BREAST CANCER; DREADED AND DEADLY
INTRODUCTION
Cancer occurs when cells in a part of the body grow out of control, normal cells split and grow in an orderly manner, but cancer cells do not. They continually grow and overcrowd normal cells; diverse forms of cancer manifestation have diverse ways of abnormal growth of cells. Lung cancer and breast cancer are different diseases; they grow at different rates and respond to different care and treatment, that’s why diverse specialist exist for different forms or types of cancer. (American Cancer Society, 2008)
Cancer cells sometimes break way from a tumour and spread to other parts of the body through the blood or lymph system. The tumours spread and create new formations or new tumours in new places which are depicted as metastasis, cancers that spread in that way are referred to as metastatic cancer.
Breast cancer erupts from a cancerous tumour that starts from cells of the breast, the disease occurs mostly in women, although men could also have breast cancer. In order to have a good comprehension of the structure of the breast and how the cells are infected through the spread of the tumour, it’s crucial we have a picture.
Culled from American Cancer Society, 2008.
Cancer of the breast is dominant in all women of all races and appears to have been prevalent throughout history, In Britain, about 24,000 new cases are diagnosed each year and 15,000 deaths are caused by the disease.(Fallowfield&Clark, 1991) Women’s breast are made up of glands that make breast milk (lobules), duct cells, small tubes that carry milks from the lobules to the breast, blood vessels , most breast cancer begins in the cells that line the ducts; ductal cancer, some begin in the lobules ; lobular cancer and the rest in other tissues . (ibid)
The lymph system is crucial because through it the breast cancers spread, the lymph nodes are small, bean shaped composed of immune systems cell connected by lymphatic vessels. The lymph vessels of the breast are under the arm, once breast cancer spreads to this node, then they swell and spread through the bloodstream making it rather complicated.
Some words used to depict breast cancer are Carcinoma, Adenocarcinoma, Carcinoma in Situ, Invasive Carcinoma, and Sarcoma.
The types of breast cancers vary and are rare, but I would briefly mention some here, the most common ones.
Dual carcinoma in situ (DCIS), a common type of breast cancer which is non-invasive, the cancer is only present in the dusts and spreads through the walls of the dusts into the tissue of the breast, the best way to know the extent of spread is through a mammogram.
Lobular carcinoma in situ (IDC), starts from the milk making glands but not through the walls of the lobules, although not a true cancer, but may develop into one later.
Invasive ductal carcinoma (ILC), this starts from the milk glands or lobules, it can spread to other parts of the body.
Inflammatory breast cancer (IBC), it’s rare and does not start with a single lump or tumour, it makes the breast look red and feel warm, it’s often mistaken for an infection in its early stage, it has a higher chance of spreading than ductal or lobular cancer.
However not all tumours are cancerous, some are non-malignant or benign, harmless as they sound except when they grow in places where they grow causes problem, malignant tumours are made up of tumour cancer cells that look abnormal, the abnormal cells or anaplastic look more aggressive as the cancer grows. Malignant tumours continue growing and spreading to other parts of the body it has the ability to spread fast and is dangerous. (Ogden, 2004)
The secondary breast cancer is one that has developed from a cancerous breast cells, tumours are made from millions of cancerous cells , malignant cells that have grown into the blood , sometimes are trapped in different organs, tissues or lymph nodes , sometimes the breast cancer cells lie dormant for years and get reactivated later. It’s crucial to disclose the causes of breast cancer.
EPIDEMIOLOGY OF BREAST CANCER
The causes of breast cancer is not vivid till date, however risk factors have been disclosed, that have impact on the likelihood of getting breast cancer. The risk factors however can not be changed or ignored. Having a risk factor however does not imply getting the disease. (cancer.org) Risk factors may increase the chance of developing breast cancer , it is not yet ascertained how this risk factors cause cells to become cancerous, hormones play a role in the many cases of breast cancer but it is not yet understood what the main factors are.
Thee risk factors are, age, personal history of breast cancer, family history, breast changes, gene changes, reproductive and menstrual history, race, radiation therapy to the chest, taking DES, being overweight or obese after menopause, drinking alcohol , the pill, having uneven breast, injury to the breast, pesticides,smoking,abortion,stress,to mention but a few.
Age, the possibility of getting a breast cancer is increased as the woman gets older, most breast cancers occur around the range of 55+ and above, this disease is not common before menopause.(medicinenet.com)
Personal history, a woman who had cancer in one breast has the greater chance of getting a new cancer in another breast, this is different from the first cancer reoccurring. (cancer.org)
Family history , this is higher among women whose blood relatives have this disease, the relatives can be from either the father’s side or mother’s side, having a relative that has breast cancer increases the probability by 70 percent to 80 percent of having the disease when it has to do with family history. (cancer.org)
Breast changes, is related to the risk factors when women cells in the breast that look abnormal under the microscope, abnormal cells like atypical hyperplasia and lobular carcinoma in situ (LCIS) increases the risk of breast cancer.
Gene changes, like changes in BRCA1, BRCA2 and others increase the chances of breast cancer, tests can sometimes show the presence of specific genes in some families, and however the gene changes have not been able to be attacked as a possible cause. Reproductive and menstrual history , the older the woman is when she has her first child determines the probability of getting breast cancer , women who had their first menstrual period before the age of 12 are at an increased risk of the disease, women who still have menopause after the age of 55 are also exposed to the risk of having breast cancer, women who never have children at all are at risk, women who took menopausal hormone therapy with oestrogen and progestin after menopause seem to be at risk of having breast cancer.(medicinenet.com)
Race is another risk factor that makes breast cancer more prevalent among Latina, Asian African-American women.
