Breast Cancer in Delhi
Breast cancer is the commonest cancer among women in Delhi, and accounts for 28.6% of cancers in women in Delhi. With the changing lifestyle, the incidence of breast cancer is increasing in younger women. Previously, around two-third of women with breast cancer were more than 50 years of age, but presently, half of the women with breast cancer are diagnosed at less than 50 years of age. Also, the percentage of breast cancer among the total cancer cases in women has increased in Delhi, from 20% to 28% in recent times.
So, with all this data, we understand that total number of cases of breast cancer in Delhi are increasing in all age groups, and the increase is much more in the youger age groups. Moreover, it presents in advanced stages in younger age groups and the survival is also lesser.
What are the types of Breast Cancer?
The breasts are paired, hemispherical-shaped, glandular organs of variable size on the chest of a woman (between the 2nd and 6th ribs and anterior to pectoral muscles). They are mostly made up of adipose (fatty) tissue and connective (fibrous) tissue that surrounds and support about 12 to 20 lobes. The nipple is surrounded by the dark skin called the areola.
Epithelial breast carcinoma or adenocarcinoma (affecting epithelial cells of the glandular tissue within breast) is the most commonly encountered (more than 95% of all cases) type of breast cancer. Breast adenocarcinoma includes ductal carcinoma in situ, invasive ductal carcinoma, and invasive lobular carcinoma.
Breast Cancer Hormone Receptors: Normal breast cells and some breast cancer cells have specialized proteins on/in their surface called hormone receptors. Hormones – estrogen and progesterone can bind to these receptors (estrogen receptor [ER] and progesterone receptor [PR], respectively) and promote the growth of these cells.
Some breast cancer cells have another growth-promoting protein on/in their surface known as the human epidermal growth factor receptor 2 (HER2/neu or HER2). Certain breast cancer cells do not have any of the above receptors, that is, negative for ER, PR, and HER2. These are called triple-negative breast cancer.
What are the Risk Factors of Breast Cancer?
What are the Symptoms of Breast Cancer?
What are the Investigations for Diagnosis and Staging of Breast Cancer?
What is the Staging of Breast Cancer?
The staging system used for breast cancer is called TNM staging system.
T1 – Tumor size is less than or equal to 2 cm
T2 – Tumor is 2 cm to 5 cm
T3 – Tumor is more than 5 cm
T4a – Tumor infiltrates the chest wall, not including only pectoralis adhesion or invasion
T4b – Involvement of skin by the tumor, ulceration of skin, satellite tumor nodules or peau de orange.
T4c – Involvement of both, skin and chest wall by the tumor.
N0 – Axillary lymph nodes are not involved by tumor clinically
N1 – Axillary lymph nodes are palpable and freely mobile
N2a – Axillary lymph nodes palpable, and are fixed or matted
N2b – Involvement of only internal mammary lymph nodes
N3a – Involvement of infraclavicular lymph nodes by tumor
N3b – Involvement of both, internal mammary and axillary lymph nodes
N3c – Involvement of supraclavicular lymph nodes
M0 – No spread of the disease to distant sites or non-regional nodes
M1 – Spread of the disease to non-regional nodes or distant sites
It may spread to lungs as multiple nodular deposits
Spread to pleura may cause pleural effusion
Spread to the liver as multiple nodular deposits.
It may also spread to adrenal gland
What is the Treatment of Breast Cancer?
Treatment of breast cancer depends on the stage of disease (as discussed above). Other factors that determine the treatment are type and grade to tumor, hormone receptor status, Her 2 neu status, menopausal status, performanace status of patient, etc. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient.
Treatment of Localised Breast Cancer
Localised disease includes cases upto T2N1M0 and T3N0M0. It may be treated with Breast Conservation Surgery (BCS) or Modified Radical Mastectomy (MRM).
For early stage disease and small tumor size, if the patient fulfills the criterion and is willing for the same, BCS is a suitable option. In case of large tumors, when BCS is not possible upfront, neoadjuvant chemotherapy may be given and then tried for BCS.
If the tumor size is large, or the patient doesn’t fulfill the criterion for BCS, or is unwilling for the same, then the suitable option is MRM. In this technique whole breast tissue and draining lymph nodes are removed.
