Dr Shilpa Lad, specialised radiologist in breast imaging and interventions, NM Medical Center, Mumbai, India, shares her perspective on the evolving technologies for diagnosis and management of breast cancer in India, in an interview with Atandra Ray
What are the new technologies that have developed in the recent times that are effective in the diagnosis and management of breast cancer? And what are the success rates for the same?
Breast cancer is now the most common cancer amongst urban Indian women. As per Population Based Cancer Registry (PBCR) breast cancer accounts for 25-32 per cent of all female cancers in urban Indian cities. This implies, practically, one fourth (or even approaching one thirds) of all female cancer cases are breast cancer.
The concerning fact for the Indian population is that for every two women newly diagnosed with breast cancer, one woman is dying of it. Since more patients in India present at later stages, they do not survive long, irrespective of the best treatment they may get, and hence the mortality is fairly high.
Lack of awareness of breast cancer and screening for disease are significant contributory factors for the relatively late stage of the disease presentation in India.
Screening mammography (which means mammogram, a specialised X-ray performed in asymptomatic women with the intension of early detection of breast cancer) is the most powerful breast cancer detection tool. Mammograms don’t prevent breast cancer but they can save lives by finding breast cancers as early as possible. According to a report by WHO, mammograms have been shown to reduce breast cancer mortality by around 20 per cent in women by early detection.
Modern day digital breast tomosynthesis also called 3D digital mammography has a 25 per cent to 50 per cent better detection rate as compared to conventional 2D analogue mammography and involves only tiny radiation even less than a standard chest X-ray. In future it is expected 3D digital mammography will become more and more common. Most oncologists agree that breast screening mammography should start at the age of 40 and earlier in patients with high risks like genetic predisposition (BRCA 1 & BRCA 2 genetic mutation) and those with strong family history.
Breast health awareness implies that women should be aware of the common presenting symptoms of breast cancer such as painless palpable lump in the breast or underarm, nipple inversion, spontaneous bloody or clear nipple discharge, change in size of breast or skin dimpling. Typically, there is no pain associated with breast cancer. Therefore, women often do not realize the above mentioned symptoms until it is too late.
If a woman experiences any of the above symptoms, she should immediately consult her physician and undergo a diagnostic mammogram. If the mammogram is abnormal the radiologist will recommend a breast ultrasound for further characterization of the mammographic abnormality followed by imaging guided breast biopsy for accurate pathology diagnosis of breast cancer or in simple words confirming the diagnosis of breast cancer.
Pathology diagnosis or tissue diagnosis plays a crucial role in diagnosis and management of breast cancer. There are several types of imaging guided breast biopsy techniques such as Fine Needle Aspiration Biopsy (FNAB), Trucut or Core Needle Biopsy (CNB) and Vacuum Assisted Biopsy (VAB). The selection of the biopsy technique depends on availability of resources and the characteristics of the breast lesion.
Give us more insights on techniques such as Fine Needle Aspiration Biopsy (FNAB), Trucut or Core Needle Biopsy (CNB) and Vacuum Assisted Biopsy (VAB).
FNAB also called fine needle aspiration cytology (FNAC) is a technique by which a few cells are aspirated from the concerning breast lump under imaging guidance, typically ultrasound guidance. FNAB is the most widely available and cheapest biopsy technique for confirmation of breast cancer. However, FNAB has a number of limitations. This technique is cytologists dependent and is often associated with false negative (I.e. cancer is present but not detected in the aspirated sample) in about 27per cent of unsatisfactory samples. In a situation such as this patient often assumes that there is no cancer in the biopsy and therefore does not receive any further treatment, only to return later with an advanced stage of breast cancer. Moreover, this type of biopsy is unable to provide information on the cancer subtype and receptors or tumour markers such as oestrogen receptors, progesterone receptors and hereceptin receptors which are crucial for further management of breast cancer.
Trucut or core needle biopsy (CNB) involves obtaining cores of tissue from the breast mass under ultrasound guidance. The sensitivity of this type of biopsy for accurate diagnosis is 96per cent to 98per cent. Also information about cancer subtype and receptors or tumour markers is available from this type of biopsy. This type of biopsy technique is now widely available and is relatively cost effective.
Vacuum assisted biopsy (VAB) involves bigger needle with vacuum assistance for optimal sampling for non palpable breast lesions such as micro-calcifications as well as for complex solid cystic masses with a high accuracy rate of almost 100per cent. This technique also has applications for non surgical removal of benign lesions such as small fibroadenomas.
In what stages of breast cancer can these techniques be used and how effective are these techniques?
Imaging guided biopsy techniques are typically performed for diagnosis of indeterminate or suspicious breast lumps. The biggest advantage of imaging guided percutaneous biopsy is that the patient has to undergo a single surgical procedure for treatment of breast cancer following imaging guided biopsy confirmation of breast cancer. Before the advent of imaging guided breast biopsy, patients would have have to undergo 2 surgical procedures. The first surgical procedure for excision biopsy for diagnosis of the breast lump and the second surgical procedure for complete clearance of the breast cancer. Therefore, imaging guided percutaneous biopsy is superior to open surgical biopsy for several reasons, including increased accuracy, decreased cost and decreased surgical morbidity and cosmetic deformity.
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