Breast Cancer: Early Awareness Makes a Difference

Breast cancer is a heterogeneous group of diseases. It typically starts locally in the breast and gradually spreads to the lymph nodes in the armpit, becoming invasive, and can then spread to other organs. Many factors shape what raises the risk of breast cancer, its symptoms and signs, how it is controlled, diagnosed and staged, and which treatment options are available.

Breast cancer facts

• Breast cancer ranks first among the most common cancers globally, regionally and in Saudi Arabia.
• Breast cancer is the most common cancer in the Kingdom, and the most common cancer among women.
• In Saudi Arabia, breast cancer is most common among women aged 40 and over.
• More than 50% of breast cancer cases in Saudi Arabia are detected at advanced stages, compared with 20% in developed countries. This raises mortality, lowers the chance of recovery and increases the cost of treatment.
• Early detection by mammography significantly increases recovery and survival rates, and widens the range and effectiveness of treatment options.

Cancer statistics in Saudi Arabia (Saudi Cancer Registry, 2016)

According to the Saudi Cancer Registry's 2016 statistics, 16,859 cancer cases were recorded in the Kingdom, of which 13,161 (78.1%) were among Saudis: 44.1% in men and 55.9% in women.

Table 1: All cancer cases recorded in Saudi Arabia in 2016, by nationality and sex

Group	Male	Female	Total
Saudi	5,803	7,358	13,161
Non-Saudi	1,872	1,826	3,698
Total	7,675	9,184	16,859

Breast cancer ranked first with 2,282 cases: 17.3% of all cancers in both sexes and 30.4% of all cancers in women, followed by colorectal cancer and then thyroid cancer. The incidence rate was 27.2 per 100,000 Saudi women, and the median age at diagnosis was 50.

Table 2: Regions with the highest breast cancer incidence (per 100,000 women, 2016)

Rank	Region	Incidence rate
1	Eastern Province	46.7
2	Riyadh	33.8
3	Qassim	31.7
4	Makkah	29.7
5	Al-Jouf	25.0
—	National rate (Saudi women)	27.2

Why early detection by mammography matters

• Early detection is one of the most important secondary-prevention strategies.
• Its aim is to diagnose breast cancer at an early stage and make it easier to reach further diagnosis and treatment in hospitals.
• Early detection improves the quality and outcome of treatment, can raise the cure rate to more than 95%, and can reduce mortality by up to 30%.

Symptoms and signs

In most cases breast cancer causes no symptoms in its early stages; symptoms appear as the tumour grows. Breast cancer sometimes changes how the breast looks or feels, including:

• A new lump in the breast or armpit, or a lump that has changed.
• A change in the shape or size of the breast.
• New, persistent pain in the breast or nipple that does not go away.
• Flaking, redness, swelling, dimpling or puckering of the skin of the breast or nipple.
• Changes in the nipple's appearance (a nipple that has turned inward when it did not before).
• Discharge from the nipple.

If any of these symptoms appear, see a doctor. Most of the time they are caused by something other than cancer.

Causes and risk factors

The causes of breast cancer are not fully known or understood. A set of interrelated factors can influence its development: genetic, hormonal, environmental, socio-biological and physiological (physical) factors. Other risk factors include proliferative breast disorders linked to breast cancer, especially when a biopsy shows atypical hyperplasia. Even so, no risk factors can be identified in 70% of breast cancer patients.

Genetic predisposition

A family history of breast cancer in first-degree relatives (mother, sister, daughter) raises the risk. The size of the risk depends on whether the cancer affected both breasts and whether it occurred before or after menopause; it can reach three times the risk of women with no family history. Inherited factors account for 5–10% of breast cancer cases, and are more likely when several relatives are affected or the cancer occurred at a younger age. Mutations in the BRCA1 and BRCA2 genes, along with the p53 gene, cause most hereditary breast cancers.

Hormonal factors

Hormone levels play a major role in the development of breast cancer. An early pregnancy and early removal of the ovaries reduce breast tumours, whereas late menopause is associated with a higher incidence of breast cancer. Many hormonal factors, such as a long reproductive period and having a first child later in life, increase exposure to high levels of oestrogen during the menstrual cycle. Ovarian tumours that raise oestrogen levels are associated with more breast cancer in women after menopause.

Other factors that affect hormonal balance and raise the likelihood of breast cancer include oral contraceptives and hormone therapy after menopause to ease its symptoms. A slight increase in risk has been seen among oral contraceptive users; it falls after stopping and is no longer noticeable 10 years after stopping. Using oral contraceptives at an older age has also been linked to more diagnosed breast cancer cases.

