Breasts, also known as mammary glands, are a pair of glandular organs that produce milk in response to the hormone changes of childbirth. They are mainly made up of fatty tissue and are supported by ligaments and large muscles.

Each breast has 15-20 lobes with a number of lobules and ducts supportive tissue (see diagram). Each lobule has about 30 major ducts that open onto the nipple. The darker area of skin around the nipple is called the areola. At the edge of the areola there are large glands that produce fluid to lubricate the nipple.

In each armpit, there are about 20-30 lymph nodes (glands) that drain fluid from the breast. These form part of the lymphatic system that helps the body to fight infection.

The term “benign breast diseases” encompasses a heterogeneous group of lesions that may present a wide range of symptoms or may be detected as incidental microscopic findings. The incidence of benign breast lesions begins to rise during the second decade of life and peaks in the fourth and fifth decades, as opposed to malignant diseases, for which the incidence continues to increase after menopause, although at a less rapid pace. A firm understanding of benign breast disease is important since sequential steps are necessary to distinguish lesions which impart a high risk of subsequent breast cancer from those which do not.

The common breast disorders in women can be seen here

A breast infection, also known as mastitis, is an infection that occurs within the tissue of the breast. The cause of most breast infections is Staphylococcus aureus bacteria, which causes what is commonly known as a staph infection.

• Acute Mastitis – Acute mastitis is usually a bacterial infection and is seen most commonly in the postpartum period. Bacteria invade the breast through the small erosions in the nipple of a lactating woman, and an abscess can result.
• Breast Abscess – A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection.
• Chronic Mastitis – Chronic mastitis occurs in women who are not breastfeeding. In postmenopausal women, breast infections may be associated with chronic inflammation of the ducts below the nipple. Hormonal changes in the body can cause the milk ducts to become clogged with dead skin cells and debris. These clogged ducts make the breast more open to bacterial infection. Infection tends to come back after treatment with antibiotics.
• Risk Factors for Breast Cancer – Age, Early Menstrual period, Genetics, Family History, Personal History of Breast Cancer, Personal history of certain non-cancerous breast diseases, Race Ethnicity, being Overweight/Obese, Pregnancy History, having dense breasts, using combination hormone therapy, previous treatment using radiation therapy, Drinking alcohol.

Breast cancer is the most common type of cancer affecting women in India. However, extensive research and technological advances in diagnosis and treatment make breast cancer the best among the worst! Not to glorify it, but if detected early, breast cancer can be treated well with minimal morbidity to the patient.

Honestly, no amount of training teaches doctors how to answer this question. Scientifically speaking, breast cancer is a multifactorial disease. It results in a combination of excess circulating estrogen, advancing age and bad genes. All women have a baseline level of estrogen. But the risk of cancer is determined by the number of years the breasts are exposed to unopposed estrogen action. Estrogen and progesterone are two hormones required for the growth of breast. While estrogen promotes the proliferation of cells in the breast, progesterone antagonizes it. Progesterone is the hormone of pregnancy. Hence, women who have never been pregnant or who attain early menarche, late menopause are exposed to longer periods of sustained estrogen action and have increased the risk of breast cancer.

BRCA 1 and BRCA 2 are genes present in our chromosome. Mutation of these genes may be inherited. Mutated BRCA genes increase the risk of breast cancer to up to 85%. They also lead to other hereditary cancers like ovarian cancer, pancreatic cancer, and colon cancer. Breast cancer caused by BRCA mutation has some specific traits. They are very aggressive tumors which might affect both the breasts at multiple sites and they strike at a younger age. If there is a family history of breast and ovarian cancers affecting younger women, consult a doctor to get tested for BRCA mutation. A blood sample is drawn and the DNA is screened for the mutation. Intensive pre-test and post-test counseling will be required to prepare the patients to deal with the results of the test.

The American Cancer Society recommends any woman above the age of 40 years to undergo a screening mammography as part of the routine annual health check-up. A mammogram is a form of X-RAY of the breasts. It helps to detect any breast lump which is very small to be detected by clinical examination. A mammogram is not done in younger women because young women have dense breast tissue which might be falsely detected as a breast lump. Women from high-risk families – families tested positive for BRCA mutation – may have to undergo a screening MR mammography regularly to detect breast lumps.

