The GIH Breast Program is different because of our dedication to the treatment of breast cancer and the resources allocated to undertake the function.

Our mission

To provide optimal coordinated patient care for the treatment of breast cancer, superior diagnostic strategies for this disease, the most influential and advanced research, and the best avenue to identify patients at risk, while using education, treatment, and diagnostic strategies to improve their well-being.

Patient services at GIH breast centre

The GIH Breast Centre offers the highest quality care for the screening, diagnosis and treatment of all medical and cosmetic breast problems. Equipped with state-of-the-art technology and staffed by an unmatched team of physicians, nurses and technologists, the Breast Centre provides patients with the latest and most innovative procedures available in a setting that is warm and supportive.

From screening mammography to breast cancer surgery and reconstruction, the GIH Breast Centre offers a full range of services to address all of your needs, including:

• Routine screening mammography
• Comprehensive evaluation for patients at high risk due to family history or prior cancer
• Timely diagnosis and treatment
• Second opinions
• Full range of medical and surgical treatment options for breast cancer
• Consultation for breast reconstruction
• Access to the latest clinical research trials
• Genetic analysis to assist in breast cancer risk assessment

Even with all the latest advances in the treatment of breast cancer, the best chance for survival is early detection. The GIH Breast Centre offers routine screening mammography and education to encourage women to stay on top of their health. Services include:

• Expert mammography readings by dedicated breast-imaging physicians
• State-of-the-art mammography facilities including digital mammography
• Convenient screening at our suburban family health centres

Accurate diagnosis and evaluation

The Breast Centre offers the latest diagnostic techniques and provides prompt, accurate evaluation of any breast problem. Services include:

• Second opinions on diagnoses
• Breast imaging capabilities, such as mammography and ultrasound, interpreted by highly trained and experienced physicians
• Nationally recognized pathology services (laboratory analysis)
• Stereotactic and ultrasound guided core breast biopsy (an outpatient procedure that requires no incision and only local anaesthesia)
• Breast MRI (magnetic resonance imaging)

Coordinated, individualised treatment
The Breast Centre’s team of experienced physicians – breast surgeons, medical oncologists, radiation oncologists, radiologists, and plastic surgeons – offers a complete range of treatments for breast cancer and other breast disorders, including:

• Surgical interventions for breast cancer
• Adjuvant medical therapies, including chemotherapy, hormone therapy and bone marrow transplantation
• Post-treatment rehabilitation and support groups
• Reconstructive surgery performed alone or together with therapeutic breast cancer surgery
• Access to clinical trials

For a second option
Many women upon hearing biopsy results suspicious for breast cancer will request a second opinion. These patients are given priority appointments and are asked to bring: mammogram films, pathology reports, pathology slides, and operative notes from their biopsy procedure (if available). All of these records and specimens will need to be reviewed so that treatment options may be discussed.
How to contact us
The Gulu Independent Hospital Breast Centre
Airfield Road
Gulu
Northern Uganda
Tel: +256-471432279
Fax: +256-471432262
Email: guluindp@aol.com

Anyone interested in making a GIH Breast Centre appointment for an initial exam or a second opinion may do so by calling the Breast Centre. It is not necessary for patients to be referred to GIH by their outside physician.

Breast Cancer – Health Aspects & Complications

Facing a breast cancer diagnosis can be overwhelming. Your stress levels may sky rocket. You may worry about finances and about your body image. And you may be asking yourself difficult questions, such as whether to write a living will. With education and supportive care, you may be better able to deal with the many issues and emotions you're experiencing.

What causes stress amongst breast cancer patients?
You may experience stress due to the uncertainty of your future, the unpredictability of the cancer, disability, and financial difficulties. In addition, you may be worried about your physical appearance after mastectomy, hair loss from chemotherapy, and possible skin changes, including darkening and thickening of your skin, from radiation therapy.

Common signs of stress can include disturbed sleep, fatigue, body aches, pain, anxiety, irritability, tension, and headaches.

How can I reduce stress?
Stress can build, influencing how you feel about life. Prolonged stress may lead to frustration, anger, hopelessness, and depression. Your breast cancer diagnosis can also affect your family members and loved ones, who are influenced by the health changes you are experiencing. To reduce stress:

• Keep a positive attitude.
• Accept that there are events you cannot control.
• Be assertive instead of aggressive. "Assert" your feelings, opinions, or beliefs instead of becoming angry, combative, or passive.
• Learn to relax.
• Exercise regularly. Your body can fight stress better when you are physically fit.
• Eat well-balanced meals.
• Rest and sleep. Your body needs time to recover from stressful events.
• Don't rely on alcohol or drugs to reduce stress.

How can I learn to relax?
There are a number of exercises that you can do to relax. These include breathing, muscle and mind relaxation, relaxation to music, and biofeedback. A few that you can try are listed below. First, be sure that you have a quiet location that is free of distractions, a comfortable body position (sit or recline on a chair or sofa), and a good state of mind. Try to block out worries and distracting thoughts.

What are some effective relaxation exercises?

Two-minute relaxation
Turn your thoughts to yourself and your breathing. Take a few deep breaths, exhaling slowly. Mentally scan your body. Notice areas that feel tense or cramped. Quickly loosen up these areas. Let go of as much tension as you can. Rotate your head in a smooth, circular motion once or twice. (Stop any movements that cause pain.) Roll your shoulders forward and backward several times. Let all of your muscles relax completely. Recall a pleasant thought for a few seconds. Take another deep breath and exhale slowly. You should feel relaxed.

