The agony of breast cancer and the way forward

STORY of a woman whose heart was full of pain and sorrow that drained her energy to death might sound scary at a point, but later one will realize it had to be the way it was.

We knew her as a strong and energetic as a baobab tree. Her energy caught our attention and she brought us to a conclusion of terming her a tremendous lady.

Her beauty and character gave her a credit of being an exceptional woman; we did not see this coming because her smile covered it all.

The late sleep, long calls made us think she was missing her siblings and perhaps her age was the result of life drama she had, later it came to our attention that cancer was the result of all, the pain that had forced her to have long calls and late sleep. Not just an early-stage cancer but the last stage breast cancer took our beloved, Rachel Barnaba.

At a point, one may say cancer can be treated. Yes, it can and has been proven by doctors. But what about those who just conceal, taking it to be a normal swell or a rash that itches and cools off over time? What about those who are ashamed of saying “it hurts here” fearing of being laughed at?  How would we help them?

Breast cancer is not an infectious disease unlike some cancers that have infection-related causes such as Human Papilloma Virus (HPV) infection and cervical cancer; there are no known viral or bacterial infections linked to the development of breast cancer.

Breast cancer arises in the lining cells of the ducts or lobules in the glandular tissue of the breast. Initially, the cancerous growth is confined to the duct or lobule where it generally causes no symptoms and has minimal potential for spread.

In 2020, there were 2.3 million women diagnosed with breast cancer and 685,000 deaths globally, as of the end of 2020 there were 7.8 million women alive who were diagnosed with breast cancer the past five years, make it the world’s most prevalent cancer.

Her fear told her to stay low, thinking of it being a normal situation perhaps in the average of 7.8 million women who survived, Rachel could be among them.

Approximately half of breast cancers develop in women who have no identifiable breast cancer risk factor other than gender (female) and age (over 40 years). Certain factors increase the risk of breast cancer, including increasing of age, obesity, harmful use of alcohol, family history of breast cancer, history of radiation exposure, reproductive history (such as age that menstrual periods began and age at first pregnancy), tobacco use and postmenopausal hormone therapy.

Unfortunately, even if all of the potentially modifiable risk factors could be controlled, this would only reduce the risk of developing breast cancer by at most 30 per cent.

Female gender is the strongest breast cancer risk factor, approximately 0.5-1 per cent of breast cancers occur in men.

Family history of breast cancer increases the risk of breast cancer, but the majority of women diagnosed with breast cancer do not have a known family history of the disease although lack of a known family history does not necessarily mean that a woman is at reduced risk.

Signs and symptoms

Breast cancer most commonly presents as a painless lump or thickening in the breast. It is important that women finding an abnormal lump in the breast consult a health practitioner without a delay of more than 1-2 months even when there is no pain associated with it. Seeking medical attention at the first sign of a potential symptom allows for more successful treatment.

Generally, symptoms of breast cancer include breast lump or thickening, alteration in size, shape or appearance of a breast, dimpling, redness, pitting or other alteration in the skin, change in nipple appearance or alteration in the skin surrounding the nipple (areola) and/or abnormal nipple discharge.

Breast cancers may spread to other areas of the body and trigger other symptoms. Often, the most common first detectable site of spread is to the lymph nodes under the arm although it is possible to have cancer-bearing lymph nodes that cannot be felt.

Over time, cancerous cells may spread to other organs including the lungs, liver, brain and bones. Once they reach these sites, new cancer-related symptoms such as bone pain or headaches may appear.

Treatment

Breast cancer treatment can be highly effective, achieving survival probabilities of 90% or higher, particularly when the disease is identified early. Treatment generally consists of surgery and radiation therapy for control of the disease in the breast, lymph nodes and surrounding areas (locoregional control) and systemic therapy (anti-cancer medicines given by mouth or intravenously) to treat and/or reduce the risk of the cancer spreading (metastasis). Anti-cancer medicines include endocrine (hormone) therapy, chemotherapy and in some cases targeted biologic therapy (antibodies).

Medical treatments for breast cancers, which may be given before or after surgery, is based on the biological subtyping of the cancers. Cancer that expresses the estrogen receptor (ER) and/or progesterone receptor (PR) are likely to respond to endocrine (hormone) therapies such as tamoxifen or aromatase inhibitors.

These medicines are taken orally for 5-10 years, and reduce the chance of recurrence of these ‘hormone-positive’ cancers by nearly half.  Endocrine therapies can cause symptoms of menopause but are generally well tolerated.

Cancers that do not express ER or PR are ‘hormone receptor negative’ and need to be treated with chemotherapy unless the cancer is very small. The chemotherapy regimens available today are very effective in reducing the chances of cancer spread or recurrence and are generally given as outpatient therapy. Chemotherapy for breast cancer generally does not require hospital admission in the absence of complications.

Breast cancers may independently overexpress a molecule called the HER-2/neu oncogene. These “HER-2 positive” cancers are amenable to treatment with targeted biological agents such as trastuzumab. These biological agents are very effective but also very expensive, because they are antibodies rather than chemicals. When targeted biological therapies are given, they are combined with chemotherapy to make them effective at killing cancer cells.

Radiotherapy also plays a very important role in treating breast cancer. With early stage breast cancers, radiation can prevent a woman having to undergo a mastectomy. With later stage cancers, radiotherapy can reduce cancer recurrence risk even when a mastectomy has been performed. For advanced stage of breast cancer, in some circumstances, radiation therapy may reduce the likelihood of dying of the disease.

The effectiveness of breast cancer therapies depends on the full course of treatment. Partial treatment is less likely to lead to a positive outcome.

WHO response

The objective of the World Health Organisation (WHO) Global Breast Cancer Initiative (GBCI) is to reduce global breast cancer mortality by 2.5 per cent per year, thereby averting 2.5 million breast cancer deaths globally between 2020 and 2040.

Reducing global breast cancer mortality by 2.5 per cent per year would avert 25 per cent of breast cancer deaths by 2030 and 40 per cent by 2040 among women under 70 years of age. The three pillars toward achieving these objectives are: health promotion for early detection; timely diagnosis; and comprehensive breast cancer management.

By providing public health education to improve awareness among women of the signs and symptoms of breast cancer and, together with their families, understand the importance of early detection and treatment, more women would consult medical practitioners when breast cancer is first suspected, and before any cancer present is advanced. This is possible even in the absence of mammographic screening that is impractical in many countries at the present time.

Public education needs to be combined with health worker education about the signs and symptoms of early breast cancer so that women are referred to diagnostic services when appropriate.

Rapid diagnosis needs to be linked to effective cancer treatment that in many settings requires some level of specialized cancer care. By establishing centralized services in a cancer facility or hospital, using breast cancer as a model, treatment for breast cancer may be optimized while improving management of other cancers.

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