No. It is true that the mammography machine uses X-rays which are 4 times stronger than the routine chest x-rays. However, there are no studies to prove that yearly mammography will increase the risk of cancer.

Do not panic. Not all breast lumps are cancerous. Consult a surgeon and get yourself examined. Based on the clinical examination, the doctor may advise you to get an ultrasound of the breast. There are certain definitive features of a cancerous lump which can be differentiated from a benign lump. If there are features suspicious of cancer, a small sample of the lump will be obtained using a needle (either FNAC or Trucut biopsy) and will be further tested to confirm cancer.

Cancer is a mass of cells which divide in an unregulated manner. These cells rest on a basement membrane. As long as the rapidly dividing cells are limited by a basement membrane, cancer remains localized. This is called carcinoma-in-situ. It is the earliest stage of cancer. Once the cells invade the basement membrane, they can spread to other organs via blood vessels or lymphatics.

All cancers are staged on a scale from stage 0 to stage 4. Carcinoma-in-situ is stage 0 and a metastatic cancer is stage 4. Other stages vary with different cancers. With respect to breast cancers, early invasive breast cancer is one which has not spread beyond the breast and axillary lymph nodes.

There are several blood tests and scans to be done to detect the spread of cancer::

• Chest X-ray – to detect spread to the lungs.
• CT scan – it provides high definition images of probable cancer spread to the liver and lungs. CT scan images can also guide the surgeon to take a biopsy.
• MRI – it detects spread to the brain and spinal cord.
• PET scan – the patient is given a radioactive sugar solution. This sugar binds to cancer cells which can be detected using the special camera. A PET scan is done to asses spread of cancer when the surgeon is not sure of the exact location of spread from clinical examination.

Any patient with early invasive breast cancer (stage 0, I and II) can be treated with breast conservation surgery. The goal is to preserve the breast tissue and shape as much as possible. Only the lump and some normal tissue surrounding it are removed. However, breast conservation surgery is always followed by radiation therapy.

Breast cancer spreads through lymphatic channels. A sentinel lymph node is the first lymph node along the lymphatic channels to receive lymph from an organ. The lymph from the breast first drains into the lymph nodes present in the armpit. Hence, if the right breast has a cancerous lump, the cancer cells would have to first reach the lymph nodes in the right armpit and only then it would spread to the rest of the body.

A biopsy of the sentinel lymph node is done when no node is felt in the armpit during clinical examination. A dye is injected through the skin over the breast and a small cut is made in the armpit to identify the first lymph node which is stained by the dye. This node is sent to the lab to detect cancer cells while the patient is still in the operation theatre, under anesthesia. It usually takes about 30 minutes for a report. If there are no cancer cells found in this biopsy, it means cancer has not spread to the lymph nodes and a mere removal of the breast lump would suffice. If the biopsy shows cancer cells, then the surgeon would remove lymph nodes from the armpit too.

Locally advanced breast cancer is one which is larger than early breast cancer but still confined to the breast and axillary lymph nodes. Such patients may require chemotherapy first to reduce the size of the lump. This would be followed by surgery and radiation therapy.

ER and PR stand for estrogen receptor and progesterone receptor respectively. If a tumor is positive for these receptors, such patients are likely to respond to hormone therapy. Drugs like tamoxifen are very useful in such patients and it reduces the risk of recurrence of cancer in the other breast. Tumors negative for these receptors will not respond to hormone therapy and such patients will have to be given chemotherapy.

HER2/nu is Herceptin receptor. Tumors which have this receptor tend to be more aggressive and rapidly growing. However, drugs targeted against the receptor are available, like Trastuzumab.

Breast cancer which has spread to other parts of the body is managed by appropriately dosed hormone therapy, chemotherapy, and radiation therapy. The role of surgery in advanced metastatic cancer is very minimal.

Several oncoplastic surgeries are done to reconstruct the breast for women who have undergone a mastectomy. The patient’s own abdominal muscles or muscles of the back are used to reconstruct the breast. A silicone prosthetic breast may also be used.

Yes. The main source of estrogen in postmenopausal women is estrogen from fatty tissue. Obese women are exposed to estrogen for the longer time period and this increases the risk of breast cancer.

