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Breast cancer is a chronic disease that is controllable, treatable, and not frightening.
Every October is Breast Cancer Awareness Month, also known as "Pink Ribbon Month." The pink ribbon is a recognized symbol of global breast cancer prevention and treatment activities, aimed at promoting early prevention, early detection, and early treatment.
2018-11-16
Fudan University Affiliated Tumor Hospital Shao Zhimin Hu Xichun Zheng Ying Liu Guangyu Yu Keda Zhang Jian
Every October is Breast Cancer Prevention and Treatment Month, also known as "Pink Ribbon Month." The pink ribbon is a globally recognized symbol for breast cancer prevention and treatment activities, aimed at promoting early prevention, early detection, and early treatment. The pink ribbon represents a narrative about breasts, love and beauty, and the warmth of life. In this issue, the expert team from Fudan University Affiliated Tumor Hospital will interpret topics related to breast cancer.
Breast cancer has become the most common malignant tumor among women in China. According to the latest national cancer data statistics, in 2014, the number of new breast cancer cases nationwide was nearly 280,000, accounting for 16.51% of all malignant tumor incidence in women, ranking first.
In 2018, The Lancet published a report on the trends in global cancer survival rates from 2000 to 2014, showing that the 5-year survival rate for breast cancer patients in China increased from 75.9% in 2000-2004 to 83.2% in 2010-2014, approaching the treatment levels of developed countries. For early-stage breast cancer patients, the 5-year survival rate after treatment exceeds 90%; however, for patients diagnosed at an advanced stage, the 5-year survival rate is only 30%. Along with the high incidence of breast cancer, treatment has increasingly focused not only on efficacy but also on the impact of the disease on patients' physical and mental health.
Compared to other cancers like liver cancer, breast cancer is not considered as dangerous, and treatment methods are more diverse. Therefore, for patients with advanced, incurable breast cancer, it is possible to gradually achieve living with the disease, truly managing and treating breast cancer as a chronic illness. Advanced breast cancer patients should strengthen the comprehensive management model while living with the disease, maintaining effective treatment methods over the long term. Timely changes to effective treatment methods after disease progression can help patients achieve the best outcomes. With the diversification of breast cancer treatment methods, from the early simple surgical treatments to the use of chemotherapy drugs, and later the emergence of endocrine therapy and targeted therapy drugs, patient survival rates have improved. Additionally, in recent years, the introduction of concepts like personalized treatment and precision medicine has brought more possibilities for improving the prognosis of breast cancer patients.
Since breast cancer is a chronic disease, comprehensive treatment after surgery is even more important. The pathological indicators after breast cancer surgery are crucial for determining the patient's treatment plan. After surgery, HER2 positive pathological indicators not only indicate a higher risk of recurrence within five years but also serve as the basis for decisions regarding biological targeted therapy. The decision for endocrine therapy mainly relies on the detection of estrogen receptors (ER). Each treatment method has corresponding evidence and optimal plans, and actively cooperating with treatment according to the doctor's instructions is the best self-management. Furthermore, for postoperative follow-up of breast cancer patients, we recommend checking every three months within the first two years; every six months from three to five years; and considering annual check-ups after five years. If there are any discomforts during the follow-up period, timely medical consultation is advised.
The first five years after cancer treatment is a high-risk period for recurrence. This is why we often use the 5-year survival rate to measure the treatment effectiveness of a certain cancer. However, breast cancer patients are different; some breast cancer patients may not show any abnormalities during follow-up within five years after surgical treatment but may experience recurrence in the following years. The reason lies in the biological characteristics of luminal-type breast cancer in molecular typing. Therefore, for these patients undergoing endocrine therapy, existing clinical trial evidence supports extending the treatment duration from five years to ten years. The vast majority of breast cancers belong to the Luminal type, which is sensitive to endocrine therapy. However, due to the long treatment duration, some patients may have poor compliance, posing potential risks for long-term treatment. Therefore, popularizing the concept of comprehensive management for these patients is essential to ensure the effectiveness of long-term treatment.
