Furthermore, psychologists, psychiatrists and philanthropists may also ferret out the ways and means of preserving the essence of mammary glands during sexual activities of these patients.
Nature has provided women with bosoms that not only serve the purpose of marital affairs but also lactation. It is proposed to discover a treatment in true sense so that the dignity of breast carcinoma patients should be conserved which is the hallmark of this article. During the second decade of the 21st century, I came across various patients with breast carcinoma who had marital issues during illness. Due to the one-wife policy in most of the countries of the orb, it is therefore requested to establish a true consolatory scenario for humanity.
The writer is a medical graduate of the Xi’An Jiaotong University, China and holds a postgraduate degree in Community Child Health from the Khyber Medical University, Peshawar. He is currently serving as a medical officer at Type-D Hospital, Banda Daud Shah, District Karak, Khyber Pakhtunkhwa. He can be reached at: drfaisalali88@gmail.com.
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