Breast cancer in women

A breast tumour is the most common malignant disease among women and, at the same time, one of the most treatable when it is found early. Most of the lumps that bring a woman to a doctor turn out to be benign: cysts, fibroadenomas, patches of dense glandular tissue. The real difficulty lies elsewhere: an early tumour gives almost nothing away. It does not hurt, does not get in the way and does not make you feel ill. So there is little point in anxious nightly self-examination, and a great deal of point in knowing which change to show a doctor and how soon.

How the tumour makes itself known

The first thing usually noticed is a lump: an area that feels different from the tissue around it, generally painless and barely movable under the fingers. But a lump is neither the only sign nor the earliest one.

• a lump in the breast, in the armpit or above the collarbone that does not go away after a period;
• a change in the shape or size of one breast that has appeared over recent months;
• skin pulling inwards, a dimple or a crease that shows up when you raise your arm;
• a patch of skin like orange peel: enlarged pores and swelling;
• a nipple that has turned inwards or changed direction when it used to look different;
• discharge from the nipple outside pregnancy and breastfeeding, especially from one breast, from a single opening, happening on its own or containing blood;
• flaking, crusting, weeping or a sore on the nipple that does not heal;
• pain always in the same spot of the breast or armpit, unrelated to the cycle and lasting for weeks.

Pain is rarely the first sign of cancer. Tenderness and swelling in both breasts before a period is almost always hormonal rather than tumour-related.

Forms that pretend to be something else

Two situations are worth knowing separately: they are mistaken again and again for an infection and for a skin condition, and that is where months get lost.

Inflammatory breast cancer. It produces no lump you can feel. Over a few weeks part of the breast, or all of it, turns red, swells, becomes hot and heavy, and the skin thickens until it resembles orange peel. From the outside it looks like mastitis. But genuine mastitis occurs almost only during breastfeeding and responds to antibiotics within a few days. If this redness appears in a woman who is not breastfeeding, or has not cleared after a week of treatment, what is needed is not a second course of antibiotics but assessment by a specialist and a biopsy.

Paget's disease of the nipple. It starts like eczema: redness, itching, flaking, crusts, sometimes weeping. It differs from ordinary dermatitis in that it affects one side only, begins on the nipple itself and spreads to the areola only afterwards, and ointments bring temporary relief at best. Behind this picture there is often a tumour inside the gland, so eczema of the nipple that does not settle within a couple of weeks should not be shown to a dermatologist alone.

When the visit cannot wait

See a doctor within days if a new lump appears, if the shape of the breast or nipple changes, if the skin pulls in or reddens over an area, or if discharge comes from the nipple outside breastfeeding. A separate reason not to delay: if a breast tumour was treated in the past and there is now persistent bone pain, yellowing of the skin, increasing breathlessness, constant headache or unexplained weight loss, since that is how spread of the disease shows itself.

Two ideas have to be held at once here. None of these signs on its own means cancer, and a harmless cause is far more likely. And none of them can be settled by watching at home, because the difference between a cyst and a tumour is not felt by hand but seen on a scan and under the microscope.

What genuinely affects the odds

The main factor is age: risk rises with every decade after forty, and most cases occur in women over fifty. The rest is spread roughly as follows.

• breast or ovarian cancer in a mother, sister or daughter, especially at a young age or in several relatives at once;
• an inherited fault in the BRCA1, BRCA2 and some other genes: it accounts for a minority of cases but sharply raises the risk for that particular woman;
• dense glandular tissue, which makes a tumour harder to see on a mammogram;
• long exposure to your own hormones: early first periods, late menopause, first birth after thirty or no births, not having breastfed;
• hormone replacement therapy and, more weakly, hormonal contraception: the increase is small and fades within a few years of stopping;
• regular alcohol, excess weight after the menopause, an inactive life, smoking;
• radiotherapy to the chest received in adolescence or young adulthood;
• atypical hyperplasia or lobular carcinoma in situ found previously.

Deodorants, underwired bras, a knock to the breast and implants, on the other hand, do not raise the chance of cancer, however long those claims have been in circulation.

Little of that list is in a woman's own hands, but the part that is happens to work: less alcohol, since the link with breast cancer shows up even at moderate amounts; keeping weight steady after the menopause; a few hours of movement a week; stopping smoking; breastfeeding where that is possible. Long-term use of hormonal preparations is worth discussing with a doctor rather than deciding alone.

Mammography and sensible self-awareness

The point of mammography is to find a tumour a few millimetres across that cannot be felt at all: such a finding is almost always treated with less surgery and with a better outcome. Most countries invite women from around forty-five to fifty and repeat the scan every one to two years; the exact intervals depend on the national programme, and with a strong family history surveillance starts earlier and is supplemented by ultrasound or MRI.

Self-examination does not replace screening, but the habit of knowing how your breasts normally look and feel helps you spot a change. It is easier a week after a period starts, when the gland is softer: look in the mirror with your arms down and raised, then feel the whole breast and the armpit. The aim is not to hunt for cancer but to notice what was not there before.

How it is established whether it is a tumour

The diagnosis is assembled from three pieces: examination, imaging and study of the cells. Mammography, ultrasound and, where needed, MRI show where the change is and what it looks like, but the final answer comes only from a biopsy: a core of tissue taken with a needle under ultrasound guidance, under local anaesthetic, in a few minutes.

The same sample is used to determine the tumour's properties: sensitivity to oestrogen and progesterone, the status of the HER2 protein, how fast the cells divide. Treatment depends on these and not on size alone, which is why the answer takes anywhere from a few days to two weeks. If cancer is confirmed, further tests are added to show whether the process is confined to the gland and the lymph nodes.

What treatment consists of

The plan is put together by a team: surgeon, medical oncologist, radiation oncologist and pathologist. The order of steps varies; sometimes drugs come before surgery, to shrink the tumour and keep the breast.

• Surgery. Removal of the area containing the tumour with a margin of healthy tissue, or of the whole gland. Armpit nodes are checked in stages: first one or two sentinel nodes, and the operation is extended only if tumour cells are found in them. Reconstruction is done at the same time or later.
• Radiotherapy. Most often after breast-conserving surgery, to reduce the chance of the disease returning in that same breast.
• Chemotherapy. Before surgery to shrink the tumour, or after it when the risk of recurrence is high.
• Hormone therapy. For tumours sensitive to oestrogen: the drugs block the receptor or lower hormone production. It is taken for years, and it is precisely this part of treatment that is most often abandoned early.
• Targeted drugs and immunotherapy. They act against specific targets, for instance the HER2 protein.

If the tumour has already produced distant deposits, a cure is usually out of reach, but treatment can hold the disease for years and preserve ordinary life. The palliative care team joins here not at the end but alongside everything else, to keep pain and other symptoms under control.

Online consultation

In an online consultation the doctor will ask when and how the change appeared, whether it follows the cycle and what is known about illness in the family, and will help work out which test comes first: mammography, ultrasound or a specialist assessment straight away. It is also a convenient way to go through reports and biopsy results already issued when the wording is impenetrable, and to discuss the side effects of long hormone therapy. Examination and biopsy cannot be replaced remotely, but putting the steps in order and not losing time certainly can be done.

This material is for information only and does not replace medical advice.