Breast Cancer 101 + Q&A with Dr. Michael McFarlane

The structure of the female breast is complex. Though it is primarily made up of fat and connective tissue, the breast also contains milk ducts, blood vessels, lymph nodes, and structures known as lobes and lobules.

After last week’s post about Breast Cancer Awareness Month, I realized that I’d assumed a lot. Not good. Yes, many of us know about Breast Cancer Awareness month or may have experienced the disease personally…but do we really know what we’re dealing with? Do we know about treatment options? Costs? Where to get screened? What to ask your doctor? What can we do to at least reduce our risk of developing breast cancer? Cancer is a scary thing for many of us. Cancer definitely scares me especially after seeing my grandmothers die from it (Grandma first got cancer in her breast but it was in remission for years before coming back in her bone, Mama J died from skin cancer) and my Grandpa battled cancer too (in the prostate & larynx yet still going strong at 82!). But knowledge is power – both about the disease and my family history – and I hope that this post will help you help yourself and maybe even someone else. So today’s post will be Breast Cancer 101 – with a concentration on the disease in Jamaica. The next two or three posts about breast cancer will be about supporting a loved one who’s been diagnosed, how to prevent or reduce one’s risk of developing breast cancer, and finally – my favourite – a breast cancer survivor speaks!

Dr. Michael McFarlane kindly answered some questions for me (and even answered my follow up questions). He’s written before in The Jamaica Gleaner about breast cancer in Jamaica and he is a volunteer with the Jamaica Cancer Society. Thank you @therealnickmack for arranging this Q&A interview for me! But first, a working glossary and some pix (yes, pictures of boobs)…

Carcinoma – This is just a medical term for cancer. Cancer is the uncontrolled abnormal growth of cells within the body. The uncontrolled growth begins in the skin or in tissues that line or cover the body’s organs. The uncontrolled growth can be caused by heredity, environment, or food (e.g. MSG). Cancerous cells grow into clumps or groups called tumors. Tumors may be benign (not harmful) or malignant (harmful). Sometimes benign tumors don’t even need to be removed, but malignant tumors are usually treated. A biopsy – a small surgical procedure to remove a piece of a tumor for study in a lab – will determine whether a tumor or benign or malignant.

Chemotherapy – A common cancer treatment (not just breast cancer). Chemotherapy is treatment with drugs that either kill cancer cells or stop them from growing or multiplying. The drugs are ingested. Chemotherapy can and does, however, harm healthy cells; it is not targeted. Healthy cells usually recover from chemotherapy. Side effects of chemotherapy include nausea, vomiting, tiredness, pain and hair loss. Not every one has side effects.

Radiation or Radiotherapy – Another common cancer treatment that uses the energy released from particles or waves. That energy is used to destroy tumors or to keep them from growing or multiplying. It is an external treatment so doctors try to protect healthy cells by “limiting the radiation dosage and spreading treatment out over time.” They will also shield the unaffected parts of your body as much as possible when using the radiation machines to target the tumor (think the covering that you have to wear when you’re getting an X-Ray).

Hormone Therapy – Treatment that uses specific hormones to shrink or stop the growth of tumors. Ironically, with breast cancer the female hormones estrogen and progesterone can promote the growth of some breast cancer cells. In those patients where this kind of promotion occurs, hormone therapy is used to block the body’s naturally occurring estrogen and to fight the cancer’s growth. Two types of hormone therapy are used to treat breast cancer: (1) drugs that inhibit estrogen and progesterone from promoting breast cancer cell growth, and (2) drugs or surgery to turn off the production of hormones from the ovaries. This is not the same kind of hormone replacement therapy used to treat postmenopausal women.

Each breast has 12 to 20 sections (lobules) that branch out from the nipple. Each lobule holds tiny, hollow sacs (alveoli). The lobules are linked by a network of thin tubes (ducts). If you're breast-feeding, ducts carry milk from the alveoli toward the dark area of skin in the center of the breast (areola). From the areola, the ducts join together into larger ducts ending at the nipple.