Breast density, occurs when the breast tissue is dense or fatty, older women whose breast x-rays show more dense tissue are at increased risk of breast cancer, the taking of DES,(Diethylstilbestrol), which was given to pregnant women between 1940 and 1971 in the United States, although its no longer given to pregnant women but during pregnancy it has an effect , studies have shown some sign of impact of the DES on the daughters of those women that used the DES during that era. (medicinenet.com)
Radiation exposure has a higher impact on having breast cancer, women who received radiation therapy in the chest area during childhood or young adulthood have a probability of having breast cancer, for example, the former medical practices like the repeated uses of fluoroscopic x-rays to check the lungs for tuberculosis, women over 45 generally have more exposure to radiation than younger women. In addition research has shown that the women exposed to atomic bomb radiation at Hiroshima and Nagasaki Japan had a high risk of breast cancer. (ehealthhmd.com)
Dietary fat and its relationship with breast cancer has created a sort of prolonged and continual debate , many United States studies have found no association between the two, however international findings suggest that breast cancer rates are minimal in countries
Where the diet is low in fat (particularly animal fat). Fat cells play a greater role in estrogen production, especially in postmenopausal women, the factor of being overweight can contribute to risky estrogen exposure, which is a trap or risk to breast cancer.
Cigarette smoking has not been an agreed form or risk , but because smoking increases the risk to so many other cancers , as well as heart diseases and lung emphysema, most physicians have started advising women to quit smoking, smoking can limit the treatment options , since
reconstructive surgery cannot be used by women that smoke.
Abortion or miscarriage history also facilitates breast cancer among women, although this is susceptible to debates.
Pills are also considered as a risk factor although not fully grounded as a widely accepted factor, but pills contains oestrogen, which can stimulate breast cancer cells to grow, in theory taking extra oestrogen can act as a catalyst for breast cancer to develop, in practice, several studies have disclosed that there is an increased risk of breast cancer while taking pills. A recent study by the royal college of GPs looked at 47,000 women and showed no increase in the risk of breast cancer in those taking contraceptive pills, but the modern pills have more oestrogen and progesterone, so older pills may have a different effect on breast cancer risk than the modern set of pills. The one conclusion from this confusing lot of old pills and modern pills is the increase in the quantity of oestrogen and progesterone. (cancerhelp.org.uk)
SIGNS CUM SYMPTOMS AND BREAST CANCER STAGING
Early stage breast cancer produces no symptoms when the tumour is small and mostly treatable, the most important physical sign is the painless mass, the discharge of blood from the nipple, breast pain and persistent changes to the breast, which are just mild symptoms, crusting or scaling on the nipple, redness, swelling and increased warmth in the affected breast, dimpling or puckering of the skin, thickening and dimpling skin is sometimes orange peel.
Staging is a method that depicts the extent of cancer growth , breast cancer is stages by information that is obtained from surgical and other findings, information is gathered from pathology disease report that accompanies a lumpectomy(lump removal) and mastectomy(breast removal) or other forms of breast surgery . In addition, staging is based on findings from imaging such as chest x-ray, abdominal ultrasound, computed tomography (CT or CAT scan, computer assisted method that produces cross sectional images of the body) and bone scans. (ehealthmd.com)
Staging helps to get the information needed to ascertain the level of damage or estimate how long the individual can live with the disease, the lower the stage, the better the person’s prognosis or expected outcome. The system used in prognosis majorly is the TNM system.
The TNM system is used by pathologist to test the stage of breast cancer, the T refers to tumour size and the N to lymph node involvement and M to the metastasis, we have different stages that I might not be able to write here considering the word limit and other vital issues yet to be discussed, but the lower the stage number ,succinctly , there are two kinds of stage 0 breast cancer,ductal carcinoma in situ and lobular carcinoma, in stage 1, tumour is 2cm or smaller and the cancer has not spread outside the breast, stage 2 the tumour is 2to 5cm or cancer has spread to the lymph nodes, stage 3, the cancer has spread to the tissues and the lymph nodes, stage 4, the cancer has spread to distant parts of the body, the stage 1, is a low grade, while 2 is moderate, 3to 4 is advanced , the less cancer has grown and spread, for example , a stage I breast cancer is relatively small and has not yet spread to the lymph nodes or other sites , the stage IV is a more serious cancer, metastasized to the lymph nodes as well as other locations. (cancer.ca)
THEORIES OF BREAST CANCER
The first theoretical basis for the explanation of breast cancer started in 1894, by Dr .W.S.Halsted, inventor of the Halsted radical mastectomy, breast cancer has opined by the Halsted theory is a disease that starts from the breast and if untreated spreads through the lymphatic system first to nearby lymph nodes and later to other organs in the body, or succinctly a theory of contiguous development of metastases.
The systemic theory as an alternative theory was formulated in 1954 and 1967 and was put forth in a rather definitive terms by Dr. Bernard Fisher, he submits that breast cancer is a systemic disease and so called local or regional variation in treatment of the disease affects the survival rate of victims. The theory further states that, the only purpose of so called local or regional control, breast surgery and local or regional radiotherapy is to prevent a local tumour from getting out of hand and not to prevent future metastases to other parts of the body, which means that under this theory any distant metastases of any portion might have already occurred at the time that a breast tumour is found by touch or in a mammogram. (darkwing.uoregon)
The spectrum theory or combined theory fits into this millennium or era; it is a reaction to the aforementioned theories, Dr Hellman states that surgical removal of tumours may be important at any stage of development of the tumours; the prevalent question however is when the distant metastases occur? Dr Hellman thinks that breast cancer is not always only a systemic disease by the time it is discovered but instead can be a disease in which the incessant presence of local tumours can lead to additional metastases in the future. He further stated that persons with small breast cancers might be of two types, a group that has indolent and clinically unimportant cancers and a second group with a localized cancer that if left to grow would be disseminated all around and that would lead to the person’s demise. The most important outcome of Dr Hellman that differs from the other theories is that the development of metastasis and the consequent death of the patient are due to a prolonged and complex growth of tumours.
CNS METASTASES IN BREAST CANCER
A crucial look at the CNS metastases in breast cancer suggests the impact that, it has on the body system, which within a short period results into a network.