30-40 % risk is seen in girls under the age of 18 who regularly use this method of contraception. HRT (Hormone Replacement Therapy) used by post-menopausal women increase the risk (63%) of development of breast cancer. However, HRT may be required to control other symptoms of menopause. So, women using HRT must undergo regular Mammography and screen themselves for breast cancer.

No. Adolescent girls may have multiple breast lumps. These are called fibroadenomas. They occur due to hormonal imbalance. However, it is advisable to get it examined and scanned to confirm the diagnosis.

Yes, definitely. The patient can get admitted on the morning of the surgery. Surgery for breast cancer takes about 2 hours to complete. If required a drain tube will be placed under the skin. The patient can be discharged from the hospital 24 hours after the surgery.

Cervical cancer is the most common cancer in women in India with breast cancer competing fast with it for the top position. In a survey conducted by ICMR (Indian Council of Medical Research), it is seen that 1 out of 22 women are affected compared to 1 in every 8 women affected in US.

• Positive family history of breast cancer – If a woman has a mother who has had breast cancer, her risk increases about 3 folds. If the woman has a sister with history of breast cancer, the risk increases by 2-3 folds.
• Women who have had breast cancer in one breast
• There is slightly increased risk in women who have had their first childbirth late in life, had an early menarche, have no children or have a late menopause
• Obesity predisposes to breast cancer after menopause
• Increased and long usage of OC pills
• Women who have taken hormones for more than 10 years
• Oncogenes- related to BRCA1 and BRCA2 genes

Some women have what’s called HER2-positive breast cancer. HER2 refers to a gene that helps cells grow, divide, and repair themselves. When cells have too many copies of this gene, cells — including cancer cells — grow faster. Experts think that women with HER2-positive breast cancer have a more aggressive disease and a higher risk of recurrence than those who do not have this type

Usually breast cancers present with:

• A painless mass in the breast- up to 10% of cases have pain and no mass
• Breast changes- thickening, swelling and skin irritation or distortion (Dimpling of the skin in the area of the lump appearing like orange peel)
• Nipple changes- discharge, erosion, inversion and tenderness( pain)
• Presence of patch of dry flaky skin on the nipple and change in appearance or texture of the breasts – Usually seen in Paget’s disease.
• General symptoms- fever, loss of appetite, fatigue

• Change in size
• Inverted nipple
• Rash in and around the nipple
• Discharge from one or both nipples
• Puckering or dimpling of skin
• Swelling in your armpits
• Swelling in the breast
• Constant pain in breast and armpit

The earlier the breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated successfully.

The following are the guidelines for finding breast cancer early in women without symptoms:

• Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, preferably every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts feel likeFor any spontaneous change, see your physician without delay!Make sure you compliment your BSE with a yearly physical exam of your breasts by a trained professional and ask about risk factors and breast screening.
• Breast awareness and breast self-exam (BSE): BSE is an option for women starting in their 30s. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally feel.

Women more than 30 years of age should do BSE regularly.
BSE should be performed about one week after the beginning of each cycle.
If the periods have stopped, it should be done in the beginning of each month.

1. While standing in front of a mirror, look at the breasts. The breasts normally differ slightly in size. Look for changes in the size difference between the breasts and changes in the nipple, such as turning inward (an inverted nipple) or a discharge. Look for puckering or dimpling.
2. Watching closely in the mirror, clasp the hands behind the head and press them against the head. This position helps make subtle changes caused by cancer more noticeable. Look for changes in the shape and contour of the breasts, especially in the lower part of the breasts.
3. Place the hands firmly on the hips and bend slightly toward the mirror, pressing the shoulders and elbows forward. Again, look for changes in shape and contour.
	4. Raise the left arm. Using three or four fingers of the right hand, probe the left breast thoroughly with the flat part of the fingers. Moving the fingers in small circles around the breast, begin at the nipple and gradually move outward. Press gently but firmly, feeling for any unusual lump or mass under the skin. Be sure to check the whole breast. Also, carefully probe the armpit and the area between the breast and armpit for lumps.
	5. Squeeze the left nipple gently and look for a discharge. (See a doctor if a discharge appears at any time of the month, regardless of whether it happens during breast self-examination.)
Repeat steps 4 and 5 for the right breast, raising the right arm and using the left hand.
6. Lie flat on the back with a pillow or folded towel under the left shoulder and with the left arm overhead. This position flattens the breast and makes it easier to examine. Examine the breast as in steps 4 and 5. Repeat for the right breast.