Mind relaxation
Close your eyes. Breathe normally through your nose. As you exhale, silently say to yourself the word "one," a short word such as "peaceful," or a phrase such as "I feel quiet." Continue for 10 minutes. If your mind wanders, gently remind yourself to focus on your breathing and your chosen word or phrase. Let your breathing become slow and steady.

Deep breathing relaxation
Imagine a spot just below your navel. Breathe into that spot and fill your abdomen with air. Let the air fill you from the abdomen up, then let it out, like deflating a balloon. With every long, slow breath out, you should feel more relaxed.

What can I do if I start to feel overwhelmed?
The most important step you can take is to seek help as soon as you feel less able to cope. (See "What types of help are available?" below.) Taking action early will enable you to understand and deal with the many effects of your chronic illness. Learning to manage stress will help you maintain a positive physical, emotional, and spiritual outlook on life.

How do I keep track of my medical information?
Don't be afraid to ask your doctor, nurse, or other health care provider to repeat any instructions or medical terms that you don't understand. Your health care providers should always be available to answer your questions and address your concerns. Also:

• Make use of resources and support services offered by your hospital and community.
• Learn more about breast cancer. This can help you feel more comfortable with your treatment.
• Ask your family and friends to help you sort through the information you receive.
• Talk with other patients and families about breast cancer and its treatment.
• Bring a family member or friend with you to your doctor appointments. It may help with remembering what your health care provider discussed with you.

What types of help are available?
There are many sources of help available to provide support for breast cancer patients and their families. Among them are:

Social workers
Social workers are just one part of the care giving team that can offer treatment in a compassionate setting. These professionals can help you and your loved ones discuss any concerns about your diagnosis, treatment, or your personal situation.

Social workers can also provide education, counselling regarding lifestyle changes, and referrals to community or national agencies and support groups. Your social worker can also help your family find temporary lodging in your community, provide information about community resources, and help you with any other needs.

Individual counselling
Sometimes people have problems that are better addressed in a one-on-one atmosphere. By participating in individual counselling, you might more effectively express sensitive or private feelings you have about your illness and its impact on your lifestyle and relationships. Counselling services can help you and your family discuss issues of concern and develop and enhance coping abilities.

In addition, mental health care providers are available to create a treatment plan to meet your specific needs. Strategies can be designed to help you regain a sense of control over your life and improve your quality of life, something everyone deserves. At times, if depression is present, medicines other than those treating the physical illness may be prescribed.

Support groups
Support groups are a very useful sharing experience. They provide an environment where you can learn new ways of dealing with your illness and gain insight from others who have been through similar experiences. Group members may be able to explain things differently than your health care providers, and you may also want to share approaches you have discovered with them. You will also gain strength in knowing that you are not facing hardships alone.

Remember that others may share information or experiences that do not apply to you. Never replace your doctor’s advice with that given to another patient.

Financial counsellors
Financial counsellors are available through your hospital and can help answer questions you may have about financial issues related to your medical care.

What if I become unable to make decisions about my healthcare?
Information about advance directives, such as living wills and durable power of attorney for health care, is also available.

The living will expresses someone’s right to refuse or accept medical treatment that artificially prolongs his or her life. This document is prepared while the person is fully competent, in case he or she becomes unable to make this decision at a later time. The living will provides clear instructions regarding the person’s choice of extended medical care.

The durable power of attorney for health care allows you to appoint another person to speak for you if you become incapable of expressing your medical treatment preference. An attorney should devise this document so that it conforms to your state laws and court precedents.

Should I write a will?
No one likes to think about his or her own mortality, but a will is necessary to ensure that those who survive you will know how to carry out your wishes. This document should be prepared with your attorney.

What should family members and friends keep in mind?
The diagnosis and treatment of breast cancer is stressful and may be a difficult time for your family and friends. Here are some tips your family and friends can use:

• Feel free to ask the doctor questions if you accompany your loved one to her appointments.
• Be prepared for changes in your loved one's behaviour and mood. Medications, discomforts, and stress can cause your loved one to become depressed or angry.
• Encourage your loved one to be active and independent, as much as possible, to help her regain a sense of self-reliance and confidence.
• Be realistic about your own needs. Be sure you are sleeping enough, eating properly, and taking some time off for yourself. It is hard to offer much help when you are exhausted. If you take care of your needs, it may be easier to meet the needs of your loved one.
• Don't hesitate to ask other family members and friends for help. They will appreciate the opportunity.

Breast Cancer – Genetic Aspects

Women with a genetic risk for breast cancer account for five to 10 percent of all women with the disease. Having a first-degree relative (mother, sister, daughter) with breast cancer poses the greatest risk to other female members of the family -- three to five times that of the general population.

Several characteristics may suggest that a woman has a breast cancer gene:

• Diagnosis of breast cancer before age 40
• Several family members diagnosed with breast and/or ovarian cancer
• Diagnosis of bilateral breast cancer (cancer in both breasts)

What are the “breast cancer genes”?
Each of us is born with two copies of about 100,000 different genes contained in each cell. Genes are tiny segments of DNA that control how cells function, such as telling them when to divide and grow. One copy of each gene comes from your mother; the other is from your father.

A gene can develop an abnormality that changes how the cell works. More than one faulty gene has been found in women with breast cancer.

BRCA1 was the first gene detected that increased a woman's risk for breast and ovarian cancer. The presence of this gene produces a greater than 80 percent risk of developing breast or ovarian cancer by age 85. An estimated one in 600 women carry this gene. The risk of developing a second breast cancer among individuals carrying the BRCA1 gene is 65 percent. Bilateral breast cancer (cancer in both breasts) is also common in women who carry this gene.

