Breast cancer is a significant health concern in Australia, but it is also an area where medical advances have dramatically improved outcomes. This guide aims to provide you with detailed information about breast cancer, from understanding its basics to navigating the complex treatment landscape. Knowledge is a powerful tool, and we hope this empowers you in your journey.

Breast Cancer in Australia: The Facts

• Other than skin cancer, breast cancer is the most commonly diagnosed cancer in women in Australia.

• Approximately 1 in 8 women will be diagnosed with breast cancer by the age of 85.

• While it is most common in women over 50, younger women and, in rare cases, men can also develop breast cancer (Dr Cheah has seen and treated a handful in his 20 years experience as a consultant)

• The average age of first diagnosis is 61 years old.

• Crucially, survival rates are higher than ever. Thanks to advances in screening and treatment, the 5-year relative survival rate for women diagnosed with breast cancer is now over 90%. This means most women diagnosed and treated go on to live long, healthy lives.

Symptoms

Being aware of changes in your breasts is the first step in early detection. Symptoms can vary, and some people may have no symptoms at all, with cancer detected first on a screening mammogram.

Common signs and symptoms include:

• A new lump or thickening in the breast or armpit.

• A change in the size, shape, or appearance of the breast.

• Dimpling, puckering, or redness of the breast skin (like an orange peel).

• A change in the nipple, such as inversion (pulling inward), redness, scaling, or discharge (which may be clear, bloody, or another colour).

• Persistent, unusual pain in the breast or armpit.

Important Note: Many of these symptoms can be caused by benign (non-cancerous) conditions. However, it is essential to see your doctor promptly for any persistent or concerning changes.

The Diagnostic Process: Triple Assessment

If you have a symptom or an abnormal screening mammogram, your doctor will recommend a "Triple Assessment." This three-pronged approach provides a highly accurate diagnosis.

1. Clinical Examination: An experienced healthcare professional (like Dr Cheah) will physically examine your breasts and lymph nodes in your armpits and neck.

2. Imaging:

   • Diagnostic Mammogram: This is a detailed X-ray of the breast. It provides high-resolution images to locate and assess the size of any abnormalities.

   • Breast Ultrasound: Sound waves are used to create an image of the breast tissue. It is particularly useful for distinguishing between solid masses (which may be cancer) and fluid-filled cysts (which are usually benign). Ultrasound is also used to guide biopsies.

   • MRI (Magnetic Resonance Imaging): In some cases, such as for women with a high genetic risk or with very dense breast tissue, an MRI may be used to get a more detailed picture.

3. Pathology (Biopsy): This is the only way to confirm a cancer diagnosis. A small sample of tissue is taken from the suspicious area and examined under a microscope by a pathologist.

   • Core Biopsy: The most common type, using a slightly larger needle to remove a small cylinder of tissue. This is the preferred method as it provides more detailed information about the cancer's type and grade.

   • Fine Needle Aspiration (FNA): A thin needle is used to extract cells. This is less invasive but can be less definitive than a core biopsy.

   • Vacuum-Assisted Biopsy: A minimally invasive procedure that removes more tissue than a core biopsy, often used for smaller or harder-to-reach lesions.

Understanding Your Diagnosis: The Pathology Report

Your biopsy results will provide critical information that guides your treatment plan. Key terms you will hear include:

• Cancer Type: Whether it is in situ (contained within the milk ducts) or invasive (has the potential to spread outside the breast).

• Tumour Grade (1-3): How abnormal the cancer cells look. Grade 1 (low grade) cells are slow-growing, while Grade 3 (high grade) cells are faster-growing and more aggressive.

• Receptor Status: This tests the cancer cells for specific proteins that fuel their growth.

  • Hormone Receptor-Positive (ER+/PR+): The cancer grows in response to the hormones estrogen or progesterone. This is common and can be treated with hormone-blocking therapy.

  • HER2-Positive: The cancer makes too much of a protein called HER2, which promotes growth. There are very effective targeted therapies for this type.