CNS metastasis accounts for the majority of malignant brain tumours, and may be in the brain parenchyma or along the leptomeninges. Breast cancer is the second most common cause of CNS metastases and is the solid tumour responsible for leptomeningeal metastases.
From the 1960s and 1970s, the spate of clinically evident brain metastases among women with stage IV breast cancer is estimated to be 10 percent to 16 percent. (Lin, etal, 2004)
An autopsy review of 1,044 patients with breast cancer reveals that the median age patients with CNS metastases was about 5 years younger than that of patients without CNS metastases, some groups have also found the relationship between hormone receptor status and the incidence of CNS relapse . In one study 217 women with primary breast cancer , estrogen receptor(ER) – negative breast cancers were more likely to metastasize to the brain(10 percent to 4percent clinical incidence)
The incidence of symptomatic brain metastases among women with metastasis breast cancer ranges from 10 percent to 16 percent, on average, the median latency between the initial diagnosis of breast cancer and the beginning of brain metastasis is 2 to 3 years, in most cases, breast cancer patients develop brain metastases after metastases have appeared systematically in the lung, liver and bone .(Wiel etal, 2005 )
Culled from http://ajp.amjpathol.org/cgi/content/full/167/4/913 , showing the spread of breast cancer to the brain.
Diagram A represents a solitary metastasis, 1cm to the brain; the tumour is situated in the posterior right frontal lobe. Diagram B, shows the tumour is surrounded by a significant amount of peritumoural edema (T2-weighted axial MR image) C, represents multiple metastasis to the brain before the administration of gadolinium for contrast and D is a surgical resection, the tumour is in the left frontal region, E is military metastases which has multiple slice ranging from 2 to 3 mm to 1 cm, F Carcinomatous meningitis, shows multiple linear around the tongues of the tumour.
The metastasis breast cancer to the CNS, through either the brain parenchyma or the leptomeninges, is generally a late feature of metastastic disease; metastases to the brain parenchyma are thought to be haematogenous in origin. In a survey of breast cancer patients with brain metastases, 78 percent had intracerebral metastases, 14 percent had a solitary intracerebral metastasis and the remaining 8 percent had leptomeningeal metastases. Breast cancer is most common solid tumour to exhibit leptomeningeal colonization. Within the three membranous coverings, or meninges, that surrounds the brain , leptomeningeal metastases arise on the innermost coverings(pia) and the middle membrane(arachnoids) or in the cerebral spinal fluid(CSF) filled space between the arachnoids and the pia(subarachnoid space) . Once the tumour cells reach the leptomeninges, they spread as evidenced in the diagram above. (ibid)
Breast cancer involving CNS is traditionally viewed as a late complication of progressive metastatic disease, for which few treatment options exist, for most brain metastatic patients , those with controlled extra- cranial tumour , of age less than 65 years, a favourable general performance fare best with older patients, patients with solitary metastases and with a longer disease free interval also tend to fare well, mean survival from diagnosis of a brain metastasis varies between studies but from 2 to 16 months , depending on involvement of the CNS , the extent of the extra-cranial metastatic disease and the treatment applied. The mean 1 year survival is estimated at 20percent, (ibid) 2percent of patients with breast cancer survive greater than 2years after the advent of CNS involvement, and the inability to control extra-cranial disease is a limiting factor. (ibid)
TREATMENT OPTIONS FOR BREAST CANCER
The most modern form of treating breast cancer is either through radiotherapy or chemotherapy and surgery, although we have cancer drugs, hormone therapy, biological therapy, and bisphosphonates. The surgeons/pathologist are basically the experts in the field of treating breast cancer. The most practical way is to conduct a diagnosis to know the extent of the spread of the tumours. After this, chest X-ray and blood tests. Therefore I would start by examining radiotherapy, when it’s needed and side effects.
Radiotherapy succinctly is the use of radiation, usually X-rays, to treat illness, X-rays as a sort of diagnosis. (cancerhelp.org)
Radiotherapy however is divided into two parts, the external and internal radiotherapy; external radiotherapy uses high energy X-ray beams, cobalt irradiation or particle beams such as protons or ions. These beams are directed at the cancer cells from a machine outside the body. The beams destroy the cancer cells, normal cells are also affected but they are repaired automatically than cancer cells. External radiotherapy is normally given as a series of short treatment sessions known as fractions. It is given in the radiotherapy department, the machines vary slightly in their configuration, and the machines also differ depending on the level or stage of the cancer. (ibid)
Conformal radiotherapy also known as 3D conformal radiotherapy (3DCRT), it is much like the external radiotherapy but metal blocks are put in the path of the radiation beam. These change the shape of the beam so that it blends to the shape of the tumour. Conformal radiotherapy can give a better chance of exterminating the cancer by giving a higher dose of radiation straight to it. It also means less healthy tissues are included and limits the probability of long term side effects. Conformal radiotherapy is most useful for tumours that are close to important organs and structures in the body. This is because it aids to avoid radiation damage to healthy body tissues and organs. It can be used to treat prostrate cancer, cancers of the gullet, lung cancer, brain tumours to mention but a few.
Intensity modulated radiation therapy (IMRT) , uses computers to control the radiothery machine, it assist in giving precise doses to the area attacked by the tumour, the treatment is planned by the 3D scan images of the patient together with computerised dose calculations to find the dose with intensity pattern that best matches the tumour shape.
Internal radiotherapy can be administered in two ways and may involve a short admission in the hospital depending on the type of treatment used; radioactive implants are solid radioactive wires or needles that are replaced into the area that needs to be treated. This normally involves a short admission for treatment in the hospital for few days and the radioactive source is removed. Some implants can be left in place permanently, as the amount of radiation they produce is very small and will gradually fade.
Internal radiotherapy can also take the form of injection , or taking of some liquids, liquids like phosphorous ; used mainly for blood disorders, strontium , used for bone cancers, iodine , used for benign (not cancerous) thyroid conditions and thyroid cancer.