A second gene, BRCA2, also plays a major part in breast cancer. Less information is available on the function of this gene; however, scientists do know that it is associated with a similar risk of developing breast cancer among carriers. BRCA2 may also account for some small percentage of male breast cancer.

Both the BRCA1 and BRCA2 genes can be inherited from either parent. Therefore, the father's family history of breast cancer is also important. Men or women who carry one of these gene mutations have a 50/50 chance of passing it on to each of their children.

Usually, these BRCA genes help to prevent cancer by creating proteins that keep cells from growing abnormally. But, if an abnormal BRCA1 or BRCA2 is inherited, you may be more susceptible to developing cancer during your lifetime. In addition, women with an altered BRCA gene usually have an increased risk of developing breast cancer at a younger age (before menopause). However, it's important to note that not all women who carry these genes will develop cancer.

At-risk families can take blood tests to screen for mutations in these genes. However, genetic testing is done only when definitely indicated by a strong personal or family history. Genetic testing may also be used to determine if a woman who has already been diagnosed with breast cancer is at an increased risk for a second breast cancer or ovarian cancer.

Breast Cancer In Younger Women

Younger women generally do not consider themselves to be at risk for breast cancer. Only 5 percent of all breast cancer cases occur in women under 40 years old. However, breast cancer can strike at any age, and all women should be aware of their personal risk factors for breast cancer. (A risk factor is a condition or behaviour that puts a person at risk for developing a disease. These risk factors have been incorporated into several risk factor models; the most well-known of these is the Gail Model.)

There are several factors that put a woman at high risk for developing breast cancer, including:

• A personal history of breast cancer or high-risk lesion found by biopsy
• A family history of breast cancer, particularly in a mother, daughter, or sister
• History of radiation therapy
• Evidence of a specific genetic chance (BRCA1/BRCA2 mutation) -- Women who carry defects on either of these genes are at greater risk for developing breast cancer.

What is different about breast cancer in younger women?
Diagnosing breast cancer in younger women (under 40 years old) is more difficult because their breast tissue is generally more dense than the breast tissue in older women. In addition, breast cancer in younger women may be aggressive and less likely to respond to treatment. Women who are diagnosed with breast cancer at a younger age are more likely to have a mutated (altered) BRCA1 or BRCA2 gene.

Delays in diagnosing breast cancer also are a problem. Many younger women who have breast cancer ignore the warning sign -- such as a breast lump or unusual discharge -- because they believe they are too young to get breast cancer. Many women assume they are too young to get breast cancer and tend to assume that a lump is a harmless cyst or other growth. Some health care providers also dismiss breast lumps in young women as cysts and adopt a "wait and see" approach.

Breast cancer poses additional challenges for younger women as it can involve issues concerning sexuality, fertility, and pregnancy after breast cancer treatment.

Can breast cancer in youger women be prevented?
Although breast cancer might not be prevented, early detection and prompt treatment can significantly increase a woman's chances of surviving breast cancer. More than 90 percent of women whose breast cancer is found in an early stage will survive.

When women learn at a young age about the risks and benefits of detecting breast cancer early, they are more likely to following the recommendations regarding clinical exams and mammograms. Young women also need to understand their risk factors and be able to discuss breast health with their health care providers.

Should women under 40 get mammograms?
In general, regular mammograms are not recommended for women under 40 years old, in part, because breast tissue tends to be more dense in young women, making mammograms less effective as a screening tool. In addition, most experts believe the low risk of developing breast cancer at a young age does not justify the low-level radiation exposure or the cost of mammography. However, screening mammograms may be recommended for younger women with a family history of breast cancer and other risk factors.

What’s the best way for younger women to be screened for breast cancer?
The American Cancer Society (ACS) recommends that all women 20 years of age or older should perform monthly breast self-examinations (BSE). The best time to perform BSE is the day after your monthly period ends. Becoming familiar with the look and feel of their breasts offers the best chance for a young woman to notice any change. In addition to monthly BSE, annual clinical breast exams are recommended for all women beginning at age 20. Annual screening mammograms also are recommended at age 40. Women younger than 40 who have a family history or other risk factors for breast cancer should discuss their risk and an appropriate screening schedule with their health care providers.

How is breast cancer treated in younger women?
The course of treatment for breast cancer at any age is based on the extent of the person's disease (within the breast and beyond the breast), as well as the woman's general health and personal circumstances. Treatment options include a lumpectomy, which involves removing the lump and some surrounding tissue, or a mastectomy, which is the removal of a breast. Radiation therapy is generally used following a lumpectomy, and chemotherapy and/or hormone therapy often are recommended after surgery to help destroy any remaining cancer cells and prevent recurrence.

Male Breast Cancer

Men don’t have breasts. How can they get breast cancer?
Even though men do not have breasts like women, they do have a small amount of breast tissue. In fact, the "breasts" of an adult man are similar to the breasts of a girl before puberty, and consist of a few ducts surrounded by fat and other tissue. In girls, this tissue grows and develops in response to female hormones, but in men -- who do not secrete the same amounts of these hormones -- this tissue does not develop.

However, because it is still breast tissue, men can develop breast cancer. In fact, men get the same types of breast cancers that women do, although cancers involving the milk producing and storing regions of the breast are very rare.

Why do I not hear about breast cancer in men as much as I hear about breast cancer in women?
Breast cancer in men is a very rare disease. This is possibly due to their smaller amount of breast tissue and the fact that men produce smaller amounts of hormones like oestrogen that are known to affect breast cancers in women.

