October is internationally recognised as breast cancer month. Breast cancer is the commonest cancer in Malta but while the incidence is increasing, the mortality has been decreasing in the last few years. In other words, more women (and a few men) are getting breast cancer but fortunately more are being cured.
While the exact cause of breast cancer has not been determined there are certain known risk factors which increase the chances of developing breast cancer. These include a family history, having children late or not at all, starting periods at an early age, late menopause, smoking and alcohol abuse.
The disease cannot be totally prevented but certain measures help to decrease the risks. Regular exercise from a young age has been proven to decrease the risk of cancer. It is also important to avoid obesity and to eat a diet rich in fruit and vegetables, rich in anti-oxidants and phyto-oestrogens, which can be found in soy products, whole grain and flaxseed.
In recent years some women at high risk of developing breast cancer have undergone surgery to prevent the disease. The breast tissue is removed preserving the skin and the breast is reconstructed with silicon implants. This procedure is not undertaken lightly and is only recommended in those with a proven high risk. Hormone therapy may also be used to prevent breast cancer in certain high-risk groups.
Breast screening is not a way of preventing breast cancer but a means of detecting it at an early stage. This is done by taking a breast X-ray, a mammogram, of asymptomatic women in a target age group. For a breast screening programme to be effective it must be done with very high standards of quality control to cut the number of false alarms and to avoid missing women with tumours. This requires a concerted effort and a breast screening project must be well planned with a strong commitment to quality.
New techniques of breast screening are being researched and magnetic resonance imaging (MRI) is promising, however, it is too slow and expensive for nationwide mass screening.
In breast cancer it is important to diagnose the tumour at an early stage before it has spread, making treatment simpler and more effective. The aim of breast screening is to diagnose tumours early. However, regular breast examination is also useful to catch the disease when it is only a small lump. Unfortunately, some women are very worried when they find a breast lump and delay going to their doctor in the vain hope that the tumour will go away.
After taking a full medical history, a breast surgeon examines the patient and then takes tests to check the lump. Fortunately, most breast lumps (90 per cent) are not cancer and can be treated simply. Breast cancers are first removed by an operation and then often require other treatment.
In the past, most women with breast cancer had the breast removed by a mastectomy operation. While mastectomies are still performed the trend is to perform smaller operations to preserve the breast. When this is not possible breast reconstruction can be offered using plastic surgery.
A new concept in breast surgery is the oncoplastic approach where the operation is planned to deal adequately with the tumour but also to endeavour to preserve the aesthetic qualities of the breast. This can involve surgery on the other breast to preserve symmetry. This new approach is so successful that some women are more content with their breasts after surgery than they were before the tumour was diagnosed!
Breasts can be reconstructed using silicon implants and even using the patient's own skin and muscle that can be moved from another part of the body.
A new technique is lipomodelling, where the fat is removed from other parts of the body and then injected into the breast through a needle as spaghetti of fat. Stem cells can also be harvested from the fat and these preserve the integrity and bulk of the injected fat. Some women with breast cancer will need other treatment besides surgery. These include radiotherapy, hormone therapy and chemotherapy.
Radiotherapy is administered at Boffa Hospital as a sequence of short daily sessions with few side-effects. Hormone therapy is usually given as a daily tablet and this can be very effective in susceptible tumours. Chemotherapy is being increasingly used as it is effective and has become kinder to the patient due to increased expertise and the use of medication to decrease side effects. A whole gamut of new treatments has been developed and these can be useful in certain patients.
The management of breast cancer is changing rapidly. The surgical trend is away from mutilating operations towards breast conservation and reconstruction. The disease is highly researched and new, more effective and gentler treatments are being developed.
In Malta we have developed a multi-disciplinary breast team where the expertise of breast surgeons, oncologists, pathologists, radiologists, breast care nurses, radiographers and physiotherapists are pooled together to deliver optimal treatment. Apart from physical treatment it is also important for the breast nurses and the rest of the breast unit team to support the patient, her husband and her family through a very difficult time. We aim to not only cure patients but also give them a good quality of life.
Mr Caruana Dingli is a consultant general and breast surgeon.