Hormone therapy treatments use the sex hormones produced by our bodies, or drugs that block them to treat cancer, but not all cancers respond to hormone therapy, they are mainly used for cancers that are hormone sensitive; hormone therapy can work either for stopping hormones being made or preventing the hormone reaching the cancer cell. The types of hormone therapy are breast cancer hormone therapy, prostrate cancer hormone therapy, womb cancer hormone therapy.
The breast cancer hormone therapies are affected by female hormones oestrogen and progesterone, hormone therapy works when these hormones are stopped from getting to the breast cancer cells. (cancerhelp.org)
Hormone therapies that are mostly used to treat breast cancer are tamoxifen, aromatase inhibitors, pituitary down regulators. Tamoxifen are used for breast cancer, it functions best as a stop to hormone oestrogen from reaching the cells. Aromatase inhibitors are only allowed to be taken by those that have been through the menopause stage, the pituitary down regulators controls the amount of sex hormones made by the ovaries. The treatment is for those that have not yet had their menopause. The prostrate cancer hormone therapy depends on the male hormone testosterone for its growth; the therapy therefore stops the body making testosterone and stops the growth of the cancer. It must be noted that mammography is used to detect breast cancer; the sensitivity range of mammography to breast cancer is 75 percent to 90 percent with specificity from 90 percent to 95 percent. (acpm.org)
Biological therapies are treatments based on natural substances alongside drugs in the fight against cancer cells. Mostly it is argued that this is a better option than the side effects of other forms of therapy. The different types of biological therapy are biological response modifiers, (BRM), biological agents or simply biologics, targeted therapies, immunotherapy.
Biological therapy is different from other forms of treatment in that natural substances are used; however the use of biological therapy mainly depends on the stage of the cancer.
Individual cancer drugs are another subsystem of biological therapy, used mostly for hormone and biological therapies. Bisphosphonates are also in this category of drug based treatment. It s used for the treatment of cancer in the bones and reduce pain in the affected areas.
Chemotherapy is also a drug treatment, cell killing drugs are used here, there are more than seventy drugs and more been researched and developed .Chemotherapy is used depending on the type of cancer, where the cancer is located, chemotherapy is complementary in some cases , its used alongside radiotherapy,surgery,hormone therapy ,biological therapy. Chemotherapy and other forms of treatment are susceptible to side effects.
Surgery is the most modern form of treatment for breast cancer, most women have some type of breast cancer surgery, and operations include mastectomy, axillary lymph node sampling and removal.
Breast conserving surgery, the affected part of the breast is removed, radiation therapy is given after the surgery, and lumpectomy removes only the breast lump and a surrounding margin of normal tissue. Radiation therapy is useful in surgery; chemotherapy is used after radiation is successfully used.
Partial (segmental) mastectomy or quandrantectomy removes more breast tissue than a lumpectomy , for a quandrantectomy , one quarter of the breast is remove, radiation is used after the surgery. (cancer.org)
SIDE EFFECTS OF BREAST CANCER TREATMENT
The impact of the treatment methods on the patient is diverse in each form of treatment, but there are strong cases of unwanted side effects. The side effects may differ from one woman to another, or for women that had the same type of treatment. A woman’s breast cancer side effect can change from one treatment session to the next. (cancercompass.com)
For breast cancer surgery, short term pains are experienced and tenderness in the area of operated on, due to this there is a huge risk of infection, long wound healing, bleeding or reaction to the anesthesia used during the surgery. Removal of breast can also cause a woman’s weight to shift out of proportion, especially women with large breasts. The imbalance can cause discomfort in the back and neck. The skin in the breast area can be tight , the muscles of the arm or shoulder could be stiff. Mostly after a mastectomy, women experience a permanent loss of strength in the muscles, but some experience reduced strength alongside limited movement.
During the process of surgery, the nerves might get injured, the patient might experience numbness and tingling in the chest, underarm, shoulder and arm, some go away after weeks but some remain permanent. The removal of the lymph nodes under the arm also slows the flow of the lymph, in some women, this fluids builds up in the arm and hand, which causes swelling. (ibid)
The side effect for radiotherapy is vast, but the most common one is fatigue and dizziness, this occurs for days and later weeks. Loss of strength is common here, making the patient inactive, the treated area also is moist and the implication is the risk of infection, the bras or clothes may cause irritation, so it’s important for patients to wear loose fitting clothes. The effect of radiation therapy is temporary, but a permanent change in the colour of the skin is inevitable. The sensitivity of the breast skin is another issue as the tissues would undergo a change.
Chemotherapy is mainly based on the use of drug against breast cancer; the effects of the drugs also depend on each individual. Anti cancer drugs however attack rapidly dividing the cells, the rate of infection is high for patients with the chemotherapy method of treating cancer. Blood cells are affected, especially the hair follicles, which leads to the loss of hairs , alongside loss of appetite , nausea, vomiting, mouth sores, although it is believed that the side effects here can be controlled to some extent with the use of antiemetics. Long term effects are rare, however there have been cases in which the heart is weakened and second cancers such as leukaemia are possible aftermaths. Some anti cancer drugs can also damage the ovaries, if the ovaries don’t produce hormones, this might affect the menstrual cycle. The
Impact of anticancer drugs has not yet been ascertained on pregnant women.
Hormonal therapy also depend on the type of drugs and the individual, which means side effects may differ from one patient to the other. Tamoxifen is the most prevalent hormonal treatment, the drug blocks the body use of estrogen but does not stop the production of estrogens, the drug may cause vaginal discharge or irritation and irregular periods. The complaints of patients using this mode of treatment is minimal compared to the other modes, but blood clothing and vaginal and menstrual cycle changes are always noticed. (cancercompass.com)
Biological therapy is usually linked to the use of Herceptin, the possible side effects are pain, weakness, nausea, vomiting, diarrhea, headaches, rashes, difficulty experienced in breathing, it may also cause heart damage which may lead to heart failure. Other forms of side effects of having breast cancer, especially as it deals with the psyche would be analysed below.