There are 1,400 cases of male breast cancer per year. In fact, only about 1% of all breast cancers affect men.

Which men are likely to get breast cancer?
It is very rare for a man under age 35 to get breast cancer, but the likelihood of developing the disease increases with age. Breast cancer is most commonly diagnosed in men between age 50 and 70. Beyond that, African-American men appear to be at greater risk than Caucasian men. In some places in Africa, breast cancer in men is much more common. Also, college-educated professionals appear to have a higher risk than the general male population.

The clearest risk for developing breast cancer seems to be in men who have had an abnormal enlargement of their breasts (called gynecomastia) in response to drug or hormone treatments, or even some infections and poisons. Obesity can also cause gynecomastia. Individuals with a rare genetic disease called Klinefelter's syndrome, who often have gynecomastia as part of the syndrome, are especially prone to develop breast cancer.

How serious is breast cancer in men?
Doctors used to think that breast cancer in men was a more severe disease than it was in women, but it now seems that for comparably advanced breast cancers, men and women have similar outcomes.

The major problem is that breast cancer in men is often diagnosed later than breast cancer in women. This may be because men are less likely to be suspicious of an abnormality in that area.

What are the symptoms of breast cancer in men?
Symptoms are very similar to those in women. Most male breast cancers are diagnosed when a man discovers a lump on his chest. However, unlike women, men tend to go to the doctor with more severe symptoms that often include bleeding from the nipple and abnormalities in the skin above the cancer. The cancer has already spread to the lymph nodes in a large number of these men.

How is breast cancer diagnosed and treated in men?
The same techniques -- physical exams, mammograms, and biopsies (examining small samples of the tissue under a microscope) -- that are used to diagnose breast cancer in women are also used in men.

The same four treatments that are used in treating breast cancer in women -- surgery, radiation, chemotherapy, and hormones -- are also used to treat the disease in men. Mastectomy is the recommended surgery in men.

Many breast cancers in men have hormone receptors, that is, they have specific sites on the cancer cells where specific hormones like oestrogen can act. Therefore, hormonal treatment in men is likely to be effective.

GIH Breast Screening

Breast Cancer – An Overview

What is breast cancer?
Cells in the body normally divide (reproduce) only when new cells are needed. Sometimes, cells in a part of the body grow and divide out of control, which creates a mass of tissue called a tumour. If the cells that are growing out of control are normal cells, the tumour is called benign (not cancerous). If, however, the cells that are growing out of control are abnormal and don't function like the body's normal cells, the tumour is called malignant (cancerous).

Cancers are named after the part of the body from which they originate. Breast cancer originates in the breast tissue. Like other cancers, breast cancer can invade and grow into the tissue surrounding the breast. It can also travel to other parts of the body and form new tumours, a process called metastasis.

What causes breast cancer?
We do not know what causes breast cancer, although we do know that certain risk factors may put you at higher risk of developing it. A woman's age, genetic factors, family history, personal health history, and diet all contribute to breast cancer risk.

Who gets breast cancer?
Breast cancer is the most common cancer among women other than skin cancer.
In the US, breast cancer is the second-leading cause of cancer death in women after lung cancer, and it's the leading cause of cancer death among women ages 35 to 54. Only 5% to 10% of breast cancers occur in women with a clearly defined genetic predisposition for the disease. The majority of breast cancer cases are "sporadic," meaning there is no direct family history of the disease. Increasing age is another risk factor for developing breast cancer.

What are the warning signs of breast cancer?

• A lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
• A mass or lump, which may feel as small as a pea
• A change in the size, shape, or contour of the breast
• A blood-stained or clear fluid discharge from the nipple
• A change in the look or feel of the skin on the breast or nipple (dimpled, puckered, scaly, or inflamed)
• Redness of the skin on the breast or nipple
• An area that is distinctly different from any other area on either breast
• A marble-like hardened area under the skin

These changes may be found when performing monthly breast self-exams. By performing breast self-exams, you can become familiar with the normal monthly changes in your breasts.

Breast self-examination should be performed at the same time each month, three to five days after your menstrual period ends. If you have stopped menstruating, perform the exam on the same day of each month.

What are the common types of breast cancer?
The most common types of breast cancer are:

• Infiltrating (invasive) ductal carcinoma. This cancer starts in the milk ducts of the breast. It then breaks through the wall of the duct and invades the surrounding tissue in the breast. This is the most common form of breast cancer, accounting for 80% of cases.
• Ductal carcinoma in situ is ductal carcinoma in its earliest stage (stage 0). In situ refers to the fact that the cancer hasn't spread beyond its point of origin. In this case, the disease is confined to the milk ducts and has not invaded nearby breast tissue. If untreated, ductal carcinoma in situ may become invasive cancer. It is almost always curable.
• Infiltrating (invasive) lobular carcinoma. This cancer begins in the lobules of the breast where breast milk is produced, but has spread to surrounding tissues or the rest of the body. It accounts for 10% to 15% of breast cancers. This cancer can be more difficult to diagnose with mammograms.
• Lobular carcinoma in situ is a marker for cancer that is only in the lobules of the breast. It isn't a true cancer, but serves as a marker for the increased risk of developing breast cancer later, possibly in both or either breasts. Thus, it is important for women with lobular carcinoma in situ to have regular clinical breast exams and mammograms.

Cancers can also form in other parts of the breast but are less common.

What are the stages of breast cancer?
Stage 0 breast cancer is when the disease is localized to the milk ducts (carcinoma in situ).

Stage I breast cancer: The cancer is smaller than 1-inch across and hasn't spread anywhere.