• At Age > 40 years – Annual mammogram, annual Clinical Breast examination ( CBE) and optional monthly breast self- examination ( BSE)
• At Age 20-39 – Every three years a CBE and optional monthly BSE
• For women at average risk- especially those who have a family history of breast cancer, should talk to their doctor about when to start screening

If there is any reason to think you might have breast cancer, your doctor may suggest further tests such as the ones below to confirm:

• Fine needle aspiration cytology (FNAC): This involves taking out a few cells from the lump with a thin needle and examining them under a microscope.
• Biopsy: Sometimes, even after doing FNAC it may not be possible to find out the nature of the lump. The lump may then have to be in part or totally under following methods, under local or general anesthesia.
• Stereotactic core needle biopsy: The needle used for this test is larger than the one for fine needle biopsy. It is used to remove several cylinders of tissue. The biopsy is done with local anesthesia (the area is numbed) on an outpatient basis.
• Surgical biopsy: Sometimes surgery is needed to remove all or part of a lump so it can be looked at under a microscope. The entire lump as well as some normal tissue around it may be removed. Most often this is done in the hospital on an outpatient basis. Local anesthesia is used and sedation may also be given to relax you and make you less aware of the process
• Mammography: This special type of x-ray of the breast is done to assess the extent of tumor in the affected breast and ascertain whether there is any abnormality in the other breast.
• Sonography of the breast: Sometimes a mammography is supplemented with this test. Both the tests are useful to detect tumor and its extent but do not offer a definitive diagnosis as is done by FNAC or a biopsy.

• Chest x-ray: This test may be done to see whether the cancer has spread to the lungs.
• Bone scan:This test can help show whether the cancer has spread to the bones. The patient is given a very low dose of radiation. The bone attracts the radiation which will show up on the scan as a “hot spot.” These hot spots could be cancer but other problems such as arthritis can also be the cause. Therefore, x-rays of hot spots may be needed.
• CT scan (computed tomography): A CT scan is a special type of x-ray. Many pictures are taken from different angles. These images are combined by a computer to produce a detailed picture of the internal organs. This test can help tell if the cancer has spread to the liver or other organs. It can also be used to guide a biopsy needle into a suspicious area.
• MRI (magnetic resonance imaging):An MRI scan uses radio waves and strong magnets instead of x-rays. This test can be helpful in looking at the brain and spinal cord.
• PET scan (positron emission tomography): This test uses a form of sugar that contains a radioactive atom. Cancer cells absorb high amounts of this sugar. A special camera can then spot these cells. PET is useful when the doctor thinks the cancer has spread but doesn’t know where. It may also be useful in checking lymph nodes for cancer before they are removed.

Breast cancer has been divided into four stages; but it is classified into three categories for the purpose of planning treatment:

• Early breast cancer – where the cancer is limited to the breast and lymph nodes in the armpit. The primary aim to treatment in this stage is to cure as well as to conserve the breast. Surgery is the first line of treatment here. Supplementary hormone therapy, chemotherapy and radiotherapy may be required later.
• Locally advanced breast cancer – where the cancer has advanced but is still confined to the breast and the lymph glands. The doctor may first give chemotherapy to shrink the lump and then operate. Hormone therapy and radiotherapy are also mandatory.
• Metastatic breast cancer – where the cancer has spread to other parts outside the breast and lymph glands
• Here the treatment cannot cure the cancer but may control it for some time. The treatment involves judicious use of hormone therapy, chemotherapy, radiotherapy and rarely surgery

Treatment is most successful when the cancer is detected early, before it has spread.

• Surgery: Breast-conserving surgery (lumpectomy- removes the tumor and surrounding tissue), mastectomy( removes the breast), and lymph node dissection, are different types of surgeries
• Radiation therapy: is a highly targeted, effective way to destroy cancer cells in the breast that may stick around after surgery.
• Chemotherapy: a cancer treatment in which drugs are given orally/ intravenously to stop the growth of the cells and to kill the cancer cells.
• Hormone therapy: It is a very effective treatment against breast cancer that is hormone-receptor-positive
  Monoclonal antibody therapy: are with Trstuzumab( Herceptin) and Lapatinib
• Often, two or more methods are used in combination with each other.

