Breast cancer is now the most common cancer amongst urban Indian women. As per Population Based Cancer Registry (PBCR) breast cancer accounts for 25 percent to 32 percent of all female cancers in urban Indian cities. This implies, practically, one fourth (or even approaching one thirds) of all female cancer cases are breast cancer.
The concerning fact for the Indian population is that for every two women newly diagnosed with breast cancer, one woman is dying of it . Since more patients in India present at later stages, they do not survive long, irrespective of the best treatment they may get, and hence the mortality is fairly high.
Lack of awareness of breast cancer and screening for disease are significant contributory factors for the relatively late stage of the disease presentation in India.
Breast Health Awareness implies that women should be aware of the common presenting symptoms of breast cancer such as painless palpable lump in the breast or underarm, nipple inversion, spontaneous bloody or clear nipple discharge, change in size of breast or skin dimpling. Typically, there is no pain associated with breast cancer. Therefore, women often do not realise the above mentioned symptoms until it is too late.
If a woman experiences any of the above symptoms, she should immediately consult her physician and undergo a diagnostic mammogram which is a specialised X-ray of the breast. If the mammogram is abnormal the radiologist will recommend a breast ultrasound for further characterisation of the mammography abnormality followed by imaging guided breast biopsy for accurate pathology diagnosis of breast cancer or in simple words confirming the diagnosis of breast cancer.
Pathology diagnosis or tissue diagnosis plays a crucial role in diagnosis and management of breast cancer. There are several types of breast biopsy techniques such as Fine Needle Aspiration Biopsy (FNAB), Trucut or Core Needle Biopsy (CNB) and Vacuum Assisted Biopsy (VAB). The selection of the biopsy technique depends on availability of resources and the characteristics of the breast lesion.
FNAB also called fine needle aspiration cytology (FNAC) is a technique by which a few cells are aspirated from the concerning breast lump under imaging guidance, typically ultrasound guidance. FNAB is the most widely available and cheapest biopsy technique for confirmation of breast cancer. However, FNAB has a number of limitations. This technique is cytologists dependent and is often associated with false negative (I.e. cancer is present but not detected in the aspirated sample) in about 27 percent of unsatisfactory samples. In a situation such as this patient often assumes that there is no cancer in the biopsy and therefore does not receive any further treatment, only to return later with an advanced stage of breast cancer. Moreover, this type of biopsy is unable to provide information on the cancer subtype and receptors or tumour markers such as oestrogen receptors, progesterone receptors and hereceptin receptors which are crucial for further management of breast cancer.
Trucut or core needle biopsy (CNB) involves obtaining cores of tissue from the breast mass under ultrasound guidance. The sensitivity of this type of biopsy for accurate diagnosis is 96 percent to 98 percent. Also information about cancer subtype and receptors or tumour markers is available from this type of biopsy. This type of biopsy technique is now widely available and is relatively cost-effective.
Vacuum assisted biopsy (VAB) involves bigger needle with vacuum assistance for optimal sampling for non-palpable breast lesions such as micro calcifications as well as for complex solid cystic masses with a high accuracy rate of almost 100 percent. This technique also has applications for non-surgical removal of benign lesions such as small fibroadenomas.
Imaging guided biopsy techniques are typically performed for diagnosis of indeterminate or suspicious breast lumps. The biggest advantage of imaging guided percutaneous biopsy is that the patient has to undergo a single surgical procedure for treatment of breast cancer following imaging guided biopsy confirmation of breast cancer. Before the advent of imaging guided breast biopsy, patients would have have to undergo two surgical procedures. The first surgical procedure is for excision biopsy for diagnosis of the breast lump and the second surgical procedure for complete clearance of the breast cancer. Therefore, imaging guided percutaneous biopsy is superior to open surgical biopsy for several reasons, including increased accuracy, decreased cost and decreased surgical morbidity and cosmetic deformity.
Apart from conventional methods of tissue sampling such as FNAB and CNB, VAB is a newer biopsy technique that is slowly but surely gaining momentum in clinical practice. VAB is based on the vacuum technology whereby with a single entry the device not only cuts through the targeted point in the lesion but also part of the lesion surrounding the targeted area by virtue of its ability to suck in and cut through a zone around the target. This ensures a bigger sample and hence accurate and timely diagnosis. VAB is indicated for biopsy of indeterminate or suspicious micro-calcifications seen on a mammogram, complex solid cystic masses seen on ultrasound and suspicious lesions seen on breast MRI which are occult on mammogram and ultrasound. Thus, VAB is compatible with all modalities offering a diverse choice to physicians for better diagnosis. Another advantage of VAB is its ability to conduct minimally invasive removal of benign breast lumps on an outpatient basis saving the patient unnecessary scarring or the trauma of going through a surgery.
Another advancement in the treatment of breast cancer that we have seen over the last decade is the revolution in surgical management. In the good old days, if a woman was diagnosed with breast cancer, irrespective of the stage of the breast cancer she would have to undergo mastectomy i.e. she would lose her entire breast. However, one of the main objectives of breast oncologists today is to conserve as much healthy breast tissue as possible for a patient diagnosed with stage 1 or stage 2 breast cancer. To address this need two ground-breaking technologies have recently been introduced in India. One is the Breast Tissue Marker and the second is the Hook Wire Localisation Needle.
The Breast Tissue Marker is small in size – about the size of a sesame seed and is made of titanium, a “biocompatible metal”. The marker is placed at the site of the lesion from where imaging guided biopsy samples have been obtained. The purpose of the marker is to precisely identify the location of the cancerous lesion. These markers are not only identified on mammogram by virtue of their radio opacity but also have a permanent ultrasound visibility. Therefore, stage 1 and stage 2 breast cancers can be identified. This also has a great utility in locally advanced breast cancers. The objective of the physician is to shrink the tumour around the marker to the maximum possible extent with the help of pre-operative chemotherapy so that a minimal healthy breast tissue needs to be removed at the time of open surgery. The marker clips help identify the site of the cancerous lesions in early breast cancer as well as post chemotherapy residual disease. Once the marker clips are identified on imaging, a pre-operative hook wire is placed at the site of pre-operative planning, such that the breast oncosurgeon is able to conserve maximum healthy breast tissue with good cosmetic outcome at the time of open surgery.
These are exciting times with the state-of-art technologies being available for diagnosis and management of breast cancer patients in India. The earlier we start applying these technologies in clinical practice the better outcome is what we will see in the long run. One cannot underestimate the value of timely and accurate diagnosis for women with breast cancer. Early diagnosis is the only way to complete cure, resulting in decreased morbidity and mortality . At the end of the day, if you save a woman, you save the entire family!