Stage II breast cancer is one of the following:

• The tumour is less than an inch across but has spread to the underarm lymph nodes (IIA); or
• The tumour is between 1 and 2 inches (with or without spread to the lymph nodes); or
• The tumour is larger than 2 inches and has not spread to the lymph nodes under the arm (both IIB).

Advanced breast cancer (metastatic) results after cancer cells spread to the lymph nodes and to other parts of the body.

Stage III breast cancer is also called "locally advanced breast cancer." The tumour is larger than 2 inches and has spread to the lymph nodes under the arm, or a tumour that is any size with cancerous lymph nodes that adhere to one another or to surrounding tissue (IIIA).

Stage IIIB breast cancer is a tumour of any size that has spread to the skin, chest wall, or internal mammary lymph nodes (located beneath the breast and inside the chest).

Stage IV breast cancer is defined as a tumour, regardless of size, that has spread to areas away from the breast, such as bones, lungs, or liver.

How is breast cancer diagnosed?
During your regular physical examination, your doctor will take a thorough personal and family medical history. He or she will also perform and/or order one or more of the following:

• Breast examination: During the breast exam, the doctor will carefully feel the lump and the tissue around it. Breast cancer usually feels different (in size, texture, and movement) than benign lumps.
• Mammography: An X-ray test of the breast can give important information about a breast lump.
• Digital mammography: A technique in which an X-ray image of the breast is digitally recorded into a computer rather than on a film. This may be better for women with dense breasts.
• Ultrasonography: This test uses sound waves to detect the character of a breast lump -- whether it is a fluid-filled cyst (not cancerous) or a solid mass (which may or may not be cancerous). This may be performed along with the mammogram.

Based on the results of these tests, your doctor may or may not request a biopsy test to get a sample of the breast mass cells or tissue. Biopsies are performed using surgery or needles.

After the sample is removed, it is sent to a lab for testing. A pathologist -- a doctor who specializes in diagnosing abnormal tissue changes -- views the sample under a microscope and looks for abnormal cell shapes or growth patterns. When cancer is present, the pathologist can tell what kind of cancer it is (ductal or lobular carcinoma) and whether it has spread beyond the ducts or lobules (invasive).

Laboratory tests, such as hormone receptor tests (oestrogen and progesterone) and human epidermal growth factor receptor (HER2/neu), can show whether hormones or growth factors are helping the cancer grow. If the test results show that they are (a positive test), the cancer is likely to respond to hormonal treatment or antibody treatment. These therapies deprive the cancer of the oestrogen hormone or use a monoclonal antibody known as herceptin to treat the cancer.

Breast cancer diagnosis and treatment are best accomplished by a team of experts working together with the patient. Each patient needs to evaluate the advantages and limitations of each type of treatment and work with her team of physicians to develop the best approach.

Other diagnostic tests
Other methods being investigated include:

• Scintimammography: A technique in which radioactive contrast agents are injected into a vein in the arm. An image of the breast is taken with a special camera, which detects the radiation (gamma rays) emitted by the dye. Tumor cells, which contain more blood vessels than benign tissue, collect more of the dye and project a brighter image.
• Positron emission tomography (PET) scanning: A technique that measures a signal from injected radioactive tracers that migrate to the rapidly dividing cancer cells. The PET scanner picks up the signal and creates an image.
• Magnetic resonance imaging (MRI): A test that produces very clear pictures, or images, of the human body without the use of X-rays. MRI uses a large magnet, radio waves, and a computer to produce these images.
• Scientists are also exploring ways to detect breast cancer or markers of cancer in the blood, urine, and in fluid taken from the nipple.

How is breast cancer treated?
If the tests find cancer, you and your doctor will develop a treatment plan to eradicate the breast cancer, to reduce the chance of cancer returning in the breast, as well as to reduce the chance of the cancer travelling to a location outside of the breast. Treatment generally follows within a few weeks after the diagnosis.

The type of treatment recommended will depend on the size and location of the tumour in the breast, the results of lab tests done on the cancer cells, and the stage, or extent, of the disease. Your doctor will usually consider your age and general health as well as your feelings about the treatment options.

Breast cancer treatments are local or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area, such as the breast. Surgery and radiation treatment are local treatments. Systemic treatments are used to destroy or control cancer cells all over the body. Chemotherapy and hormone therapy are systemic treatments. A patient may have just one form of treatment or a combination, depending on her needs.

Surgery: Breast conservation surgery involves removing the cancerous portion of the breast and an area of normal tissue surrounding the cancer, while striving to preserve the normal appearance of the breast. This procedure has often been called a lumpectomy, which is a partial mastectomy. Some of the lymph nodes under the arm are also removed. Usually, six weeks of radiation therapy is then used to treat the remaining breast tissue. Most women who have a small, early-stage tumour are excellent candidates for this approach.

Mastectomy (removal of the entire breast) is another option. The mastectomy procedures performed today are not the same as the older, radical mastectomies. Radical mastectomies were extensive procedures that involved removing the breast tissue, skin, and chest-wall muscles. Today, mastectomy procedures do not ordinarily remove muscles and, for many women, mastectomies are accompanied by either immediate or delayed breast reconstruction.

What happens after treatment?
Following local breast cancer treatment, the treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with the surgeon, may advise the use of the drugs like tamoxifen or anastrozole (ARIMIDEX®) or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

Does a benign breast condition mean that I have a higher risk of getting breast cancer?
Benign breast conditions rarely increase your risk of breast cancer. Some women have biopsies that show a condition called hyperplasia (excessive cell growth). This condition increases your risk only slightly.