Surgery forms the mainstay of treatment of breast cancer. It involves removal of the cancerous lump with either preservation or complete removal of the breast.

• Lumpectomy: Also called breast conservation therapy, lumpectomy involves removing only the breast lump and some normal tissue around it. Radiation treatment is often given for about 6 weeks after this type of surgery. If chemotherapy is going to be used as well, the radiation may be postponed until the chemo is finished.
• Partial (segmental) mastectomy : This surgery involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy.
• Simple or total mastectomy: In this surgery the entire breast is removed but not the lymph nodes under the arm or muscle tissue from beneath the breast.
• Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm.
• Radical mastectomy: This is extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because of disfigurement and fewer side effects.

There are various re-constructive plastic surgery procedures that can reconstruct the breast mound. The surgery involves utilisation of your muscle on the back or abdomen to reconstruct a breast. Breast reconstruction can also be done by implantation of’ silicon prosthesis’.

It is possible to have artificial breast (prosthesis). These prostheses can either be worn externally or a special type of prosthesis can be surgically implanted beneath the skin so as to give the mound

• Relaxation exercise
• Meditation
• Psychological counselling
• Support of family and colleagues

It is proved that greater the breast tissue, greater is the area for the cancer to develop and higher risk for development of breast cancer. It is always seen that most cancers develop at outer rim of the breast due to more tissue mass.

If anyone from the paternal side has breast cancer, there is no chance of developing breast cancer. The risk doubles if a first degree relative (mother > or sister) suffers from it. If more than two first degree members suffer, the risk increases to 50 times.

• 30-40 % risk is seen in girls under the age of 18 who regularly use this method of contraception
• HRT used by post -menopausal women increases the risk (63%) of development of breast cancer.

It does not cause breast cancer but women who wear ill-fitting bras may get fat necrosis not cancer.

Breast cancer can be prevented by the following measures:

• Having your first child between 20 -25 years and second before 28 years
• Do breastfeeding for a year and maintain healthy diet and weight
• Abstain from alcohol
• Regular self- examination of the breast for lumps.
• If there is a positive family history of breast cancer, after 30 years, regular mammography should be conducted

It does expose the patient to radiation but in a very negligible amount. It is advisable to get routine physical check- ups after the age of 50 years, once in two years for prevention.

No men get it too. Data has shown that for every 100 women diagnosed with breast cancer, one male is diagnosed too.

Some drugs which cancer patients used to take are being developed for taking by women who have breast cancer for prevention of breast cancer.
Oncoplasty is a procedure which is being developed for reconstructing the breast after mastectomy using woman’s own healthy breast tissue
Trastuzumab is a drug under pipeline for reducing the risk of recurrence

A Testimonial from a Breast Cancer Patient to Dr Nanda & Nova Clinic, Koramangala

I was diagnosed with breast cancer in February 2013 and was advised surgery immediately. It was suddenly a bolt out of the blue. A friend advised me to go for a second opinion and suggested that I meet Dr. Nanda Rajneesh at NOVA Superspeciality clinic, Koramangala.

Although I live near Koramangala, I was not aware of the clinic. I followed my friend’s directions and located it. As I entered the clinic, I was very impressed by the clean, aesthetic interiors and cordial and polite staff at the reception. I had no idea that it was a clinic meant for surgery.

I took an appointment and met Dr. Nanda at the clinic. I took an immediate liking to her and when she offered to perform the surgery at the clinic, I readily agreed as I have a mortal fear of big hospitals.

I was totally relaxed on the day of the surgery as I trusted that I was in very competent hands. The staff in the operating theatre was very kind and gentle. I felt no discomfort prior to or post surgery. The entire procedure was performed so smoothly. Although I could have been discharged on the same day, I requested to stay overnight. The staff on night duty checked on me regularly.

After surgery, I had to visit the clinic for dressing which was done so deftly by Dr. Nanda and her wonderful team of nurses. I would like to make a special mention of Sr.Ponds with a kind and re-assuring smile who did my dressing regularly for almost a month.

Dr. Nanda herself is a gem of a person. She helped me put away all my fears and doubts aside and face the situation with confidence. She is my oncologist, friend and support during this trying period.