October is Breast Cancer Awareness month and on Friday (23rd October) charities are encouraging individuals to wear pink to raise awareness and money for breast cancer research.
When I think deeply about breast cancer, I get extremely emotional. Have I ever experienced it? No. Do I know someone who has? Yes. Breast cancer is the most common cancer in the UK. Many of us will know at least one person who is battling breast cancer or who has sadly lost their battle with the disease. The reason I feel so overwhelmed with emotion is that I imagine the fear at a doctor diagnosing me with the disease. I imagine the scenario where you are sitting in a doctor’s consultation room and they give you such life-shattering news. Then, I think to myself, if I feel this way just by imagining something that has not happened to me, imagine how it feels actually experiencing it.
Breast cancer takes the lives of around 12,000 women and 80 men each year in the UK alone. 12,000 women and 80 men with goals, with dreams, with futures. Gone. I often reflect on how these are not just statistics; each one of these men and women have lives and families completely altered as a result of this disease.
As it is Breast Cancer Awareness Month, we wanted to draw your attention to the epidemiology, prevention and treatment of breast cancer. For some of you, this article may not contain anything new. However, if this article helps someone then we are making progress and helping spread awareness.
Epidemiology of breast cancer
Breast cancer is the most common cancer in women from both developed and less developed countries. Estimates indicate that 1 in 8 women will develop breast cancer in their lifetime. Breast cancer in men is rare, with about 350 men diagnosed in the UK each year.
It is an extremely complex disease, that is generally classified into two types – invasive and non-invasive. Ductal carcinoma in situ (DCIS) is a stage 0 non-invasive breast cancer and typically associates with an excellent prognosis. The two most common types of invasive breast cancer include invasive ductal carcinoma and invasive lobular carcinoma. Invasive ductal carcinomas make up about 70-80% of all breast cancers. There are several other special types of invasive breast cancers. These types have specific features, including triple-negative breast cancer (cells test negative for oestrogen and progesterone receptors and HER2) which accounts for 15% of all breast cancers and is often very difficult to treat.
While it is commonly assumed that most cancers are hereditary, hereditary variants in fact only cause about 5-10% of cancers. Mutations that randomly occur throughout an individual’s lifetime, e.g. as a result of ageing or environmental exposures, cause the remaining 90-95% of cancers. For breast cancer, there are several factors that increase the risk of developing the disease, including increasing age, family history, hormone replacement therapy, obesity and drinking alcohol.
BRCA1 and BRCA2 are two major genes involved in cancer susceptibility, particularly breast and ovarian cancer. They are tumour suppressor genes that have key roles in the DNA damage response (DDR). People with an inherited variant in BRCA1 have a 65-85% increased risk of getting breast cancer and a 39-46% increased risk of getting ovarian cancer. Whereas people with an inherited BRCA2 variant have a 45-85% and 10-27% increased risk of developing the respective cancers. There are over 1000 known BRCA variants that increase cancer risk. Loss of function of the BRCA proteins impairs the cell’s ability to undergo homologous recombination, which leads to genomic instability – a hallmark of cancer. Genomic instability results in manifestation of abnormalities including large-scale rearrangements that initiate cancer development and progression.
Prevention and treatment of breast cancer
Prevention and screening
In the UK, all women aged from 50-71 are invited for breast cancer screening every 3 years. Screening typically involves having a mammogram (x-ray) of each breast at different angles. Regular mammograms enable early detection of cancer, which reduces likelihood of having a mastectomy or chemotherapy.
Identifying potentially harmful BRCA variants early has shown to be very powerful. Currently, the UK offer BRCA gene testing to individuals who meet a set of criteria: specific presentation, a family history of breast, ovarian or prostate cancer or a Manchester score of ≥ 15. It is also offered to individuals where there is a known familial BRCA variant, affected individuals with Ashkenazi Jewish ancestry and occasionally unaffected individuals that have a high Manchester score with a family history or Ashkenazi Jewish ancestry. The range of tests offered by the NHS include sequencing of the entire coding region or specific exons of the BRCA gene, testing for known familial variants and targeted mutational or copy number analysis.
Generally, the main treatments for breast cancer include surgery, radiotherapy, chemotherapy, hormone therapy and targeted therapy. Depending on the type and stage of cancer, these treatments can be used on their own or in combination.
