Breast Cancer: Top 10 FAQs

If you have been newly diagnosed with breast cancer you may have questions about your outlook.  Below are some of the commonest questions women have following a diagnosis of breast cancer:

1. What causes breast cancer?

2. How long has my breast cancer been there?

3. What stage am I?

4. Will I need chemo?

5. Is there anything I can do / avoid / eat / take to help fight breast cancer?

6. Do I have the breast cancer gene / should my daughter get gene tested?

7. What’s the difference between chemotherapy and radiotherapy?

8. Are breast and ovarian cancer linked/ do I need my ovaries removed?

9. Is there a blood test to detect breast cancer?

10. Isn’t getting an MRI better than mammogram to test for breast cancer?

 

  1.  What causes breast cancer?

There is no single cause for breast cancer but there are well-established risk factors associated with the development of breast cancer in women who have never had breast cancer before.

The following multiply your risk of developing breast cancer by 4 times or more:

  • Being female (vs male)
  • Age over 50 years old (vs younger)
  • Having a breast cancer gene
  • Previous breast cancer diagnosis

The following  multiply your risk of developing breast cancer by between 2 and 4 times:

  • A previous breast biopsy showing atypical cells
  • Having 2 or more first degree relatives (eg: mother and sister) with breast cancer

The following  multiply your slightly risk of developing breast cancer by up to 2 times:

  • Having one first degree relative with breast cancer (eg: mother or sister)
  • Having multiple second degree relatives with breast cancer (eg: grandmother, aunt)
  • Early onset of periods (menarche under 12 years old)
  • Late onset of menopause (after 55 years old)
  • Long term use of oral contraceptive pill or hormone replacement therapy (HRT)
  • Being overweight (BMI >25 vs BMI <21)
  • 3 or more standard drinks of alcohol consumed per day

Nevertheless up to 70% of women diagnosed with breast cancer have no identifiable risk factors.  There are also exist many myths about what causes breast cancer for which there is no reliable proof:

  • Stress
  • Caffeine
  • Smoking
  • Living next to power lines
  • Breast implants
  • Having larger breasts or lumpy breasts
  • Having regular mammograms
  • IVF treatment
  • Previous abortion
  • Underarm deodorant
  • Underwire bras

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 2. How long has my breast cancer been there?

It is perfectly understandable for a women to wonder whether she could have found her breast cancer any earlier.

Breast cancer is normally detected either by imaging (such as mammogram or ultrasound) or when a patient becomes symptomatic (presence of a lump, skin dimpling, nipple discharge, nipple inversion).  Knowing this there are two ways to consider time to detection: tumour doubling time and sojourn time.

On the one hand tumour doubling time (the time it takes for 1 cancer cell to become 2 cells, then for 2 cells to become 4 cells etc) is about 4 months.

Another way to look at it is sojourn time (the time it takes for a cancer to grow from a size at which it becomes detectable by imaging to a size it can be felt with your fingers) is about 1.5 years.

Taken together this means that in most women with newly diagnosed early breast cancer their tumour has likely been there for  quite some months, rather than a few weeks or years.  Secondly it means that it is normally OK to spend up to 2 weeks planning for surgery  to remove the tumour as it won’t suddenly spread overnight.

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 3.  What stage am I?

Stage refers to how far a breast cancer has spread in the body.

There are four stages (Stages I. II, III and IV) taking into account:

  • Tumour size (T),
  • number of lymph Nodes involved (N) and
  • whether the cancer has spread to other parts of the body, called distal Metastases (M).

Your breast surgeon can make a rough estimate of your stage at the time of diagnosis but a final staging may not be possible until your surgery is complete or after staging investigations have been performed to see if there has been spread to other parts of the body (usually a whole body bone scan and CT scan).

Staging is important because it guides your treatment and the earlier the stage the better the prognosis.  As a rough guide:

  • Stage I has a 5 year survival rate (5ysr) of  between 98-100%, meaning that of all people who have Stage I breast cancer, 98-100 of every 100 are still alive five years after diagnosis.
  • Stage II 5ysr approx 93%
  • Stage III 5ysr approx 72%
  • Stage IV 5ysr approx 22%

It is important to note that these figures are general estimates meant as a guide only and will vary considerably depending on each patient’s circumstances.