Breast cancer recurrence is not the end of the world.
Yao Beina, Chen Xiaoxu, Asang—when these names come up, people think of breast cancer as the "red-faced killer." Early diagnosis (routine health check-ups), early treatment, and standardized treatment are very helpful for the radical cure of breast cancer. However, as time passes, 20% to 30% of patients who initially underwent radical treatment still experience recurrence and metastasis, or due to late discovery, the proportion of patients who initially present with metastatic breast cancer is 3.5% to 7%. According to the latest statistics, nearly 50,000 patients die from breast cancer in China each year, accounting for 12.2% and 9.6% of global deaths, respectively. However, is it really that terrifying when breast cancer recurs and metastasizes? Not at all. The recurrence and metastasis of breast cancer is not the end of the world. Song Meiling was diagnosed with breast cancer at 77, underwent surgery and recurrence, yet even in an era lacking new drugs and treatment methods, she lived to 105.
There are many factors that lead to recurrence and metastasis after breast cancer surgery. In addition to pathological types, factors such as age < 35 years, the number of lymph node metastases, larger tumor size, higher grade, presence of vascular cancer thrombus, low hormone receptor expression, and high HER2 (human epidermal growth factor receptor 2) expression can also increase the risk of recurrence. Patients can communicate with their attending physician. Recurrence actually includes both local recurrence and distant metastasis. For breast cancer that is deemed to have a chance for re-radicalization after comprehensive evaluation by the doctor, it is strongly recommended to surgically remove the local recurrence site. For example, patients who have recurrence after breast-conserving surgery may undergo total mastectomy, and surgical removal may be performed for nodules that recur in the chest wall. For these patients, it is recommended to consolidate with chemotherapy ± targeted therapy (evidence shows it can improve survival time), and subsequently assess whether radiation therapy is needed for the chest wall and regional lymph nodes. For patients with distant metastasis after surgery or those who were already at an advanced stage at diagnosis, there is no need to be overly fearful. Currently, drug treatments for metastatic breast cancer are diverse, but how to choose is very nuanced and needs to be based on evidence-based medicine and good communication between doctors and patients.
After recurrence and metastasis of breast cancer, it is not advisable to simply wait in a palliative manner. Instead, based on supportive treatment, active individualized interventions should be conducted, which can significantly extend survival. Although breast cancer is a complex disease, there is already sufficient understanding internationally, with classification into four different molecular subtype characteristics, such as hormone receptor-positive types (A and B), HER2-positive types, and triple-negative types. Different subtypes have different sensitive drugs for treatment, and the mechanisms of resistance vary.
There are many misconceptions regarding the understanding and treatment of breast cancer recurrence and metastasis. These misconceptions affect people's enthusiasm for treating breast cancer. Only through correct understanding and scientific treatment, along with good and close cooperation among patients, family members, and healthcare personnel, can the quality of life and survival of patients with recurrent metastatic breast cancer be improved. Although breast cancer can recur and metastasize, with multidisciplinary collaboration and individualized treatment, it is not terrifying, nor is it the end of the world.
Avoid the four major misconceptions in the diagnosis and treatment of breast diseases.
Currently, the growth rate of breast cancer incidence in China is twice the global average growth rate. Breast cancer is a multifactorial disease, related not only to our susceptibility and genetics but also closely linked to our lifestyle. During the diagnosis and treatment of breast diseases, many people have misconceptions.
Misconception 1: Lobular hyperplasia
is an early signal of breast cancer.
Lobular hyperplasia can become increasingly severe; although it may temporarily be benign, it will inevitably develop towards malignancy, so it must be addressed immediately, with surgery.