THE PSYCHOLOGICAL IMPACT OF BREAST CANCER
That breast cancer has got treatment and side effects leaves us asking, how does it affect the psyche or emotions of the patients? The most common argument is the issue of psychiatric morbidity; this has been associated with the psychological distress, social and sexual difficulties linked with breast cancer treatment. Radical mastectomy has been the price to pay for increased survival of breast cancer patients; this has developed a crucial question, about the concomitant psychological trauma experienced under this form of treatment. The effect of this breast cancer treatment especially when it has to do with breast amputation is a debated issue, of those women who undergone mastectomy 32 percent were rated as anxious or depressed as 38 percent of the women who underwent breast conserving surgery. (Fallowfield&Clark, 1991) The part of counselling has really been left out till date, as more patients are left depressed of a possibility of having breast cancer.
The majority of women who have lumpectomy and some women who undergo mastectomy have a course of external beam radiotherapy, which means daily treatment for up to six weeks, which symbolizes adverse reactions, subsequent psychiatric morbidity, and the mere thought of such long treatment creates anxiety and depression. Radiotherapy also scares causes a misunderstanding as to the use among potential patients, as some are not properly enlightened as to the impact of radiation whether it is used to cure cancer or produces cancer. The benefits of breast conservation as against mastectomy with reconstruction, as it affects the patients are something crucial to analyse.
The tables indicate a research or study on the impact of the three forms of breast cancer treatment on patients. The body image, sexuality and partnership is important ,women in lumpectomy group reported statistically fewer problems with body image and feelings of sexual attractiveness than women in either the mastectomy with reconstruction or mastectomy group alone. Women under going breast conservation felt their cancer would affect their sex life, more than 40 percent of women exposed to mastectomy with or without reconstruction, reported a negative impact.(Rowland etal , 2000)
The patients who undergone surgery are faced with skin sensitivity and irritation , but the mastectomy patients with or without reconstruction, experienced more physical symptoms and discomfort around the surgical site than women with lumpectomy.
The response of partners of women with breast cancer brings to fore more depression and a state of been rejected, as the men experience sleep disorder, emotional unresponsiveness, a bad communication style between the couples and death fantasies.
The psychosocial outcomes of most of this treatment leads to a psychological depression or distress, troubling thoughts ,anxiety, sadness ,anger, problems sleeping, lack of sexual interest, loss of appetite ,concern about cancer reoccurring , problems enjoying social events, problems with sexual relations,, negative feelings about self nude. A table in the form of a research by a particular group further explains this.
Culled from Schain etal, National Institute of Health, USA
SCIENCE, POLITICS AND MAMMOGRAMS
The question of when and at what time is it appropriate to have a mammogram screening as a woman has generated lots of debates from the political to health sector. For instance a woman in her mid-forties with an average risk of breast cancer, should she have an annual mammogram screening? Would the benefits of mammography justify potential harm or a positive result that would pave way for extra diagnostic workup?
Certainly detecting breast cancer at the early period is beneficial, but this woman does not know in the near future if she won’t be among the majority who does not have breast cancer or few who will. (Finkel, 2005)
Mammogram screening however gives a clear picture of the age range of those that might have breast cancer or not, cancers that arise between the screening exams have a rapid growth, the question of who at what age should be screened has been represented in political cum health debates.
Decisions on whether to offer the screening to everyone is complex as we consider the potential harm or benefits of the screening. Screening does not reduce the risk for being diagnosed with breast cancer, it is just meant to reduce the risk of dying of breast cancer. Technology used can’t detect all tumours, digital mammography, ultrasound and MRI are good adjuncts to mammography in screening and diagnosis but they are not replacements for mammography. According to the Canadian National Breast Screening Study, mammography screening itself does not reduce the mortality rate of breast cancer victims, it shows no beneficial impact of mammography regardless of the age, however the argument of the Canadian study findings have been subject to debates.(ibid)
The Danish researchers also found no statistical evidence that screening decreases the mortality of breast cancer patients; the UK school of thought however disagrees totally with most researches not in favour of the mammogram. The trade-off between the benefits of screening and its harms is complex, while the effectiveness of mammography continues. The guidelines differ in what age to begin screening and how frequently? As breast cancer is rare among very young women, only the very young women, younger than 35, the small number of individuals who potentially would benefit from the screening would be outweighed by the much larger number of women who potentially could be harmed by regular screening, the acceptable and safe age range as continually been a subject of debate and still is, as women over the age of sixty nine years are more prone to heart diseases which outweighs the harm.
The age debate is further complicated by the fact that mammograms of younger women, premenopausal are difficult to read, the anxiety and discomfort in the diagnosis of women is something that needs more attention. The detectable clinical phase for breast cancer is shorter in younger women who develop breast cancer compared with that in women fifty years and older, a crucial issue that is unresolved as to the appropriate screening interval, whether there should be a twenty four month screening or annual screening .
The social reasons attached to the use of mammogram has argued, the time and money spent in social programs encouraging women in their forties to get mammograms would be better spent on those in their 50s, because that group is more likely to benefit, some also argued that the money should be better spent on improving methods of detecting early invasive cancer.
The emotional concerns over the issue are , the risks of over treatment and emotional distress outweigh the small benefit to the overall survival rate, if mammogram results disclose a false negative result, a woman would be ruled by a false sense of security , paving way to non -challant towards self examinations. If the mammogram results are false positive, doctors might be led to perform biopsies, which have a potential of scarring, which decreases the future ability to detect cancer. (bookpage.com)
INDIVIDUAL EXPERIENCES; THE PRACTICAL OVERVIEW OF BREAST CANCER
That breast cancer is no respecter of age or gender is a valid proposition, the real life experiences of patients or people dying of breast cancer is crucial here before examining government policies as a response to the teeming population of breast cancer patients.
I hereby consider the plights of breast cancer patients one from breast cancer survivors.