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 4. Will I need chemo?

One of the most feared consequences of breast cancer diagnosis is the prospect of having chemotherapy.  Chemotherapy theoretically improves survival rates for every patient with invasive breast cancer (note: not for DCIS) but it is the degree of benefit which determines whether it will be recommended or not.

A medical oncologist can help you decide this but the following patient and tumour factors tend to favour recommending chemotherapy:

  • Younger age at diagnosis
  • Lymph node involvement
  • Presence of distal metastases
  • Grade 3 tumours (Note grade is not the same as not stage.  Grade refers to how abnormal the tumour cells look under a microscope. Stage refers to how far a breast cancer has spread in the body)
  • Type of breast cancer (eg: lobular breast cancers tend not to respond as well to chemotherapy as ductal breast cancers)
  • Oestrogen receptor negative or HER2 receptor positive breast cancer
  • Medical fitness to tolerate chemotherapy

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 5. Is there anything I can do / avoid / eat  to help fight breast cancer?

Yes, yes and no.

Women understandably want to do everything they can to gain control of their diagnosis and one way is to become proactive by taking extra supplements, avoiding certain foods, meditating etc.

There is evidence that the following factors are marginally protective against developing breast cancer:

  • Having given birth to multiple children (especially more than 4 children)
  • Having given birth under the age of 25 years old (compared to giving birth after 29 years old)
  • Breast feeding for more than 1 year

Unfortunately these are often features of one’s past medical history which we can’t modify and women can still develop breast cancer despite having these protective factors.

The following, however, are modifiable risk factors that have been shown to lower your chance of breast cancer:

  • Minimising how long you use the oral contraceptive pill or hormone replacement therapy (HRT)
  • Maintaining a body mass index <25 before menopause
  • Drinking no more than 2 standard drinks of alcohol per day
  • Regular exercise, eg:  2 hours of brisk walking per week

Patients are encouraged to inform their doctors of any special supplement or preparations as they may adversely interact with certain anti-cancer treatments may be prescribed.

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 6.  Do I have the breast cancer gene / should my daughter get gene tested?

There are a few genes that can be tested for that predispose to developing breast cancer, the commonest being a BRCA mutation.  Your surgeon will help decide on your suitability for genetic testing for a BRCA mutation based on your family history of breast cancer, particularly if there are 2 first or second relatives on one side of the family diagnosed with breast or ovarian cancer plus one or more of the following on the same side of the family:

  • additional relatives with breast or ovarian cancer
  • breast cancer diagnosed before the age of 40
  • bilateral breast cancer
  • breast and ovarian cancer in the same woman
  • Ashkenazi Jewish ancestry
  • breast cancer in a male relative

Other factors such as your personal history of other cancers, such as ovarian cancer and sarcoma, a young age of onset of breast cancer and tumour characteristics such as triple negative breast cancer are taken into consideration.  Dr Chong uses the Cancer Australia online familial risk assessment tool which can been found here.

Genetic testing is usually only possible if there is someone in the family with a previous or current breast cancer diagnosis who can give blood for testing to detect a founder mutation; this person may be the patient her or himself.

It is important to note that genetic testing should be done in conjunction with  counselling through a familial cancer centre as the implications of positive and negative results can be far-reaching for both patient and family members involved.  Furthermore the absence of a detected gene does not mean that there is definitely no genetic component to a family’s breast cancer; a responsible mutation may simply have not yet been discovered and hence not tested for.

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 7.  What’s the difference between chemotherapy and radiotherapy?

Both chemotherapy and radiotherapy are important but different components of breast cancer treatment.  When performed in association with breast cancer surgery they are termed adjuvant treatments: surgery alone is rarely curative for breast cancer and so chemotherapy and radiotherapy are ways we can maximise cancer survival and minimise the chance of cancer recurrence.

Chemotherapy is a combination of drugs administered by injection into the veins every 2 to 3 weeks by a medical oncologist over a 4 to 6 month period.  Chemotherapy is a systemic treatment, meaning that the drugs are designed to destroy cancer cells that may be circulating in your bloodstream and prevent them from forming secondary tumours elsewhere in the body, called distal metastases.  Side effects are reversible once chemotherapy has finished but include hair loss, nausea, fatigue, nail changes, possible weakening of the heart function and  low blood counts which including susceptibility to infection.  The decision to recommend chemotherapy is explored in FAQ number 4, above.