When the biopsy shows hyperplasia and abnormal cells, which is a condition called atypical hyperplasia, your risk of breast cancer increases somewhat more. Atypical hyperplasia occurs in about 5% of benign breast biopsies.

How can I protect myself from breast cancer?
Follow these three steps for early detection:

• Get a mammogram. The American Cancer Society recommends having a baseline mammogram at age 35, and a screening mammogram every year after age 40. Mammograms are an important part of your health history. Recently, the US Preventive Services Task Force (USPTF) came out with new recommendations regarding when and how often one should have mammograms. These include starting at age 50 and having them every two years. We do not agree with this, but we are in agreement with the American Cancer Society and have not changed our guidelines, which recommend yearly mammograms starting at age 40.
• Examine your breasts each month after age 20. You will become familiar with the contours and feel of your breasts and will be more alert to changes.
• Have your breast examined by a healthcare provider at least once every three years after age 20, and every year after age 40. Clinical breast exams can detect lumps that may not be detected by mammogram.

Anatomy Of The Breast

Each breast has 15 to 20 sections, or lobes, that surround the nipple, like spokes on a wheel. Inside these lobes are smaller lobes, called lobules. At the end of each lobule are tiny "bulbs" that produce milk. These structures are linked together by small tubes called ducts, which carry milk to the nipples. The nipple is in the centre of a dark area of skin called the areola. The areola contains small glands that lubricate the nipple during breastfeeding. Fat fills the spaces between the lobes and ducts. There are no muscles in the breasts, but muscles lie under each breast and cover the ribs.

Each breast also contains blood vessels and vessels that transport lymph. Lymph is a fluid that travels through the lymphatic system and carries cells that help the body fight infections. The lymph vessels lead to the lymph nodes (small, bean-shaped glands that are part of the infection-fighting lymphatic system). A group of lymph nodes are located in the armpits, above the collarbone, and in the chest. If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body.

Lymph nodes are also found in many other parts of the body.

Breast development and function depend on the hormones oestrogen and progesterone, which are produced in the ovaries. Oestrogen elongates the ducts and causes them to create side branches. Progesterone increases the number and size of the lobules in order to prepare the breast for nourishing a baby. After ovulation, progesterone makes the breast cells grow, and blood vessels enlarge and fill with blood. At this time, the breasts often become engorged with fluid and may be tender and swollen.

Breast Cancer – Prevention

Screening for breast cancer
There is no doubt that the best chance for curing breast cancer is through early detection. Early detection relies on a program of screening, which involves breast self-examination (BSE), clinical breast examination, and mammography.

Women who have not had any breast problems should probably have their first baseline, mammography examination at age 35. After that, they should follow this general screening schedule:

• Women ages 40 and over, a mammogram every year.

Mammograms are the standard of care to detect breast cancer before it can be felt during a breast examination. Research has shown that mammograms can increase breast cancer survival. However, not all breast cancers can be detected on mammography. This is especially true for younger women who have denser breast tissue. Thus, it is important to include a breast examination (by BSE and an examination by a doctor or nurse) as part of the screening process.

Recognising normal, hormonal changes
Breast physical examinations can be very challenging. Breast tissue changes during a woman's entire life. It is particularly sensitive to oestrogen and progesterone hormone influences.

In some women, changes in hormone balances during normal, monthly cycling can create symptomatic breast changes that are referred to as "fibrocystic change." This is a general term that consists of a number of different findings, including breast swelling, tenderness, pain, nodularity (tissue resembling or containing small nodes), thickening, lumps, and masses.

Fibrocystic changes can occur in one or both breasts. The changes are often prominent during a woman's 40s. It is relatively uncommon for postmenopausal women to have symptomatic breast changes due to a lack of hormone stimulation of the breast tissue.

Detecting breast cancer through self-examination
Many women are anxious about practicing breast self-examination. They wonder what is normal and what is not normal. The best way for a woman to become familiar with her breast tissue is to practice BSE regularly.

Breast self-examination should be performed at the same time each month. For premenopausal women, the best time is usually 3-5 days after the end of a menstrual period. Over time, women who practice BSE become familiar with how their breast tissue changes from month to month. This can help them to be more alert to any changes that are not normal.

Conditions that should be checked by a physician include:

• An area that is distinctly different from any other area on either breast
• A new fullness or thickening that persists through one's menstrual cycle
• A mass or a lump, which may feel as small as a pea
• A marble-like area under the skin
• Any changes in the skin, nipple, or contour of the breast
• Bloody or clear discharge (fluid) from the nipple

Fortunately, the majority of breast lumps are non-cancerous.

Diagnosing
Breast cancer is diagnosed by taking a sample of cells or tissue from an abnormality found during breast examination or by mammography. These procedures are called breast biopsies. Cells from breast tissue are obtained by a form of breast biopsy called fine needle aspiration (FNA). Breast tissue is obtained using a surgical procedure that takes a core of tissue or by removing a larger portion of tissue. For abnormalities identified by mammography (termed non-palpable abnormalities), the stereotactic breast biopsy is used. This technique samples but does not remove the tissue.

Cells or tissues that are removed are given to a pathologist, a physician who specializes in diagnosing abnormal changes in tissue. Pathologists have years of advanced training in determining which cells and tissue are derived from breast cancer.

Treating breast cancer
If breast cancer is diagnosed, treatment plans are made to reduce the chance of the cancer returning in the breast or traveling to a location outside of the breast. Treatment of the breast itself can be done by one of two methods. The first method is called breast conservation. If breast conservation therapy is not used, then mastectomy (removal of the breast) is another option.