Targeted Therapy – Treatment that uses drugs to target cell-level processes in order to interfere with specific molecules involved in carcinogenesis (the process by which normal cells become cancer cells) and tumor growth. Most targeted cancer therapies are in preclinical testing (research with animals), but some are in clinical trials (research studies) or have been approved by the U.S. Food and Drug Administration (FDA). Targeted cancer therapies are being studied for use alone, in combination with each other, and in combination with other cancer treatments, such as chemotherapy.

Breast Cancer Stages – Breast cancer is usually diagnosed on a 5-stage system (Stage O, Stage I, Stage II, Stage III, Stage IV). Staging usually takes into account 3 factors: the tumor (the size of the tumor), nodes (the number & location of lymph nodes with cancer) and, metastases (whether the cancer has spread to other areas of the body = is it invasive or not). This is called the TNM system. The higher the number (e.g. Stage III or Stage IV) means that the cancer is more advanced and the lower the projected survival rate.

Palpable - Medically this means that an illness or disease is discovered through touch.

BRCA Genes – Genes determine how we look (our phenotype) and what our body does. They are encoded in our DNA. The BRCA Genes – BRCA1 and BRCA2 – are the class of genes known as tumor suppressors. A mutation (abnormality or change) of these genes has been linked to hereditary breast and ovarian cancer. A woman’s risk of developing breast (and/or ovarian cancer) is significantly increased if she has inherited this harmful BRCA1 or BRCA2 mutation. (Men with these mutations also have an increased risk of breast cancer.) Genetic tests are available to check for BRCA1 and BRCA2 mutations. A blood sample is required for these tests, and genetic counseling is recommended before and after the tests.

Mastectomy – A medical term for the surgical removal of a part or all of a breast. It is used to treat or prevent breast cancer. Preventative mastectomy is only done in high risk patients. There are four kinds: (1) a total mastectomy removes breast tissue and nipple; (2) a modified radical mastectomy removes the breast, most of the lymph nodes under the arm, and often the lining over the chest muscles; (3) a lumpectomy removes the tumor and a small amount of normal tissue around it; and (4) a radical mastectomy removes the breast, lymph nodes, and chest muscles but is no longer common.

Mammogram – A breast X-ray.

Finally, breast cancer may be too small to feel when it first develops. Eventually symptoms will occur and they include:

  • New lump in the breast or underarm (armpit).
  • Thickening or swelling of part of the breast.
  • Irritation or dimpling of breast skin.
  • Redness or flaky skin in the nipple area or the breast.
  • Pulling in of the nipple or pain in the nipple area.
  • Nipple discharge other than breast milk, including blood.
  • Any change in the size or the shape of the breast.
  • Pain in any area of the breast.

Now for Q&A with Dr. McFarlane…

What are the common kinds of breast cancer among Jamaican women? What trends are you noticing?

Breast cancer is regarded as having two main presentations in any population and the Jamaican population is no different. The most common type is invasive cancer referred to as invasive carcinoma and is seen in nearly 80% of cases. Noninvasive sometimes called insitu carcinoma is an earlier form of cancer that does not invade or grow into normal tissues in the breast. In a general way breast cancers can be considered to arise in the lobules of the breast, which are the milk producing glands or the ducts, that drain milk from the lobules to the nipple. Cancers that arise in the ducts are more common and are called ductal carcinomas and those that arise in the glands are called lobular carcinomas.

At what stage is breast cancer being diagnosed among Jamaican women?

Breast cancers are diagnosed in Jamaica usually when they are palpable. Because size is an important determinant in the stage of the cancer, most cancers are detected at a relatively late stage. A palpable cancer with or without lymph nodes may be staged higher that stage I. Breast cancers in Jamaica are usually diagnosed at stage II or stage III. Advanced cancers or stage IV are now much less frequent than in the past. In populations where screening is common breast cancers can be detected at a very early stage.

The lymphatic system is a network of blood vessels, lymph nodes and lymph ducts that helps fight infection. Lymph nodes — found under the armpit, above the collarbone, behind the breastbone and in other parts of the body — trap harmful substances that may be in the lymphatic system and safely drain them from the body.

What do you think are the obstacles to early diagnosis among Jamaican women? Top 3.

The main obstacles to early diagnosis of breast cancer among Jamaican women include education, awareness, access to early medical care and the absence of a national breast cancer-screening program.

If you were responsible for crafting a national breast cancer-screening program for Jamaica, what 5 things would you include? What, if any, would be barriers to implementation of the program & how could they be addressed?