Current or recent users of hormone replacement therapy are at higher risk of developing breast cancer than women who have never used it. The risk grows with the length of use, drops markedly after stopping, and the added risk disappears five years after stopping. A US study of about 160,000 women over five years, assessing the benefits and risks of combined hormone therapy (oestrogen and progesterone together), found a 26% higher risk of breast cancer among users compared with non-users.

Environmental factors

The main environmental factor directly linked to breast cancer is ionising radiation. Epidemiological studies show a higher breast cancer risk among women exposed to radiation from nuclear war or during diagnostic and therapeutic procedures. Radiotherapy for a malignant tumour of the chest, particularly lymphoma (Hodgkin's disease), and for thyroid cancer is also linked to a higher risk. Exposure after age 40 adds a small risk, while exposure during adolescence carries a greater risk.

Socio-biological factors

Age and sex are risk factors for breast cancer: 75% of new breast cancer cases worldwide, and 84% of breast cancer deaths, occur in women aged 50 and over. Breast cancer is diagnosed in about 1 in 232 women in their thirties, compared with 1 in 29 women in their sixties, an increase that may be directly attributable to hormonal changes in this age group.

Diet and how balanced it is may also affect the risk: eating plenty of fruit and vegetables lowers the risk of breast cancer, while a high-fat diet raises it. Obesity after menopause increases the risk, a link not seen in women before menopause.

Physiological (physical) factors

Physical activity can affect breast cancer risk: studies show a 30% lower risk with a few hours of vigorous activity a week, compared with none at all.

Breast conditions

Clinically, among every 100 women aged 40–60 with a breast problem, the most likely distribution is: 30% have no breast lesion, 40% have fibrocystic changes, 7% have a benign tumour and 10% have cancer. Breast conditions can be grouped as follows:

• Inflammatory lesions: rare, acute or chronic lesions, including acute mastitis, duct inflammation, post-traumatic inflammation and granulomatous mastitis.
• Benign fibrocystic lesions: the single most common breast disorder and the reason for about 40% of all breast operations. They are usually diagnosed between ages 30 and 40, rarely develop after menopause and are often affected by hormonal imbalance.
• Benign breast tumours: rare tumours, including adenomas, intraductal papilloma and phyllodes tumours.
• Proliferative breast disorders: epidemiological studies have identified breast changes that can increase breast cancer risk, namely those associated with hyperplasia, with or without atypia. These lesions are often accompanied by fibrocystic changes that appear abnormal on a mammogram.

How breast cancer is diagnosed

• Breast examination: the doctor examines both breasts and the lymph nodes in the armpit, feeling for lumps or other abnormalities.
• Mammography: an X-ray of the breast, done when an examination finds something abnormal.
• Breast ultrasound: uses sound waves to produce images of structures deep in the body, and shows whether a new lump is solid or a fluid-filled cyst.
• Biopsy: the only definitive way to diagnose breast cancer. A special needle, guided by X-ray or another imaging test, removes a sample of tissue from the suspicious area; a small metal marker is often left in place so the area is easy to find on future imaging. The laboratory determines whether the cells are cancerous, the type of cells, how aggressive (the grade) the cancer is, and whether the cells carry hormone receptors or other receptors that affect treatment options.
• Breast MRI: uses magnetic and radio waves to create images of the inside of the breast. Unlike other imaging tests, it does not use radiation to create the images.

Staging breast cancer

Once breast cancer is confirmed, the treating doctor determines its stage to estimate how the disease will progress and choose the best treatment. Tests and procedures used for staging may include:

• Blood tests, such as a complete blood count.
• A mammogram of the other breast to look for signs of cancer.
• Breast MRI.
• A bone scan.
• A computerised tomography (CT) scan.
• A positron emission tomography (PET) scan.

Not every patient needs all of these tests; the treating doctor chooses the appropriate ones. Breast cancer stages range from 0 to IV:

• Stage 0: also called non-invasive or in-situ breast cancer. These tumours cannot invade healthy breast tissue or spread to other organs, but they should still be removed because they may become invasive in the future.
• Stages I to IV: invasive tumours that can invade healthy breast tissue and then spread to other organs. A stage I tumour is small and localised, with a very high chance of complete recovery; the higher the stage, the lower the chance of recovery.
• Stage IV: cancer that has spread beyond the breast to other organs such as the lungs, bones and liver. Although it cannot be cured at this stage, it may respond well to a range of treatments that shrink the tumour and keep it under control for a long time.

Treatment options

Treatment depends on the type, stage, grade and size of the breast cancer and whether its cells are sensitive to hormones, taking the patient's overall health into account.

Surgery

Most patients have breast cancer surgery, and many also receive further treatment afterwards, such as chemotherapy, hormone therapy or radiotherapy. In some cases chemotherapy is given before surgery.

