Ger­ald Gui, con­sul­tant breast sur­geon at the UK’s Lon­don Clinic, brings us up to speed on some of the tech­ni­cal as­pects of the dis­ease

Friday - - My Working Life -

Why is the breast seem­ingly so sus­cep­ti­ble to can­cer?

I don’t think any­one can an­swer that, but it’s the most com­mon fe­male can­cer. Now, the ma­jor­ity of pa­tients will sur­vive breast can­cer. Eight out of 10 lumps are be­nign.

Howis a di­ag­no­sis typ­i­cally made?

Most clin­ics per­form a rapid di­ag­no­sis as­sess­ment via a mam­mo­gram or ul­tra­sound. Where needed, there is also nee­dle biopsy to take a piece of tis­sue, which, in­most in­stances, will give you a di­ag­no­sis. If it’s be­nign, usu­ally noth­ing more is needed.

Are all breast can­cers the same?

No. There’s a range de­pend­ing on the pro­lif­er­a­tion – ie how it grows – its size when it is found, and its abil­ity to spread to the lymph nodes. The ma­jor­ity of breast can­cers are duc­tal be­cause they form in the ducts of the breast, and th­ese ac­count for about 70 per cent of all breast can­cers. An­other type is lob­u­lar, and th­ese are found to­wards the milk-pro­duc­ing end of the duct. They make up about 15 per cent of breast can­cers. Duc­tal tu­mours tend to in­duce amore fi­brous re­ac­tion around them so they’re more likely to be seen on mam­mo­grams and felt as lumps. Lob­u­lars tend not to and are harder to de­tect.

Howhas treat­ment ad­vanced?

Thirty years ago, can­cers were treated by mas­tec­tomy and rad­i­cal surgery to the armpit to re­move a block of lymph glands ir­re­spec­tive of whether they had been af­fected by can­cer or not. Now, we per­form a sen­tinel node biopsy, which pro­vides a se­lec­tive way of do­ing such rad­i­cal surgery on the armpit only for those who have can­cer in the glands. Sig­nif­i­cant progress has also been made in es­tab­lish­ing the safety of wide lo­cal ex­ci­sion or lumpec­tomy, which means that breasts can be con­served.

How have the drugs im­proved?

There has been sig­nif­i­cant progress in the chemo­ther­apy agents avail­able for use and there has also been de­vel­op­ment in bi­o­log­i­cal treat­ments. The best ex­am­ple of this is Her­ceptin, which is used in women who demon­strate Her-2 (hu­man epi­der­mal growth fac­tor re­cep­tor). About 20 per cent of breast can­cers ex­press this and it is as­so­ci­ated with­more ag­gres­sive tu­mours. Her­ceptin is a bi­o­log­i­cal ther­apy tar­geted specif­i­cally at this re­cep­tor and has­made sig­nif­i­cant progress in im­prov­ing the sur­vival rate of pa­tients. An­other class of drugs worth men­tion­ing is Aro­matase in­hibitors, which has also shown to have im­proved sur­vival in post-menopausal women.

What does chemo­ther­apy ac­tu­ally do?

It af­fects how cells grow and di­vide – all chemo­ther­apy agents work by block­ing this mech­a­nism. The dif­fi­culty is be­ing able to dis­tin­guish cell divi­sion in nor­mal cells and that in can­cer­ous ones. The­main dif­fer­ence is that can­cer cells di­vide quicker, and so it hits th­ese more than the nor­mal cells. But be­cause it hits the nor­mal cells as well, there are side ef­fects.

What is the typ­i­cal time span of treat­ing breast can­cer?

Most of the time, it re­quires a multi-mo­dal treat­ment, which in­cludes surgery, chemo­ther­apy, ra­dio­ther­apy and hor­mone treat­ment. While that’s the se­quence in the ma­jor­ity of cases, some­times chemo­ther­apy pre­cedes surgery. Chemo­ther­apy can last from four to six months as the treat­ment is cycli­cal. Ra­dio­ther­apy typ­i­cally lasts three to five weeks, and hor­mone treat­ment five to 10 years.

When is a pa­tient given the all-clear?

That’s not re­ally a term we use, but breast can­cer has an ex­cel­lent prog­no­sis nowa­days and­most of the time we look at five years as a kind of bench­mark. But that doesn’t mean the can­cer won’t re­turn.

How of­ten do you rec­om­mend that women have amam­mo­gram?

Screen­ing pro­grammes vary around the world. The risk of breast can­cer typ­i­cally goes up over the age of 45, and over the age of 50 I think there is uni­ver­sal agree­ment that screen­ing works well. But we also need to take into ac­count risk fac­tors, so some­one who has a strong fam­ily his­tory of can­cer form­ing sooner should start screen­ing at a younger age.

How com­mon is pre­ven­tive mas­tec­tomy?

It only ap­plies to women who have a very high risk of de­vel­op­ing breast can­cer, usu­ally be­cause they have in­her­ited a pre­dis­po­si­tion gene. The com­mon­est genes are BRCA1 and BRCA2, where the risk of de­vel­op­ing breast can­cer could be higher than 80 per cent. So women choose to re­move their breasts. This is a unique group of peo­ple, and genes do not ac­count for more than 5-10 per cent of the to­tal breast can­cer cases, so it shouldn’t be some­thing that’s over­stated. Nonethe­less it’s very im­por­tant.

It’s a chal­leng­ing job– does it get to you?

I think it is a team ef­fort be­cause we work with spe­cial­ist nurses and coun­sel­lors who pro­vide emo­tional sup­port. The suc­cess in terms of treat­ment out­comes can also be very re­ward­ing be­cause most pa­tients nowa­days sur­vive breast can­cer.

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