Setting up an effective breast cancer screening programme in Jamaica will have its challenges. The availability of mammography equipment will be paramount. The health system will also need appropriate information systems, quality assurance programmes, and training of specialist staff together with services to support the programme. The pace of implementation will also be important. An educational program to sensitize all women will be necessary and it may take several years before all eligible women have access to the breast cancer screening programme. This will depend on such facts as the availability of sufficient numbers of trained professionals. The Government will also have to decide on the adoption of screening guidelines based on best practice and also the interval of screening will be important so that the health system will be able to adequately meet the challenges of setting up the programme for women aged 50-69 years.

What is the most common treatment for breast cancer, generally? Among Jamaican women?

The most common treatment for breast cancer in Jamaica is surgical mastectomy, which involves removal of the breast. Newer surgical options such as lumpectomy, and cosmetic procedures are also being performed. Generally the treatment of breast cancer in Jamaica follows well-established international guidelines and includes, surgery, radiotherapy, chemotherapy, hormone therapy and occasionally targeted therapy.

What’s the average cost of treatment for breast cancer in Jamaica (broken down by treatment type)?

The cost of medical care for breast cancer in Jamaica varies depending on whether the care takes place in the public hospitals or private hospitals. In Jamaica user fees have been abolished in the public hospitals and health care is free of cost to patients being treated in these hospitals. Private care incurs a cost that varies among medical providers and the availability of insurance reimbursement. (Editor’s note: A recent article in the Jamaica Observer contained a quote about treatment costs from Elite Sellars-Wright, who chairs the Reach for Recovery group. She said that private radiation treatment can cost up to JA$1.6 million.)

What kind of support and services does the Jamaica Cancer Society (JCS) provide? How, if at all, is Reach For Recovery different from the JCS?

The Jamaica Cancer Society plays a role as an advocacy group as well as performing the role of increasing public awareness of all cancers in Jamaica. The society also conducts a breast-screening clinic on site. Reach for Recovery is an affiliate group of the Jamaica Cancer Society. (Editor’s note: While talking to my Mother she mentioned that Grandma got lots of support from the JCS and RFR when she was first diagnosed. I think that they also supported Grandpa when he was first diagnosed. The on-site clinic also provides very low cost mammograms.)

The Breast Cancer Awareness Pink Ribbon. Be aware. Know what you're dealing with!

What’s your involvement with the Society?

I am a volunteer with the Jamaica Cancer Society and am one of the specialists who work in the breast-screening clinic. I also give lectures on cancer related topics and take part in pubic awareness programs.

What’s the rate of breast cancer among Jamaican men? What kind of support is available for them either from the JCS or otherwise?

The incidence of breast cancer in Jamaican men is similar to the incidence in other populations. This cancer is 100 times less likely to occur in men as it is in women. Men are seen at the Jamaica Cancer Society by self-referral or by referral by their physician with suspicious breast lumps.

Many women now do a double mastectomy after initial diagnosis, is this something you recommend?

Double mastectomy is rarely recommended by doctors for the treatment of breast cancer in Jamaica or in other medical facilities in other parts of the world. It is only recommended in patients with inherited BRCA genes who have a significant risk of bilateral breast cancer. The majority of patients with cancer in one breast will never develop cancer in the opposite breast.

Why did you choose to focus your career on cancer diagnosis and treatment? And why breast cancer?

My involvement with breast cancer or cancer as a whole arises out of my training as a general surgeon which necessitates the treatment of cancer. My involvement with the Jamaica Cancer Society has also increased this interest.

_______________________________

Dr. McFarlane is a Senior Lecturer in the Faculty of Medicine at the University of the West Indies (Mona). He’s written extensively on cancer pathology and treatment.

The definitions above were compiled from research on the following websites: American Cancer Society, the U.S. National Library of Medicine, and Susan G. Komen for the Cure. Pictures & captions are from the Mayo Clinic.

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  1. [...] Other posts on breast cancer can be found here and here. [...]

  2. [...] breast cancer and how to arm themselves against it.  Wrong. A remedy was in order - Breast Cancer 101 and a few personal stories, I thought.   Knowledge is power.  About the same time that [...]



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