Analysis: The breast is an endocrine-regulating organ, controlled by estrogen and progesterone. With the fluctuations of estrogen and progesterone caused by the menstrual cycle, breast cells sometimes proliferate and sometimes regress. When estrogen levels are high, breast cells expand and grow; when estrogen recedes, the glands contract and relax, and the degree of lobular hyperplasia often corresponds with the normal physiological cycle of women. Therefore, lobular hyperplasia is merely a necessary characteristic of normal women, a physiological phenomenon rather than a pathological one. The transition from normal lobular hyperplasia to breast cancer involves processes such as mild hyperplasia, severe hyperplasia, mild atypical hyperplasia, and moderate to severe atypical hyperplasia, and the chance of continuous deterioration is very low. Thus, there is no necessary connection between lobular hyperplasia and breast cancer. Attempts to treat or remove lobular hyperplasia are fundamentally unreasonable, as medication cannot treat normal physiological phenomena, just as you cannot make your normal nose or ears disappear by taking medicine. However, some breast cancers may be misidentified as lobular hyperplasia when a certain breast lump is painless, does not itch, and does not show significant changes with the menstrual cycle; in such cases, a visit to the hospital is necessary.
Misconception 2: Breast ultrasound is better than mammography,
mammography has high radiation.
Many patients come to the clinic requesting a specific examination, such as preferring mammography, believing it is more accurate than ultrasound; or insisting on only having an ultrasound, thinking that mammography has strong radiation.
Analysis: Each imaging examination has its own characteristics, advantages, and disadvantages. Because each has its strengths and weaknesses, they cannot replace each other. Ultrasound has a clear advantage in viewing nodules, especially cystic nodules. Ultrasound can accurately describe the size, boundaries, and cystic or mixed nature of nodules. The advantage of mammography lies in detecting calcifications, especially some small calcifications (which may be manifestations of very early breast cancer). Mammography is particularly sensitive, while ultrasound may not detect it. Of course, when neither ultrasound nor mammography can provide clarity, magnetic resonance imaging can be employed. It has higher accuracy but is also more sensitive. This means that sometimes there may be overdiagnosis, increasing unnecessary surgical burdens on patients. However, whether it is mammography, ultrasound, or MRI, each has its blind spots; some lesions may only be visible under certain examinations, while others may be completely undetectable, so it is very important to use them in combination.
In addition, some people insist that mammography should only be done once a year, otherwise there will be excessive radiation. This is also a misunderstanding. Because if there are no issues after one mammogram, it is generally safe for a year; the progression of the disease is not that rapid. Increasing the frequency of mammograms does not bring benefits for early diagnosis, so it is commonly believed that once a year is sufficient. However, this view has been misinterpreted by many as meaning that one cannot have two mammograms within a year. In fact, for some patients with calcification as the main issue, observing every six months is also reasonable.
Misconception 3: Breast cancer patients cannot have children,
cannot have sexual relations.
Many people feel inferior about their body after being diagnosed with breast cancer; on the other hand, they also hear others say that they cannot have marital relations or have children.
Analysis: First, regarding fertility issues, the currently accepted view is that after ensuring a sufficient and effective treatment period, such as 2 to 5 years post-surgery, it is possible to conceive. Pregnancy will not cause tumor recurrence or metastasis. Some large retrospective studies suggest that whether the breast cancer is hormone receptor positive or negative, the process of pregnancy itself does not affect the prognosis of breast cancer. Therefore, it is safe to conceive after ensuring adequate treatment. Of course, when deciding to conceive, endocrine drug withdrawal must be performed first, otherwise it may lead to fetal malformations. Secondly, marital relations will not cause abnormal hormonal fluctuations; a harmonious family life and marital relations are more conducive to the physiological and psychological recovery of breast cancer patients, helping them reintegrate into society.
Misconception 4: Once a gene mutation is found, one must immediately undergo prophylactic mastectomy.
With the improvement of genetic testing levels and the popularization of medical awareness, genetic testing is becoming increasingly common. Some women are found to have breast cancer-related gene mutations and believe that once a gene mutation is discovered, they must immediately undergo mastectomy, the sooner the better.
