By Godswill Boni, PharmD
Breast cancer is a tumor originating in the epithelium of the ducts or lobules in the breast’s glandular tissue. When the cancerous growth is confined to the duct or lobule, it is said to be localized. However, when the cancerous cells spread to other body parts, it is said to have metastasized.
Statistics from the WHO show that as of the end of 2020, 7.8 million women diagnosed with breast cancer in the prior five years are alive, making breast cancer the most prevalent female cancer.
Although breast cancer is much more common in women, men do develop breast cancer. Although male breast cancer accounts for less than 1% of all breast cancer diagnoses, more men die from their disease on a percentage basis compared to women. According to the American Cancer Society, in 2022, new cases of breast cancer were diagnosed in 2,710 men (compared to 287,850 women), and 530 men died from breast cancer (approximately 20%) compared to 43,250 deaths among women (about 15%). While more common in older men, breast cancer can occur at any age.
Is there a difference between breast cancer in men and women? Interestingly, breast tissue is similar in men and women; however, the lower prevalence of breast cancer in men is partly due to men having mainly fat and fibrous breast tissue called stroma and fewer ducts and lobules where the cancerous cells generally develop.
In this blog, I will discuss what you should know about breast cancer and its treatment, focusing on chemotherapy.
What are breast cancer risk factors?
Non-modifiable risk factors:
- The major non-modifiable risk factor for developing breast cancer is being female. This is because females have more estrogen, which promotes breast tumor growth. Furthermore, female breast cells are more likely to mutate because they are more active than male breast cells, which are primarily inactive.
- Age is another non-modifiable risk factor. Older women have a higher risk because they have had more menstrual cycles increasing their lifetime exposure to estrogen.
- In normal cells, two essential genes, breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), make proteins that repair damaged DNA. Inherited genetic mutations in these genes lead to abnormal cell growth, which can lead to breast cancer. Gynecologic history (early menarche or late menarche) is also a risk factor for breast cancer because it causes more exposure in women to estrogen.
Modifiable risk factors:
- Being overweight or obese (especially in post-menopausal women)
- Low physical activity,
- Some hormone replacement therapy
- Poor nutrition
It is unclear what causes breast cancer in men; however, it is thought to occurs when some breast cells divide more rapidly than healthy cells. The risk increases in men with a BRCA mutation and any condition that increases estrogen production (for example, Klinefelter syndrome). Furthermore, being overweight in males increases estrogen production, increasing the risk of breast cancer.
What are breast cancer’s signs and symptoms?
In both women and men, symptoms of breast cancer include:
- A new lump or mass in the breast
- Breast skin dimpling (sometimes looking like an orange peel)
- Breast or nipple pain
- Nipple discharge
- Swollen lymph nodes under the arm or near the collarbone
How is breast cancer screened and diagnosed?
Breast self-examination can help identify a change in the look or feel of the breasts or nipples, or nipple discharge, which would warrant a follow-up screening. Breast self-examination alone is not sufficient as a screening modality for breast cancer but useful to raise suspicion of breast cancer.
Clinical breast examination should be part of routine annual care for women 40 years and older. The American Cancer Society recommends against screening with clinical breast examination; the American College of Obstetricians and Gynecologists recommends counselling patients about its diagnostic limitations. However, in some countries where mammography is considered expensive, clinical breast examination is the exclusive screening for breast cancer.
In addition to clinical breast examination, screening modalities include:
- Mammography (including digital and 3-dimensional). This involves passing low-dose x-rays of both breasts taken in two views.
- Magnetic Resonance Imaging (MRI). It is used to screen those with a BRCA gene mutation who are at a higher risk of developing breast cancer. For these women, screening should include magnetic resonance imaging, mammography, and continuous breast examination. MRI has a higher sensitivity but may be less specific.
Men are usually not taught about breast self-examination and may be unaware of breast cancer signs and symptoms. Furthermore, due to feelings of embarrassment and emasculation, they may ignore them. Consequently, men generally have poorer outcomes than women because they are diagnosed at more advanced stages and when they are older. This suggests a need for awareness campaigns and education about male breast cancer. In addition, men must learn about breast cancer symptoms, their breast cancer risk, and what they can do to reduce the risk.
A qualified oncologist diagnoses breast cancer. Diagnostic tests include:
- Screening by mammography, breast examination, and imaging.
- Biopsy – includes analysis for estrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2) protein.
- Biopsy should be done if physical findings suggest breast cancer (for example, palpable mass), even if mammogram results are negative.
What do we mean by breast cancer staging?
Breast cancer staging describes how extensive cancer has spread, including its size and location. Of interest is whether the tumor is localized in the breast, spread to the lymph nodes near the breast, or spread to distant organs. Also of interest is the tumor biomarker, which provides information about the cancer genes and proteins that can help tailor treatment to the specific cancer type.
The tumor, nodes, and metastasis (TNM) staging system is an internationally accepted system used to determine the breast cancer stage. It guides the prognosis and management of breast cancer. Click here to read more about it.