Decision to add chemotherapy in the neoadjuvant or adjuvant setting is taken on the basis of size of tumor, involvement of axillary lymph nodes, type of surgery (BCS or MRM), performance status, etc.
Addition of hormonal therapy and/or targeted therapy is done on the basis of hormone receptor status (ER/PR positive or negative) and Her 2 neu status of the tumor, along with other factors.
Adjuvant radiation is required in all patients after BCS, but only in selected cases after MRM.
Treatment of Locally Advanced Breast Cancer
Starting from T3N1 onwards, and all cases of T4, N2 and N3 disease are classified as locally advanced breast cancer.
It is treated as localised breast cancer (as discussed above), witjh addition of radiation therapy in all cases.
T4, N2 or N3 disease
These cases are upfront unresectable, so neoadjuvant therapy is required in all the cases. Thereafter, decision for BCS and MRM is taken depending on response to neoadjuvant treatment, patient’s preference and other factors.
Then, adjuvant radiation is required for all patients.
Decision to add adjuvant chemotherapy, targeted therapy and/or hormonal therapy is taken by the oncologist on individual patient basis.
Treatment of Metastatic Breast Cancer
Treatment options for metastatic breast cancer are chemothrerapy, hormonal therapy, targeted therapy, and/or immunotherapy. Radiotherapy and/or surgery may be done in selected cases.
What is Breast Conservation Surgery?
n this surgical procedure, only a part of the affected breast is removed, along with the axillary lymph nodes. This surgery is sometimes referred to as lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy.
The advantage of this technique is that the patient can retain most of her breast. In most of the cases, breast-conversion surgery is followed by radiation therapy to prevent disease recurrence.
If the patient is willing for BCS, it may be done upfront in the early stage and after neoadjuvant chemotherapy in the advanced stage if the patient is the suitable candidate for the same as assessed by the oncologist.
What is Modified Radical Mastectomy?
In this surgical procedure, the entire breast containing the tumor is removed, along with axillary lymph nodes.
Radiation therapy is not required in all the cases after mastectomy, hence the procedure can be employed in patients who are not good candidates for the same (e.g., pregnant women, prior radiation to the chest wall). Also, it may be preferred in patients with certain genetic mutations (eg, BRCA) when there are high chances of tumor recurrence.
Some patients may wish to restore their breast’s appearance after deformation of breasts due to breast cancer surgery. This can be achieved by a breast reconstruction surgery that can be performed at the same time as breast cancer surgery or at a later time as a separate procedure. Artificial graft or patient’s own tissue may be used for breast reconstruction.
What is Hormonal Therapy for Breast Cancer?
Normally, breast cancer cells have specialized proteins on/in their surface, called receptors. Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) are most common receptors detected on breast cancer cells, which can promote the growth of these cells.
This treatment approach is based on the fact that ER or PR positive breast cancer cells grow under the influence of estrogen and progesterone, respectively. Estrogen is predominately produced by the ovaries and a small amount is also produced by the fat tissue in the females.
Depriving the breast cancer cells of the estrogen or by lowering the estrogen level in the blood might reduce their rate of growth. The hormonal therapy is considered as the standard treatment for hormone receptor-positive disease.
Following are the types of hormonal therapy used for the treatment of breast cancer:
Selective Estrogen Receptor Modulator, SERM (Tamoxifen)
Tamoxifen blocks the estrogen receptors in breast cancer cells (ER-positive) and acts as a weak estrogen in other body tissues like the uterus and bones. It is generally used for the treatment of ER and/or PR positive breast cancer. Common side effects of tamoxifen include hot flushes, venous thromboembolism, increased risk of uterine cancer, etc.
Selective Estrogen Receptor Downregulator, SERD (Fulvestrant)
Fulvestrant selectively and permanently blocks and degrades the estrogen receptors in breast cancer cells. It is generally used for the treatment of ER and/or PR positive metastatic breast cancer. Common side effects of fulvestrant include hot flushes, headache, nausea, bone pain, etc.
Aromatase Inhibitors (AIs)
Aromatase is an enzyme that helps in the production of estrogen from fatty tissue. In post-menopausal women, fatty tissue is the main source of estrogen. Thus, AIs (e.g. letrozole, anastrozole, and exemestane) help in lowering estrogen level in post-menopausal women and used for the treatment of breast cancer in these patients. AIs can also be used in pre-menopausal women in combination with surgical or medical oophorectomy (with GnRH/LHRH analogs). Side-effects of AIs include hot flushes, muscle pain, joint stiffness, arthralgia, osteoporosis, etc.