Radiotherapy is an external beam of radiation administered to the involved breast by a radiation oncologist every working day for 3 to 6 weeks .  Radiotherapy is a locoregional treatment, meaning that the beams are designed to destroy cancer calls that may be unaccounted for in the remaining breast and armpit lymph nodes and prevent them from forming a recurrent tumour.  Side effects can include redness and eventual tanning of the involved skin (like a severe sunburn, maybe even blistering), skin thickening  and shoulder stiffness.  As a general rule most women undergoing  a lumpectomy for their cancer where the breast is conserved will undergo radiotherapy while only a few women who undergo mastectomy will need radiotherapy.

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 8.  Are breast and ovarian cancer linked/ do I need my ovaries removed?

Actress Angelina Jolie’s recent preventative double mastectomy with reconstruction and subsequent salpingo-oophorectomy (surgical removal of fallopian tubes and ovaries) has raised public awareness of the link between breast and ovarian cancer.  This is only true for the few women who carry the BRCA gene, a mutation which bestows a very high risk of BOTH breast and ovarian cancer.  Since most women with breast cancer will not be BRCA carriers then removal of ovaries  will be unnecessary.

Traditionally a select few women with oestrogen-dependent metastatic breast cancer were considered for oophorectomy to help control their disease progression.  But in 2014 a landmark Melbourne-led study, called the SOFT Trial, greatly expanded the indications for ovarian suppression which includes oophorectomy to include younger women under 47 years of age with oestrogen-dependent breast cancer.  Dr Chong routinely performs day-case laparoscopic (keyhole) oophorectomy for such patients.

In summary a BRCA mutation, where present, can cause breast and ovarian cancer.  Otherwise a patient’s ovaries may be removed to prevent oestrogen-dependent breast cancers from recurring, but not for preventing ovarian cancer as such.

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 9.  Is there a blood test to detect breast cancer?

Following a diagnosis of breast cancer your breast surgeon will tailor an individualised regimen of follow up for the early detection of breast cancer should it occur, which is rarely the case.  This is called surveillance and includes history taking, physical examination and annual imaging with mammogram and ultrasound.

Certain blood tests known as tumour markers (eg: Ca 125) can be used to monitor the progress of advanced or metastatic breast cancer in certain circumstances.  However, since there are many other conditions that can raise these markers that are not breast cancer and because they may not rise in the presence of a new breast cancer, tumour markers are not recommended as part of routine screening or surveillance for breast cancer.

In fact the peak body for standards of cancer treatment in Australia, Cancer Australia, states the following:

“Intensive follow-up involving chest X-rays, bone scans, CT, PET or MRI scans, and/or blood tests including full blood count, biochemistry or tumour markers does not confer any survival benefit or increase quality of life compared to a standard follow-up schedule.”

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 10. Isn’t getting an MRI better than mammogram to test for breast cancer?

Ultrasound and mammography are together considered the gold standard of imaging for the detection of breast cancer and the vast majority of breast cancer can be successfully treated using by these “conventional” imaging modalities alone.

While ultrasound uses sound waves and mammograms use X-rays, MRI uses the the magnets to image the breast.

MRI is a an less commonly used method to detect breast cancers although your breast cancer surgeon may order one in special circumstances.  These include reconciling discordant findings on conventional imaging, characterising special breast cancer subtypes, monitoring a cancer’s response to upfront (neoadjuvant) chemotherapy, imaging very dense breasts and screening of women who carry a BRCA gene mutation to name a few.

Although MRIs are excellent and can pick up breast cancers that may not have been initially detected on conventional imaging they are in fact so sensitive that they often detect changes in the breast which don’t turn out to be cancer at all.  These have the potential of unnecessary patient anxiety and biopsies.  Furthermore, in Australia a breast MRI can be expensive (~$500-600 AUD) if a patient doesn’t satisfy the strict eligibility criteria for a Medicare rebate relating to a strong family history of breast cancer.

In summary, breast MRIs have their place in a minority of breast cancer workups and women should consult with their surgeons about whether or not a breast MRI is indicated for their particular circumstance.

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