What is Breast Cancer Prognosis?
Poor prognosis is associated with the following factors:
- Young age at diagnosis
- Race: According to the American Cancer Society, breast cancer death rates from 2012 to 2016 were higher in the US in non-Hispanic black females (28.9 per 100,000) than in Hispanic white females (20.6 per 100,000).
- Larger primary tumour: This confers a worse prognosis than smaller tumors.
- High-grade tumour: Cancer cells grow and spread faster than low-grade cancer cells. Patients with high-grade cancer usually have a worse prognosis and require immediate and intensive treatment.
- Presence of BRCA gene mutations.
- Overexpression of HER2 protein
How is breast cancer treated?
Several breast cancer treatment options are highly effective, especially when the disease is identified early from regular self-examination and screening. The approach to breast cancer treatment is similar in men and women. However, the treatment choice will depend on the specific breast cancer type, grade, and stage. Ideally, the oncologist should determine treatment and be individualized to the particular patient’s cancer type.
The treatment of early-stage breast cancer may include some combination of surgery, chemotherapy, and radiation. Chemotherapy is a commonly used breast cancer treatment, and the treatment is focused on in this blog.
Chemotherapy is a treatment that destroys cancer cells using anti-cancer drugs. Chemotherapy kills cancer cells by interfering with their ability to divide and grow.
In chemotherapy, a combination of drugs is often used. This is because the various chemotherapy drugs work in different ways to interfere with cancer cells at different stages of their growth.
When is chemotherapy given after breast cancer is diagnosed?
- Before surgery–Chemotherapy may slow the growth of rapidly growing breast cancer or shrink the size of more extensive breast cancer before surgery. This is known as primary or neoadjuvant chemotherapy.
- After surgery–Chemotherapy may be given to reduce the risk of cancer returning or spreading (metastasis). This is called adjuvant chemotherapy.
What are some examples of chemotherapy drugs for breast cancer?
Several chemotherapeutic agents are available to treat cancer and are used alone or in combination with other drugs. The chemical structure and mechanism of action differ between the different agents, so selecting the appropriate treatment effective against a specific cancer type is essential. Examples of commonly used chemotherapeutic agents include:
- Anthracyclines, such as doxorubicin (adriamycin) and epirubicin
- Taxanes, such as paclitaxel (taxol) and docetaxel
- Carboplatin
- Cyclophosphamide
- 5-fluorouracil or capecitabine
- Methotrexate
Treating breast cancer with chemotherapy in an African hospital
I spoke with Dr. Emmanuel Mduma, a Clinical and Radiation Oncologist based in Dar-es-Salaam, Tanzania. He explained, “we usually give chemotherapy for breast cancer in 3 different settings:
- As neo-adjuvant before surgery: AC-T chemotherapy entails 4 cycles of Doxorubicin (Adriamycin) and Cyclophosphamide 3 weekly, followed by a taxane. Primarily the taxane used is paclitaxel 4 cycles, 3 weekly regimens, and 12 cycles weekly regimens. There are also other regimens like TAC (docetaxel (Taxotere), doxorubicin hydrochloride (Adriamycin), and cyclophosphamide) or CMF (cyclophosphamide, methotrexate, fluorouracil).
- As adjuvant chemotherapy – This is done 4-6 weeks post-surgery. The treatment used is the same as the neoadjuvant regimen.
- In palliative care for metastatic disease patients with visceral crisis (end-organ dysfunction), triple negative receptors, BRACA1 and BRACA2 carriers and positive hormonal tumours refractory to hormonal therapy-AC-T can be used or Carboplatin/Paclitaxel.”
Side effects of chemotherapy
Chemotherapy, just like any treatment, have side effects. The side effects can vary among patients because everyone reacts differently to drugs; thus, some people have more pronounced effects than others. These side effects can usually be managed; some are transient and will subside when treatment stops.
Common side effects of chemotherapy include:
- Hair loss or thinning
- Neutropenia (low neutrophil level) which leads to an increased risk of infection
- Anaemia (a drop in the number of red blood cells)
- Thrombocytopenia (low platelets) leads to bruising and bleeding
- Nausea and vomiting
- Extreme tiredness
- Sore mouth
- Taste changes
- Bowel changes
Bottom line
Although breast cancer is significantly more prevalent in women, men also get breast cancer. The risk factors, signs and symptoms of breast cancer are similar in men and women. However, the relatively poorer survival of men with breast cancer is partly due to lower screening in men, the feelings of embarrassment, and emasculation resulting in men ignoring early warning signs and symptoms. Despite the devastating consequences, little attention is paid to male breast cancer. Therefore, it is critical that both men and women receive breast cancer education. Regular breast self-examination, screening, and reducing modifiable risk factors are essential components of cancer education.
Where available, it is advised to follow the Ministry of Health guidelines in your local setting.
Godswill Boni, PharmD, is a multi-talented pharmacist who loves health blogging and medical writing. You can reach him here.
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