The first individual is a ten year breast cancer survivor, her cancer was found after a breast reduction surgery, a lump occurred again after surgery which she thought was just a scar tissue, she never imagined that the lump was cancerous, as the surrounding tissues were healthy , the surgeons decided not to have another breast surgery. She went through radiation treatments and chemotherapy afterwards, she was scared by the duration of the whole treatment for radiation and therapy, scared about different stories been told about breast
Cancer patients, the chemotherapy involved going to the hospital twice a month through a programme of two weeks on and two weeks off and taking pills during those two weeks on, she also had to take blood tests, she loosed her hair after the radiation treatments, well in a way she never really suffered much , but the hair loss was a significant side effect for her ,the time been spent is another, if not she had a job that accommodated her going off for treatment for 10 months then ,a dismissal or loss of her job would affect her more. She recounts the five times a week visit to the hospital for six weeks is more of a stress coupled with the lying down on a table for long for radiation treatment also is another stress, but one vital thing is the patients attitude , which is quite crucial ,people with positive attitude and approach seem to overcome or stay alive longer than their counterpart, this positive attitude would be explored in counselling and care for breast cancer patients.(gather.com)
The other patient went for her annual mammogram and results were irregular meaning that she was scheduled for another in two weeks .She had already been treated of stage IIIB non-Hodgkin’s Lymphoma in 1977, the treatment included radiation and chemotherapy. For the past 30 years she enjoyed a perfect health, she took another mammogram of which she was recommended a biopsy. She took the biopsy and remained anxious and curious considering she has to wait for few days to know the result, the results disclose she has an early stage of breast cancer, radiotherapy was the treatment option recommended to remove the tumour.
Her Medical records had to be scrutinized, eventually it was noted that she was due for a lumpectomy. She was operated on successfully and she started to wear a surgical bra , which she says is more convenient, she has been really encouraged by the expertise and comfort provided by the medical team ,after the lumpectomy, she was told she would likely go on chemotherapy , which might not be a good choice for her considering she had reached the e lifetime maximum of some chemotherapy drugs . She eventually got a low risk, recurrence score of 17, which marked the beginning of her mental recovery; she completed her radiation in early 2006 and will take aromatase inhibitor for the next five years, the good medical team she had favoured her as they were always keeping an eye on her progress.(mytreatmentdecisions.com)
One thing that keeps the breast patients going is the positive attitude of the medical team and their families. At this stage it would be crucial to examine the governmental policies and the counselling, the cultural response and religious response and help for breast cancer patients before considering my personal observations and recommendations.
CULTURAL RESPONSE AND RELIGIOUS RESPONSE TO CANCER; A CASE FOR MORE COUNSELLING
The response or attitude towards negative life events are highly motivated by the cultural context, this can range from stoicism to severe depression .There is a consensus that culture may determine the way an individual responds to cancer both in terms of the psychological and physical symptoms including pain . (Dein, 2006)
Common reactions to cancer include denial, anger, depression and anxiety; anger may be directed towards doctors or God or another religious figure or belief. It is known that poor adjustment is related to previous psychiatric history, lack of support, inability, low expectation that the treatment would be effective based on previous bad experience of cancer in the family or to some loved ones. For instance a 17 year old man a Hindu , became angry when his father developed terminal colon cancer, he asked why should it be his father and not criminals and people with bad behaviour, he sought a pundit who told him, his fathers illness is just a trial and that the father would recover , his only consolation was the rebirth of his father since he held reincarnation to be a possibility. From the foregoing is a point that is vivid that cultural and religious differences and beliefs play a crucial role in the adjustment to cancer. In some cultures and religion there is a resignation to the fate or problem of an individual and they seek to tend to handle them mostly in a spiritual way, saying one witch , wizard is behind the scene or problem. Some Asian patients and Africans are known to be either religious or stoic.
The cultural shaping of depression is expressed and dependent on the cultural context, various emotional states such as anxiety are subject to cultural influence. The degree of somatization, guilt feelings and suicidal intent differs from cultures, this as a reaction to breast cancer, religion plays a greater role, when linked to the question of hope in circumstances when medical reports are negative, for a Muslim the question of hope is turned into laughter or mentioning of depression is seen as a lack of respect to Allah.(ibid)
The psychosocial well being as it concerns breast cancer from the Hispanic ,non-Hispanic, white women to the African American women study reveals that black women reported fewer concerns in terms of emotional distress than Hispanic women, particularly before surgery and fewer depression symptoms. Hispanic women reported the highest level of distress and self destructive thoughts, non –Hispanic White women commonly resorted to humour in handling the case, the use of venting was prevalent among Hispanics, the Africans were noted to take to spirituality. The coping strategies depicted by these women, African women are a reliance on prayer, avoiding negative people, developing a positive attitude, a will to live. (ibid)
Poor communication between the patient and doctor may further create barriers and depression, physicians may feel partially engaged in a more progressive assistance to people who they have closer connection with, socio-economic status ,religious affiliation , ethnicity in most cases influence the discharge of efficient services, which may further ease or complicate the problem of the breast cancer patient.
The individual and family support for breast cancer patients is essential, the stigma attached to the disease paves way for exclusion from the society and lack of love from some family members, especially in the case of someone married, the partner praying for the death of the other or abandoning the individual. In such cases, a health based organization with the support of the government is needed. The counselling issue as it cuts across ethnicity and beliefs, a more embracing unit, preferably charity groups are needed to spread the news of chances of living and been free from cancer, because as explained some people out of ignorance or indoctrination , would decline getting tested or getting treated or would just belief that the medical facilities are not of quality in some cases. A need to institute counselling groups or unit is something important in the fight against breast cancer, as an old disease and something that cuts across nations and countries, its therefore expedient that an urgent intervention is needed.
GOVERNMENTAL AND NON-GOVERNMENTAL RESPONSE TO BREAST CANCER
The picture of breast cancer has been well painted, however we need to look into the response and efforts of the government and non-profit organizations to reduce the disease if not eradicate it completely.