• Lumpectomy: also called breast-conserving surgery or wide local excision. The surgeon removes the tumour and a small margin of the surrounding healthy tissue.
• Mastectomy: removal of all breast tissue, including the lobules, ducts, fatty tissue and some skin, including the nipple and areola (simple or total mastectomy), or a skin- and nipple-sparing mastectomy.
• Sentinel lymph node biopsy: removal of the few lymph nodes that first receive lymphatic drainage from the tumour, to find out whether the cancer has spread to them. If no cancer is found there, it is unlikely to be in the remaining nodes and they do not need to be removed. This reduces problems in the armpit after surgery, including arm swelling (lymphoedema).
• Axillary lymph node dissection: removal of more lymph nodes, done if cancer is found in the sentinel nodes.

Radiotherapy

Radiotherapy uses high-energy beams, such as X-rays and protons, to kill cancer cells. It is usually given by a large machine that aims the beams at the body (external beam radiation), but radioactive material can also be placed inside the body (brachytherapy). External beam radiation is usually used after a lumpectomy for early-stage breast cancer, and doctors may also recommend chest-wall radiotherapy after a mastectomy if the cancer was large or had spread to the lymph nodes.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells and reduce the chance of the disease returning or spreading. It is sometimes given before surgery to women with large breast tumours, to shrink the tumour so it is easier to remove surgically.

Hormone therapy

Hormone therapy treats hormone-sensitive breast cancers, such as oestrogen receptor-positive (ER+) and progesterone receptor-positive (PR+) cancers, lowering the chance that the cancer returns. If the cancer has already spread, hormone therapy may slow it and help keep it under control. It uses medicines, or surgery to stop the ovaries producing hormones.

Targeted therapy and immunotherapy

• Targeted (biological) therapy: drugs that attack specific abnormalities inside cancer cells.
• Immunotherapy: uses the patient's own immune system to fight the cancer, which cancer cells evade by producing proteins that blind immune cells. One use is combining it with chemotherapy to treat advanced triple-negative breast cancer that has spread to other parts of the body.

Supportive (palliative) care

Specialised medical care focused on relieving pain, other symptoms and the side effects of treatment, aiming to improve the quality of life of people with cancer and their families.

Complementary and alternative medicine

No alternative treatment cures breast cancer, but some complementary therapies may help patients cope with side effects. Many breast cancer survivors experience fatigue during treatment and afterwards, sometimes for years. Things that can ease fatigue:

• Light exercise a few times a week, such as walking, swimming, yoga or tai chi.
• Managing stress, for example muscle relaxation, meditation and time with friends and family.
• Expressing your feelings: keeping a journal, joining a support group or talking with a counsellor.

How breast cancer is controlled

Early detection and prevention of breast cancer is a systematic, continuous management process: planning, developing and evaluating an early-detection programme, including setting policies and priorities. It requires comprehensive screening plans covering public awareness and education, medical and technical training for programme staff, and accurate diagnosis followed by timely treatment. Responsibility for creating and running the programme lies with the Ministry of Health or other relevant bodies, and a successful programme rests on these activities:

• Surveillance: the key to measuring the size of the problem and acting in time. Its aims include assessing the burden of the disease, identifying the risk factors that raise the likelihood of breast cancer, and establishing a basis for appropriate clinical interventions.
• Protection: activities that protect people from developing cancer or a recurrence and reduce the burden and disability it causes, including continuing education, health promotion, prevention and early detection (screening).
• Awareness and continuing education: starts by showing decision-makers why the programme matters so it is included in national plans. Public education focuses on prevention, a better understanding of the disease, the benefits of early detection and better care for patients and their families. Health promotion, with several sectors taking part, is the main strategy for controlling breast cancer risk factors.
• Prevention: breast cancer cannot be fully avoided, but its risk can be reduced through lifestyle changes, a healthy diet, physical activity and avoiding obesity, plus preventive treatment for high-risk women with tamoxifen and other anti-oestrogens.
• Early detection: the most important and most beneficial protection activity, since diagnosing breast cancer at an early stage is linked to lower breast cancer mortality.
• Care: diagnosing the disease at a very early stage, when treatment is most effective and recovery most likely, then providing the right treatment, including medication, radiotherapy and adjuvant therapies to prevent recurrence. More psychological and social support and palliative care improve the quality of life of women with breast cancer and their families.

Source

Saudi Ministry of Health – health awareness content: Breast Cancer (in Arabic).

This content is for health awareness only and is not a substitute for medical advice or diagnosis.

The AndroHealth team wishes you lasting health and wellbeing.