THE BREAST CANCER SPECIALIST

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

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.