At the moment, according to the Indian Breast cancer Registry, one in every 20 women is likely to have Breast cancer. But very soon…by 2020… it is likely to meet the western statistics and the occurrence could be one in 10 women!

Fibrocystic Disease is not a Disease but an exaggeration of the response of the breast tissues to the normal hormonal changes. Hence it is called Fibrocysitc Changes (FCC) and not disease! The Patient typically has cyclical or non-cyclical Pain, fullness and on examination we find lumpishness as well as tenderness. Sometimes there is a clear or greenish/brownish nipple discharge also.
There is no definite treatment for FCC except reassurance. Symptomatic relief can be offered by either anti-inflammatory drugs and hot fomentation typically. A variety of drugs like Vitamin E, Danazol, diuretics, Primrose oil etc have been tried and are useful.

Nipple discharge can be of different variety.

A clear or yellowish discharge is usually present in FCC.

Milky discharge is present in a pregnant or lactating woman.

Greenish or brownish discharge usually again is a sign of FCC, but requires a cytological examination.

Bloody discharge is a sign of Papilloma or even malignancy, hence cytology and a Ductoscopic examination as well as USG/Mammogram becomes mandatory.

Ductoscopy is the microendoscopic examination of the breast ducts. It is usually done in cases of nipple discharge and it helps in picking up lesions like Papillomas and locating the ducts which are to be explored for the lesion. Research is also being done for therapeutic applications like endoscopic laser ablation or removal of Papillomas and early detection of lesions in the ducts.

The dictum is that “Unless otherwise proved treat any breast lump as cancer and go the reverse way till it is proved to be benign or otherwise.” The first investigation is USG and a Mammogram (if the patient is above 35 years of age) to define whether it is a cyst or a solid lump. If it is a cyst a simple aspiration may suffice unless it recurs and then you need to excise it surgically. If it is a solid lump-fibroadenoma, excision is the treatment of choice with a cosmetic scar.

If the USG/Mammography shows a doubtful lump, suspicious of malignancy, then a biopsy is advisable before further treatment.

With the modern technology there are minimally invasive modalities for biopsy-

• FNAC-Fine needle aspiration cytology
• Trucut/Core biopsy-from four different quadrants and centre – give tissue diagnosis
• Vaccum Assisted Biospy (VAB)-gives more tissue, done under USG/Mammography guidance
• Steriotactic Biopsy-done under Mammography guidance in lesions which are only mammographically visible and not palpable
• Frozen section Biopsy-in doubtful cases
• Excision Biopsy
• Nipple discharge cytology
• Ductoscopiclavage cytology and biopsy

The standard recommended protocol is :

• Breast Self Examination(BSE) every month after 20 years of age
• Clinical Examination by a specialist every year after the age of 35 years
• USG/Mammography every 2 years after after 40 years and yearly after 50

The exact cause is yet unknown. But there are a number of risk factors like-Early menarche, Latemenopause, Late first pregnancy, No breast feeding, Oral contraceptives or hormonal pills for Hormonal replacement therapy (HRT), Alchohol, Fatty diet…but most importantly it is the stress which leads to hormonal changes which eventually leads to some changes in the response of these hormones on the breast tissue. There is also a role of genetic factor or family history and previous occurrence of the disease.

About 5-10% of Breast cancers are hereditary or familial. The genes that carry this are BRCA1 and BRCA2. The genetic testing should be done if there is a strongly positive family history, though it is expensive and done only in specialized laboratories in India.

Some breast cancer cells have receptors to the hormones Oestrogen and progesterone. When the biopsy is sent it is also sent for receptor assay. If the report is positive the cancer is said to be ER + ve, PR + ve. If so the disease responds to the hormonal treatment.

Some cancer cells have a receptors for protein HER 2. If the tissue is positive for HER 2 then it responds to Biological therapy like Herceptin. The prognosis is good if the receptor assay is positive. The triple negative disease is the most difficult to treat!

There are different classifications for staging of Breast Cancer but the standard staging has Stage 0-Carcinoma in situ Stage I-Stage IV which are subdivided into A, B, C depending on the size of the lump, the number of lymph nodes and the local and distant spread of the disease.

Once the biopsy says that the lump is positive for malignancy we need to stage the disease and the treatment is accordingly.

Stage I and II-Breast Conservation Surgery (BCS) or Modified Radical Mastectomy (MRM) Stage III-BCS/MRM + Radiation + Adjuvant chemotherapy (pre-operative&/or post-operative) and Hormonal therapy (in Receptor positive patients), Biological therapy (In Her 2 neu positive patients) depending on stage A/B/C Stage IV-Palliative treatment in the form of Radiation/Chemotherapy/Hormonal therapy.

BCS is offered to the patient in cancer which is early and which can obtain a good surrounding margin of normal tissue without distorting the breast appearance. Generally lumps smaller than 2.5cms can be offered BCS though it would largely depend on the size of the breast. But this is always associated with Radiation therapy in order to achieve completeness of therapy.

The results of both in the rightly selected cases are comparable and so are the recurrence rates.

The results of both in the rightly selected cases are comparable and so are the recurrence rates.

It is very important that a woman who is mastectomized should be offered reconstruction!!

It is a psychological trauma to loose the breast! There are musculocutaneous flaps like the LatimusDorsi or TRAM flaps. But in this modern era, Breast Implants are becoming very popular as a reconstructive modality after mastectomy. The implant could be Saline or Silicone depending on the choice of the patient-both have their pros and cons but are safe, if used from a standard FDA approved company. There are expandable implants also available from the Mentor (Johnson & Johnson) company which can be placed at the same time as mastectomy. Usually the Breast surgeon does the MRM and teaming up with the Plastic surgeon, the implant of the right size is placed at the same time, so as to avoid a second surgery!!