• Breast conservation strives to preserve the normal appearance of the breast. It consists of removing the cancer portion of the breast and an area of normal tissue surrounding the cancer. This procedure has often been called a lumpectomy, a partial mastectomy, or a quadrantectomy. Some of the lymph nodes under the arm are also removed. Usually, six weeks of radiation therapy is then used to treat the remaining breast tissue. Most women who have a small, early stage breast cancer are excellent candidates for this approach.
• The mastectomy procedures performed today are not the same as the older, radical mastectomies. Radical mastectomies were extensive procedures that involved removing the breast tissue, skin, and chest-wall muscles. Today, mastectomy procedures do not ordinarily remove muscles and, for many women, mastectomies are accompanied by either immediate or delayed breast reconstruction.

Breast reconstruction can be done either by using an artificial breast implant or by using the patient's own tissue, which is usually taken from the lower abdomen. The second method is called transverse rectus abdominus myocutaneous flap reconstruction or TRAM reconstruction.

Following local breast cancer treatment, the treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with the surgeon, may advise the use of tamoxifen, an aromatase inhibitor or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

Breast cancer diagnosis and treatment are best accomplished by a team of experts working together with the patient. Each patient needs to evaluate the advantages and limitations of each type of treatment, and work with her team of physicians to develop the best approach.

Breast Cancer – Risk Factors

More than ever before, women are taking an active part in their breast health. At the centre of this change is our growing concern and understanding of breast cancer, the second most common form of cancer among women in the Africa.

What is breast cancer?
Cells in the body normally divide (reproduce) only when new cells are needed. Sometimes cells will divide for no reason, creating a mass of tissue called a tumour. Tumours can be benign (not cancerous) or malignant (cancerous).

In breast cancer, as well as in some other cancers, a tissue cell becomes abnormal and reproduces without control or order, forming a malignant tumour. Cancer cells can break off from the tumour, travel to other parts of the body, and form new tumours. This process is called metastasis. Metastasis is a late stage of cancer.

Am I at risk for developing breast cancer?
If you are a woman, you are at risk. (Men can also develop breast cancer, but this is rare.) You may be more likely to develop breast cancer if you have one or more risk factors, but risk factors do not cause breast cancer. However, not having a risk factor does not mean that you will not get breast cancer.

In many cases, it's not known why a woman develops breast cancer. In fact, 70% of all women with breast cancer have no known risk factor.

What are the risk factors of breast cancer?
A risk factor is anything that increases a person’s chance of getting a disease. Different cancers have different risk factors:

Significantly higher risk
History of previous cancer in one breast, especially if it occurred before menopause, increases a woman’s risk of developing a new breast cancer unrelated to the first one. This is different than a recurrence of the previous breast cancer.

Genetics also plays a role. Carriers of either of two familial breast cancer genes called BRCA1 or BRCA2 are at higher risk. Ten percent of women are carriers of these genes. Also, 10% of all breast cancers are thought to be from either gene. In addition, the risk of getting breast cancer is up to 85% in a woman’s lifetime if she has inherited these genes.

Moderately higher risk

• Getting older. Your risk for breast cancer increases as you age. About 77% of women diagnosed with breast cancer each year are over age 50, and almost half are age 65 and older. Consider this: In women 40 to 49 years of age, there is a one in 66 risk of developing breast cancer. In the 50 to 59 age group, that risk increases to one in 40.
• Direct family history. Having a mother, sister, or daughter (a "first-degree relative") who has breast cancer puts you at higher risk for the disease. The risk is even greater if your relative developed breast cancer before menopause and had cancer in both breasts. Having one first-degree relative with breast cancer approximately doubles a woman’s risk. Having two first-degree relatives with breast cancer increases her risk five-fold. Having a male blood relative with breast cancer may also increase a woman’s risk of the disease.
• Breast lesions. These include multiple papillomatosis, atypical ductal hyperplasia, and lobular carcinoma in situ.

Slightly higher risk

• Distant family history. This refers to breast cancer in more distant relatives such as aunts, grandmothers, and cousins.
• Large cysts in the breast. Large cysts increase your risk, especially if accompanied by early atypical hyperplasia (abnormal cell changes in the breast). A previous breast biopsy result of atypical hyperplasia increases a woman’s breast cancer risk by four to five times.
• Age at childbirth. Having your first child after age 30 or never having children puts you at higher risk.
• Early menstruation. Your risk increases if you got your period before age 12.
• Late menopause. If you begin menopause after age 55, your risk increases.
• Weight. Being overweight (especially in the upper body), with excess caloric and fat intake, increases your risk, especially after menopause.
• Excessive radiation. This is especially true for women who were given radiation for postpartum mastitis, received prolonged fluoroscopic X-rays for tuberculosis, or who were exposed to a large amount of radiation before age 30 (usually as a treatment for cancers such as lymphoma or Hodgkin’s disease).
• Other cancer in the family. A family history of cancer of the ovaries, cervix, uterus, or colon increases your risk.
• Heritage. Female descendents of Eastern and Central European Jews (Ashkenazi) are at increased risk.
• Race. Breast cancer occurs more frequently in Caucasian women than in Hispanic, Asian, or African-American women.
• Alcohol. The use of alcohol is linked to increased risk of developing breast cancer. Compared with nondrinkers, women who consume one alcoholic drink a day have a 10% increase in risk, and those who have two or three drinks daily have about 20% to 30% higher risk than women who drink no alcohol. Alcohol is also known to increase the risk of developing cancers of the mouth, throat, and esophagus.
• Hormone replacement therapy. Combination estrogen-progestin hormones taken during menopause increase a woman’s risk of developing breast cancer by 26%. This risk increases with longer use of hormones.