Since the ovaries are the chief source of estrogen before menopause, their surgical removal reduces the blood estrogen level significantly, which leads to shrinkage of ER-positive breast cancers. It may be used in premenopausal women, or in combination with AIs in postmenopausal women.
Luteinizing Hormone-Releasing Hormone (LHRH) analogs
These drugs (e.g., leuprolide and goserelin) acts on the pituitary gland which in turn signals to stop the production of estrogen from the ovaries. It may be used in premenopausal women, or in combination with AIs in postmenopausal women, in patients who wish to retain their ovaries.
Cyclin Dependent Kinase 4/6 (CDK 4/6) Inhibitors
Multiple clinical research studies have reported encouraging results with a combination of Cyclin-dependent kinase 4/6 (CDK 4/6) inhibitor (e.g. palbociclib) with hormonal therapy.
What is Targeted Therapy for Breast Cancer?
Targeted drugs are designed to target a specific gene or protein characteristic of the breast cancer cells. With the advancement in diagnostic techniques, a number of genetic abnormalities for breast cancer have been identified that can be targeted with the help of targeted drugs. Molecular testing to confirm the genetic abnormality is the pre-requisite for starting a targeted therapy.
Examples of targeted drugs for breast cancer include
- Anti Her2 therapy (eg, trastuzumab, pertuzumab, etc) for Her2/Neu receptor-positive disease,
- CDK4/6 inhibitors (e.g. Palbociclib, ribociclib, abemaciclib, etc) that target cyclin-dependent kinases (CDKs, particularly CDK4 and CDK6),
- mTOR Inhibitors like everolimus
- PARP Inhibitors like Olaparib in BRCA positive breast cancers
What are the Bone Directed therapies for bone metastasis?
Spread of breast cancer to bones may lead to various symptoms like pain in bones, fractures, hypercacemia, etc.
To relieve symptoms of bone metastasis, and to prevent further complications, following bone directed therapies are generally employed:
(e.g. Zoledronic acid, Pamidronic acid, etc)
Normally, bones are constantly remodeled by two types of bone cells: osteoblasts (they increase bone density) and osteoclasts (they decrease bone density). Bisphosphonates decrease the activity of osteoclasts by inducing apoptosis (natural cell death) in them, and thus, help in maintaining bone density and to relieve symptoms of bone metastasis. Bisphosphonates may cause side effects such as flu-like symptoms, renal dysfunction, hypocalcemia and rarely, osteonecrosis of the jaw (ONJ).
Denosumab is a monoclonal antibody that binds to RANKL and blocks osteoclast maturation, thus reducing bone resorption and helps in maintaining bone density and relieve symptoms of bone metastasis. It can cause side effects like hypocalcemia, osteonecrosis of the jaw, etc.
Breast Cancer Treatment Cost in Delhi
Treatment cost for breast cancer depends on many factors like stage of disease, type and number of treatment modalities that are being used for treatment, whether the patient is Her 2 Neu positive or negative, etc. For example, in localised and locally advanced breast cancer, cost of surgery is there. But radiation therapy, chemotherapy, and/or targeted therapy cost adds up depending on the various factors discussed above. In case of metastatic disease, cost of treatment depends on the treatment protocol being used, like number of chemotherapy drugs used, whether Her-2 Neu targted therapy is being used or not, other palliative modalities (like radiation,etc) being used, etc. So the cost of treatment will depend on the above and many other factors.
Best Breast Cancer Specialist in Delhi
Dr Sunny Garg is a renowned Medical Oncologist in New Delhi with an experience of more than 6 years of treating breast cancer patients. He has practiced in leading cancer hospitals in Delhi, and currently practicing at Manipal Hospital, Dwarka.
He has a vest experience of treating breast cancer patients in all stages of disease. He is well versed with Immunotherapy, Targeted therapy, Hormonal Therapy and Chemotherapy for Breast Cancer treatment and also general supportive care for patients. He works in close collaboration with surgical and radiation oncologists, oncopathologists, nuclear medicine, and genetic counselors for comprehensive cancer care for the patients.
Call +91 9686813020 for appointment.