Surgery involves the physical removal of the tumour, typically along with some surrounding tissue. Types include mastectomy (whole breast removal), quadrantectomy (removal of one-quarter) and lumpectomy (removal of a small part of the breast). After removal of the tumour or breast, healthcare providers typically offer individuals breast reconstruction surgery. Doctors often give radiotherapy after surgery in the region to lower the risk of recurrence in the breast.
Oncologists predominantly use chemotherapy for breast cancer cases in stages 2-4 and have found that it is particularly beneficial in oestrogen receptor negative (ER-) cases. Common drugs include docetaxel, paclitaxel, cisplatin, methotrexate and fluorouracil. Patients can receive one or a combination of different drugs at a given time, usually for periods of 3-6 months.
Hormonal therapy is an effective treatment for most tumours that test positive for either oestrogen (ER+) or progesterone (PR+) receptors. This type of tumour is dependent on hormones to grow. Therefore, blocking hormones can help prevent cancer recurrence and death. Oncologists typically give this by itself or after chemotherapy. Common types include tamoxifen (blocks oestrogen binding) and aromatase inhibitors (decreases amount of oestrogen produced). However, aromatase inhibitors are only suitable for women after menopause.
In recent years, across cancer treatment there has been a shift towards more individualised care. Healthcare professionals use targeted therapy to target cancers’ specific genes, proteins or tissue environment that contribute to cancer growth and survival. Trastuzumab is a monoclonal antibody against HER2. Researchers found that it improves 5-year disease free survival of stages 1-3 HER2-positive breast cancers to about 87%. Other HER2-targeted therapies include pertuzumab and neratinib. For severe disease, oncologists recommend the use of trastzumab and pertuzumab in combination.
In popular culture
Before the 20th century, many feared breast cancer and often did not discuss it. Many women tended to suffer in silence rather than seeking care. Popular culture has a massive impact on the awareness of breast cancer, including its symptoms and treatment. The breast cancer movement developed in the 1980s and 1990s, out of 20th century feminist movements. Breast cancer advocacy has since rocketed, with several charities and organisations aiming to raise awareness and reduce the stigma of breast cancer through education on symptoms and treatment. For many the pink ribbon has become a symbol of breast cancer awareness and solidarity.
In 2015, Angelina Jolie sparked mass media attention when she made an announcement in The New York Times that she had decided to have a preventative double mastectomy to reduce her risk of getting cancer. Since then, Jolie has become a sort of symbol for breast cancer, mentioned across education and in pieces like this. Why? Having such a high-profile individual publicly share their experience and hardship was a stimulus for change. It opened up conversation and reinforced the fact that cancer can affect anyone, anywhere.
Several studies have shown that prophylactic surgery, such as a mastectomy, can have a negative impact on body image and quality of life of women. Many individuals frequently refer to Jolie as one of the most beautiful women in the world. After her announcement, no evidence emerged to suggest that public perception of her beauty had changed. In fact, for many people, Jolie only became more beautiful through the way she shared her experiences in such an open and honest manner.
Breast Cancer Now (a UK registered charity), recently reported that almost one million women in the UK missed their breast cancer screening appointment because of the COVID-19 pandemic. During the height of the pandemic, healthcare providers halted breast cancer screening services to reduce the risk of spread and help free up emergency NHS resources. The charity estimates that there could be 8,600 women who are now living with undetected breast cancer. They have urged leading government bodies to set out a plan to tackle this rise in demand for imaging and diagnostics.
Like the rest of the world, breast cancer care is changing. While healthcare systems have restarted services, many appointments have begun to be conducted virtually. Not only this, therapies are becoming increasingly targeted and diagnostic techniques such as liquid biopsy are continually advancing. According to the National Breast Cancer Foundation, someone receives a breast cancer diagnosis every two minutes. Successful treatment is heavily dependent on the early detection of the cancer. Therefore, it is imperative that patients keep up with their screenings and medical visits.
While October is Breast Cancer Awareness Month, we should not restrict generating awareness of this disease to just one month of the year.
When it is not impacting you specifically, you may often unintentionally see cases as just statistics. But these are human beings, not statistics. We are seeing it daily with the COVID-19 pandemic, numbers on our screens. We need to take a moment to truly comprehend that these people are not numbers. They are individuals who love, who have families, who make a difference to society. Whilst we might not be able to save everyone, we can still try and save at least one person by generating awareness of breast cancer.
Image credit: By freepik – www.freepik.com