Breast cancer might have received several funding and policies in different countries especially in the developed economies , but if we are to rely on the findings of science daily , then , I think efforts need to be revamped towards the dreaded disease and more government participation rather than the one sided effort of NGOs .
According to the research 44,000 women in UK are diagnosed with breast cancer each year and around 12,500 will die. (sciencedaily.com)
The soaring of the breast cancer disease from previous years needs to be given a higher preference by the government; breast cancer in 2005 was 32 percent, the highest in the categories of cancer. (statistics.gov.uk)
The increase of breast cancer each year , gives the government more to do, the government must not only stop at the achievement of providing early detection devices or detection devices , but the urgent need now is the treatment of breast cancer and making more people survivors of this disease. The impact of environmental pollution is another case , as the EU ranks high among the fighters of environmental pollution ,more efforts is needed to ensure low level of exposure to toxic cocktail of carcinogens and hormone disruptors in the home , and workplace .The overall prediction is that by 2025 cancer would be widespread, further research has disclosed that breast cancers are due to unknown factors and not the common risk factors, a need for more research and funding is therefore inevitable on the part of each government.
The most unpleasant part is the waiting of patients for diagnosis and treatment, the question to be answered is the availability or unavailability of skilled manpower, especially in the UK, this is a life saving duty and should not be postponed or prolonged. A need for a more rapid response to the problem is important.
The Non-governmental response has remained apparent on the internet, through campaigns, counselling sections but more needs to be done, as breast cancer is on the rampage.
It is vivid that the government , the research community , medical establishment, non-governmental organisations each have their way of interaction and problem solving with breast cancer related trends and patients, however more interaction with the patients, innovation research and development , policies favouring the global community in terms of pollution and environmental issues are needed. Breast cancer is a social phenomenon, with no respect to social status, therefore must be treated with all the strength and budget unlike the wars against terrorism, more research is definitely needed to engage the dreaded disease.
The real cure for cancer must therefore involve changes to the way that the society functions and interacts with women with breast cancer, changes that would be effected through intense lobbying most likely be women and NGOs. Women must set the breast cancer agenda has a high priority, women can change the level of government dedication to the fight by forcing governments to make environmental policies and laws in favour of the fight against breast cancer. Activism might really be a useful weapon or instrument in the fight for a voice and change, through social change by the efforts of women (both those affected and unaffected by breast cancer) the real cure for cancer may evolve.
RECOMMENDATION; CLINICAL, GOVERNMENTAL, NGOs, INDIVIDUAL LEVEL
After a concise exploration of the topic of discussion, it is necessary to draw up recommendations at the closing stage of the paper; this is just an addition to several writings about the trends of breast cancer. The crude incidence of breast cancer in the EU and other continents every year shows there are some neglected issues both in the theory and practice of breast cancer treatment. First, the diagnosis is an area that needs to be effectively organized and funded by the government, there has been discrepancies and several reports of incorrect analysis of diagnosis, which is a technical problem, however it is crucial to stem the tide considering the negative impacts it has on individuals. The use of mammography and radiation, ultrasound, magnetic resonance is highly appreciated. However pathological diagnosis with needle aspiration or core needle biopsy should be obtained before any surgical procedure.
The staging and risk assessment should be geared towards a full clinical staging in the case of primary surgery, pathological staging based on haematoxylin-eosin staining, standardized grading and evaluation of resection margins should be appropriately analysed and scrutinized.
The determination of estrogens receptor(ER) and progesterone receptor should be done by specialist, specifically an immunohistochemistry. Routine staging examinations should include physical examinations, full blood counts, routine chemistry including liver enzymes, alkaline phosphate, calcium and assessment off menopausal status, the staging process is crucial for all patients, the conduct of additional investigations is crucial for those with preoperative treatments rather than just jumping into a surgery as I can observe in the real practice. The method of risk stratification has to be reassessed considering the high rate of mortality due to breast cancer, vascular invasion should be further researched on as it has been depicted as a prognostic factor, patients with high risk however should be given optimal consideration in terms of chest X-ray, abdominal ultrasound, isotopic bone scan.
Treatment plans should also be followed based on composition of a multidisciplinary team, made up of surgical, medical, radiation oncologist, and pathologists. The chance of hereditary cancer should be taken into consideration and counselling of relatives should be a crucial part.
Generally, operable breast cancer is initially treated by surgery using breast conserving surgery or mastectomy, sentinel node biopsy should be carried out in centers with documented experience and accuracy as it involves expertise. The use of several forms of treatment for breast cancer .Adjuvant radiation for instance is considered when patients have ER-positive DCIS (II, B) while its use in ER-negative disease is detrimental, treatment decisions should therefore be based on estimated endocrine responsiveness of tumour tissue and risk of elapse. Individual cases would therefore determine the right form of therapy.
In the case of primary systemic therapy, a full clinical staging should be carried out to prevent metastatic therapy. Primary systemic is an alternative for large operable breast cancer to allow for breast conserving surgery. The distinction of pre-menopausal patients and menopausal patients should always be considered. In postmenopausal patients, adjuvant endocrine therapy should include an aromatase inhibitor at some point, combination of ovarian function ablation with tamoxifen alone is delicate, bilateral ovarectomy, or irradiation of the ovaries leads to irreversible ablation of ovarian function, Tamoxifen is another option, with a planned switch to aromatase inhibitor years later. Adjuvant aromatase are known to be disease free survival compared to tamoxifen, so in most cases are recommended. Women treated with aromatase inhibitors however should be given Vitamin D and calcium supplements as there is no clear evidence for the use of bisphosphonates in the adjuvant setting concomitantly with aromatase inhibitor. The standard duration of therapy treatments is another problem that medical practitioners should show restraint and careful decision on, for instance there is no evidence for the use of trastuzumab in patients with node –negative, small (1cm) tumours, as it has side effects on patients, the standard duration of adjuvant trastuzumab has not yet been known although one year is always recommended but the most important is the use and application. When combining chemotherapy with tamoxifen the latter should be at the end of chemotherapy, the order of all this treatment is something that a practitioner or specialist should be careful with as it can lead to a negative aftermath if used wrongly. The path of clinical treatment is complex and thus must be treated with care and sensitivity. The mammography scandal some years ago is a case to sight as an example in the United States of America and some other places, reminds of the deficiencies of human administration and the need for constant scrutinization and follow-up. The blame game is played here, as no specialist is willing to give up his/her name, but the emphasis in regulating the behaviour and professional practice is crucial.