Low risk

• Pregnancy before age 18
• Early onset of menopause
• Surgical removal of the ovaries before age 40

Factors not related to breast cancer

• Fibrocystic breast changes
• Multiple pregnancies
• Coffee or caffeine intake
• Antiperspirants
• Underwire bras
• Abortion
• Breast implants

There are other factors that may affect your risk for breast cancer, but medical research has not yet determined the exact role they play. One of these is long-term use of birth control pills. Scientists are also investigating whether smoking, high-fat diets, lack of exercise, and environmental pollution increase breast cancer risk.

How can I protect myself from breast cancer?

• Get a mammogram:
• Baseline mammogram at age 35
• First mammogram by age 40
• Ages 40 and over: every year
• Examine your breasts each month.
• Have your breasts examined by a health care provider at least once a year.

Breast Cancer – Diagnosis

In 1940, the lifetime risk (to age 85) of a woman developing breast cancer in 1940 was 5%, or 1 in 20. Today, nearly 65 years later, the risk is 12.6%, or 1 in 8. In women 40 to 49 years of age, there is a 1 in 66 risk of developing breast cancer compared with a 1 in 40 risk among women in the 50- to 59-year age group. While these facts may sound disheartening, innovations in the diagnosis and treatment of breast cancer offer hope for those affected by this disease.

What are some advances in the diagnosis of breast cancer?
While mammography is still the primary method for diagnosing breast cancer, technologies such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans are finding some cancers missed by mammograms. In addition, microarray technology shows promise for predicting the growth potential of cancerous tumours.

What is magnetic resonance imaging?
Magnetic resonance imaging (MRI) is a test that produces very clear pictures, or images, of the human body without the use of X-rays. MRI uses a large magnet, radio waves and a computer to produce these images.

How is MRI used in diagnosing breast cancer?
MRI may be used to distinguish between benign (non-cancerous) and malignant lesions, which can reduce the need for breast biopsies. Although MRI can detect tumours in dense breast tissue, it can't detect microcalcifications (tiny specs of calcium), which account for one-half of the cancers detected by mammography.

What is a PET scan?
A positron emission tomography (PET) scan is a unique type of imaging test that helps doctors see how the organs and tissues inside your body are actually functioning.

The test involves injecting a very small dose of a radioactive chemical, called a radiotracer, into the vein of your arm. The tracer travels through the body and is absorbed by the organs and tissues being studied. Next, you will be asked to lie down on a flat examination table that is moved into the centre of a PET scanner. This machine detects and records the energy given off by the tracer substance. With the aid of a computer, this energy is converted into three-dimensional pictures. A physician can then look at cross-sectional images of the body organ from any angle in order to detect any functional problems.

How does PET detect breast cancer?
Because of their high rate of metabolism, cancer cells absorb high amounts of the radioactive tracer. After the tracer is absorbed, PET scans create an image of the breast, and the scan computes the rate at which the tumour is using the tracer.

How is a PET scan different from an MRI scan?
One of the main differences between PET scans and other imaging tests like MRI scans is that the PET scan reveals the cellular level metabolic changes occurring in an organ or tissue. This is important and unique because disease processes often begin with functional changes at the cellular level. A PET scan can often detect these very early changes whereas an MRI detects changes a little later as the disease begins to cause changes in the structure of organs or tissues.

What is microarray technology?
Microarray technology is a way of studying how thousands of genes interact with each other and how a cell's regulatory networks control these genes at one time. The proper expression of genes is vital for maintaining health, as well as for normal growth and development. Disruptions or changes in gene expression are responsible for many diseases.

What is “gene expression”?
The term "gene expression" describes the how information contained within a person's DNA is copied into messenger RNA molecules. These molecules are then translated into the proteins that perform critical cell functions.

How does microarray technology assist in diagnosing cancer?
Although this technology is still in its infancy, studies have shown that microarray technology can be used to measure the activity of many tumour genes simultaneously. Based on the activity of these genes, the test can predict the aggressiveness of tumours and also aid physicians in determining which patients may need follow-up chemotherapy, and which do not.

What are some new treatment options for breast cancer?
Herceptin® (generic name: trastuzumab), is a monoclonal antibody designed to attack specific cancer cells.

Herceptin targets cancer cells that "overexerts," or make too much of a protein called HER-2 or erb B2, which is found on the surface of cancer cells. Herceptin slows or stops the growth of these cells. Herceptin is used only to treat cancers that overexert HER-2 protein.

This protein acts as a receptor on the outer walls of cells. When stimulated by growth factors, an excess of HER-2 receptors can cause the cells to replicate, divide and grow uncontrollably.

Approximately 25 to 30 percent of breast cancers overexert HER-2. These tumours tend to grow faster and are generally more likely to recur than tumours that do not overproduce HER-2.

How is this drug given?
Herceptin is injected directly into your vein through an IV (intravenously) and must be administered by a health care provider. For the first treatment, the dose you receive will be twice the normal dose and will be infused slowly for about 90 minutes.

Breast Cancer – Care & Treatment

The GIH Breast Program is unique because it follows the GIH’s multidisciplinary approach to medical care. The program serves as a model—an excellent example of how teams of specialists from all disciplines can work together for the good of the patient.

There is no other place in the Africa like GIH and no better place to receive care. Our team approach is unique, and serves as the very fibre of GIH. We are a national resource and a driving force of medicine in this part of the country. Our structure allows us to offer world-class care and research.

• X-Ray