Analysis: Regarding the mutations mentioned in genetic testing reports, they should be viewed with caution. Genetic mutations are a very complex and specialized issue, including frame-shift mutations, insertions/deletions, point mutations, etc. Only those significant mutations that affect protein function are pathogenic mutations. Many mutations may only cause a change in a single amino acid but do not significantly alter protein function. Therefore, even if the report mentions mutations, it is essential to consult a professional doctor to determine whether this mutation is clearly harmful or of unclear significance. Truly harmful mutations accumulate the risk of developing breast cancer over time. The longer the time and the older the age, the higher the accumulated risk. Therefore, for women with pathogenic gene mutations, it is advisable to consider prophylactic mastectomy combined with breast reconstruction after pregnancy, childbirth, and breastfeeding. Of course, it is not necessary to undergo mastectomy; close monitoring primarily using breast MRI or using chemoprevention to reduce the risk of breast cancer is also an option. For patients with BRCA1/2 gene mutations, attention should also be paid to the ovaries and fallopian tubes, as these individuals have a significantly increased risk of ovarian and fallopian tube cancers.
Using multiple tools to capture early "clues" of breast cancer.
Chinese guidelines recommend that women over 40 years old undergo breast screening. High-risk groups for breast cancer (those with significant genetic predisposition, a history of atypical hyperplasia or lobular carcinoma in situ, or those who have previously undergone chest radiation) can start screening before the age of 40. Evidence from evidence-based medicine indicates that mammography (X-ray) can reduce the mortality rate of breast cancer in women over 40, so it is recommended that women over 40 undergo a mammogram every 1 to 2 years. However, this examination is not accurate for women under 40 and those with dense breast tissue. It is not recommended for women under 40 without clear high-risk factors for breast cancer and no abnormalities found during clinical examination to undergo mammography. For women with dense breast tissue or those with a BI-RADS 0 indication from mammography, breast ultrasound can be used as a supplement. If ultrasound detects a breast mass, fine needle aspiration or core needle biopsy can be performed to determine whether it is benign or malignant.
High-risk groups undergoing genetic testing for BRCA gene mutations are closely related to the occurrence of breast and ovarian cancer. The risk of breast cancer for mutation carriers is 2 to 6 times that of normal women throughout their lives. However, the mutation rate of the BRCA gene is low in the general population, so large-scale genetic screening is not very meaningful. Clinically, it is recommended that breast cancer patients with an onset age of ≤45 years, a history of primary ovarian cancer, fallopian tube cancer, primary peritoneal cancer, and those with a significant family history (bilateral primary breast cancer patients, at least two family members with breast cancer, ovarian cancer, pancreatic cancer, or prostate cancer, or male relatives with breast cancer, or relatives confirmed to carry BRCA gene mutations, etc.) undergo BRCA gene testing.
Regular breast self-examination includes both visual inspection and palpation. The recommended examination time is 7 to 14 days after menstruation ends. At this time, the effect of estrogen on the breast is minimal, making it easier to detect lesions. Visual inspection should be done while sitting, with both hands on the hips, paying attention to whether there is asymmetry between the two breasts, whether the skin has any irregularities, ulcerations, or color changes, and whether the nipples and areolas show any erosion or scaling. If new asymmetry in the breast or changes such as skin indentation, protrusion, or redness are found, medical attention should be sought promptly. Palpation should use a cross-checking method, with the left hand examining the right breast and the right hand examining the left breast. Starting from the outer side of the breast, use the pads of the index, middle, and ring fingers to touch the breast in the same direction (clockwise/counterclockwise), applying enough pressure to feel the breast tissue and cause slight pain, while checking for lumps and comparing both sides. The palpation area should include the axillary tail, areola area, and accessory breast tissue. If a painless lump is felt, medical attention should be sought promptly. Additionally, it is recommended to wear light-colored lined underwear to observe if there is any non-milk-like discharge. If there is spontaneous (not manually squeezed) bloody, clear, or light yellow discharge from one breast, it may indicate an intraductal lesion, and further examination by a breast specialist is recommended.