The response of the government thus in terms of policies should be adopting and implementing policies that would favour the breast cancer patients, there is also a need to enforce proper monitoring system to curb administrative or service delivery deficiencies ,that might be an obstruction to the purpose of dealing with breast cancer issues.
Funding is another part that is needed alongside research and development (R&D), a crucial need for adequate funding to such issues as R&D, innovation in the area of improving the instruments of treatment is crucial. The data about the increase in the number of people with breast cancer, should not just be broadcasted or shared with the public without the government stepping up with ideas, funding, a variety of support in terms of counselling units and lectures to educate the whole populace, instead of the stem wiping out the independent population and mothers in the society.
The part of the NGOs had been defined by their efforts in the past and present , launching an ever interactive and people oriented campaign , they have also been hitting or telling the government in most case what needs to be done, this creates an interactive atmosphere for the fight against cancer, however this is not the end, both the government and non profit organizations should cooperate to make the fight much more intensive and focused to dealing with main issues, funding is such a huge task for non profit organizations as such cooperative projects should be embarked on by the duo in tackling this ever urgent problem. The conscientious effort of engaging the media strongly in the campaign is crucial, the media’s active dissemination of information of breast cancer must not be seasonal or at any time when its needed, but talk shows dedicated to breast cancer, the staging, treatment options, counselling should be more active from the non-profit sector to the government sector, this would further eradicate the disbelieves and false depiction of the treatment options and breast cancer.
As previously stated, the individual level would be well organized if at the governmental and non-governmental level, there is a sensitization and help rendered to people that their loved ones are victims of breast cancer. At the individual level, thus much counselling and advice is needed. The feeling of exclusion is countered when the government, NGOs assist, then the individual has enough strength to deal with the situation.
REFERENCE
American Cancer Society, breast cancer facts and figures ,2005-2006, accessed 5th May 2008,
http://www.cancer.org/downloads/STT/CAFF2005BrF.pdf
American Cancer Society, overview of what is cancer, accessed 5th May 2008, http://www.cancer.org/docroot/CRI/content/CRI_2_2_1x_What_Is_Cancer.asp?sitearea=
Bookpage.com, the mammogram debate, accessed 5th May, 2008, http://www.bookpage.com/9705bp/sponsor3/mamdebate.html
Canadian Cancer Society, staging and grading for breast cancer, accessed 6th May 2008, http://www.cancer.ca/ccs/internet/standard/0,3182,3172_10175_420456596_langId-en,00.html
Cancer compass.com, Breast cancer information, side effects, accessed 8th May, 2008 , http://www.cancercompass.com/breast-cancer-information/side-effects.htm
Cancerhelp.uk, cancer treatments, accessed 6th May 2008, http://www.cancerhelp.org.uk/help/default.asp?page=156
Darkwing.urgeon.edu, theories on natural history of breast cancer, accessed 7th May, 2008,.
http://darkwing.uoregon.edu/~jbonine/rad02.html
Dein, S, Culture and cancer care: Anthropological Insights in Oncology, Open University press, England, 2006
EhealthMd.com, what causes breast cancer, accessed 6th May 2008, http://www.ehealthmd.com/library/breastcancer/BRC_causes.html
Fallowfield,J, etal , psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial, accessed 8th May 2008, http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1663731&blobtype=pdf
Fallowfield, L&Clark, A, Breast cancer, Tavistock Routledge, 1991.
Ferrini, R, etal, Screening Mammography for Breast Cancer: American college of Preventive medicine practice policy statement, accessed 8th May 2008, http://www.acpm.org/breast.htm
Finkel, M, understanding mammography controversy: Science, Politics, and Breast Cancer Screening, Praeger publishers, Westport, 2005.
Gather.com, Personal experiences with breast cancer, accessed 8th May, 2008 http://www.gather.com/viewArticle.jsp?articleId=281474977271299&nav=Namespace
Lin etal, CNS Metastases in Breast Cancer, Journal of clinical oncology, 2004, accessed 7th May, 2008, http://jco.ascopubs.org/cgi/reprint/22/17/3608?ijkey=561bffd62f2502cc974cf8788e3d9a67cb11e87a
Medicinenet.com, what are risk factory for breast cancer?, accessed 5th May, 2008,
http://www.medicinenet.com/breast_cancer/page3.htm#toce
NHS Direct, radiotherapy, how is it performed?, accessed 8th May, 2008, http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=309§ionId=24
Ogden, J, Understanding Breast Cancer, Wiley publishers, New Jersey, 2004.
Rowland, J, etal, role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors, accessed 8th May, 2008, http://jnci.oxfordjournals.org/cgi/reprint/92/17/1422
Sciencedaily.com, too many women still dying from breast cancer, says UK charity, accessed 8th May 2008, http://www.sciencedaily.com/releases/2008/03/080327172227.htm
Treatmentdecisons .com, my treatment diary, accessed 6th May, 2008, http://www.mytreatmentdecisions.com/210-my-treatment-diary.aspx
UK national statistics, Cancer statistics, accessed 6th May, 2008, http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=7720&Pos=1&ColRank=2&Ra
Weil,J etal, Breast Cancer metastasis to the Central Nervous System, American Journal of pathology, 2005, accessed 8th May 2008, http://ajp.amjpathol.org/cgi/content/full/167/4/913