Change bad lifestyle habits to keep breast cancer away.
The mechanism of breast cancer development is a very complex process, related to both individual genetic factors and environmental factors. From a genetic perspective, if one first-degree relative has breast cancer, the risk of developing breast cancer doubles. If more than one first-degree relative has breast cancer, the risk increases by 3 to 4 times. Individuals carrying certain gene mutations such as BRCA1, BRCA2, and p53 have a very high risk of developing breast cancer throughout their lives, but the number of people carrying these gene mutations is very small, accounting for only 2% to 5% of all cases.
Reduce exposure to estrogen and progesterone. Estrogen and progesterone play an important role in the formation of some breast cancers. Therefore, many hormone-related events in a woman's life are associated with the risk of breast cancer. Early onset of menstruation (before age 12), late menopause (after age 55), not giving birth, and having the first pregnancy after age 30 all increase the time the body is exposed to estrogen and progesterone, raising the risk of breast cancer. The age of menarche in girls is also influenced by nutritional factors; a high-calorie, high-protein diet can lead to earlier puberty and later menopause. Many women use hormone replacement therapy during the perimenopausal period to alleviate menopausal symptoms, but using medications containing estrogen (with or without progesterone) can also increase the risk of breast cancer, and this risk should be understood during use.
Maintain a healthy weight. There is now conclusive evidence that obesity is a significant factor leading to postmenopausal breast cancer. Body fat directly affects the concentrations of insulin, insulin-like growth factor, estrogen, various fat factors, and growth factors in the body, creating a carcinogenic environment that promotes the occurrence of breast cancer. For every 5 kg/m2 increase in body mass index (BMI), the risk of developing breast cancer increases by 12%. Excess body fat increases the risk of breast cancer, while being underweight can affect the body's normal functions.
Quit smoking and drinking. Alcohol itself is a known carcinogen. Since alcohol can be metabolized in breast tissue, it can damage breast tissue, and it can also increase the risk of breast cancer by raising estrogen levels in the body and affecting lipid metabolism. For every 10 grams of alcohol consumed daily, the risk of breast cancer increases by 8%. Even occasional heavy drinking can increase the risk of breast cancer. Both tobacco and alcohol are recognized as Group 1 carcinogens, and there is no safe threshold for these substances. From a cancer prevention perspective, the best practice is to quit smoking and avoid alcohol.
Regular exercise. The WHO recommends at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity aerobic exercise per week. Exercise not only helps maintain a healthy weight but also has cancer-preventive effects. People who exercise regularly have a lower risk of developing breast cancer compared to those who do not, even after adjusting for weight factors.
Balanced diet. Eat more non-starchy vegetables (such as leafy greens), fruits, and legumes. Maintaining a nutritionally balanced diet also helps in maintaining a healthy weight. Some international studies suggest that consuming more non-starchy vegetables, foods rich in carotenoids, and calcium-rich foods may reduce the risk of certain types of breast cancer, but these suggestions still require further research for validation.
Regular check-ups. While maintaining a healthy lifestyle, developing good examination habits is also essential. Women over 30 need to have a breast ultrasound examination once a year, and after 40, they should add a mammogram every 1 to 2 years. Women with a family history or other high-risk factors should start screening 10 years earlier, so that even if they develop the disease, it can be detected early.
Be Cautious with Supplements Many people feel the need to supplement their health through health products to achieve health goals, especially after getting sick. In reality, the use of health products should be cautious. Most nutrients can be obtained through a balanced diet. Some health products with unclear ingredients may not only be ineffective but could also be harmful. For example, health products rich in estrogen, such as bird's nest, are strictly prohibited for breast cancer patients. If health products are needed, they should be used only after thorough communication with a doctor and obtaining consent from medical personnel.
Key words:
Breast cancer,Early prevention,Early detection,Early treatment
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