  • Triple-Negative: The cancer is negative for estrogen, progesterone, and HER2. This type can be more aggressive but is often very responsive to chemotherapy.

A Detailed Overview of Treatment Options

Treatment is highly personalised and often involves a combination of therapies (multimodal therapy). Your team will create a plan based on your cancer's stage, type, grade, receptor status, your age, and your overall health.

1. Surgery (Local Treatment)
The goal of surgery is to remove the cancer from the breast.

• Breast-Conserving Surgery (Lumpectomy or Wide Local Excision): Only the tumour and a small margin of surrounding healthy tissue are removed. This is almost always followed by radiotherapy to the remaining breast tissue to eliminate any microscopic cancer cells. The reoperation rate (if clear margins are not achieved the first time) is about 20%.

• Mastectomy: The entire breast tissue is removed. This may be recommended for larger tumours, multiple tumours, or patient preference. Options include:

  • Simple Mastectomy: Removal of breast tissue only.

  • Skin-Sparing/Nipple-Sparing Mastectomy: These techniques preserve the breast skin and/or nipple for a more natural appearance during immediate reconstruction.

• Breast Reconstruction: Can be performed at the same time as mastectomy (immediate) or later (delayed). Options include:

  • Implant-Based Reconstruction: Using saline or silicone implants.

  • Autologous or Flap Reconstruction: Using your own tissue (e.g., from the abdomen, back, or buttocks) to create a new breast. (e.g., DIEP flap, TRAM flap).

• Lymph Node Surgery:
  The aim is to see if the cancer has spread beyond the breast, which is a key factor in staging and planning further treatment.

  • Sentinel Lymph Node Biopsy (SLNB): This is the standard procedure for patients with no obvious lymph node involvement. A radioactive tracer and/or a blue dye is injected near the tumour. These substances travel to the "sentinel" nodes—the first few lymph nodes that drain the breast. The surgeon uses a gamma probe to locate these nodes and removes only them (typically 1-4 nodes). If these nodes are free of cancer, it is highly likely that the remaining nodes are also clear, avoiding a more extensive dissection. Risks include a small chance of an allergic reaction to the blue dye, seroma (fluid collection), and a very low risk of lymphedema.

  • Targeted Axillary Dissection (TAD): This is an advanced technique increasingly used for patients who have already had a biopsy-proven cancerous lymph node and have received chemotherapy before surgery (neoadjuvant chemotherapy) to shrink the cancer. In TAD:

    1. Before chemotherapy, the cancerous node is marked with a small, harmless metal clip.

    2. After chemotherapy, the surgeon uses the same techniques as an SLNB (radioactive tracer and dye) to find the sentinel nodes.

    3. They also use a radar or magnetic marker system (e.g., Savi Scout®) to locate and remove the clipped node.
       By specifically removing the known cancerous node along with the new sentinel nodes, TAD provides a more accurate assessment of how well the chemotherapy worked. This precision helps to safely minimise the number of nodes removed, significantly reducing the risk of lymphedema compared to a full axillary clearance.

  • Axillary Lymph Node Dissection (ALND): This involves removing most (Level I & II) of the lymph nodes from the armpit. It is now less common but may be necessary if several nodes are known to be cancerous before surgery, or if cancer is found in sentinel nodes after surgery without prior chemotherapy. This procedure carries a much higher risk of side effects, most notably lymphoedema (chronic, often lifelong arm swelling), seroma, nerve damage leading to numbness or pain in the upper arm, and reduced shoulder mobility.

2. Radiotherapy
Uses high-energy rays to destroy cancer cells in a specific area. It is standard after breast-conserving surgery and sometimes after mastectomy if the tumour was large or nodes were involved. A typical course involves daily treatments (Monday-Friday) for 3-6 weeks.

3. Systemic Therapies (Treatments that travel throughout the body)

• Chemotherapy: Uses powerful drugs to destroy fast-growing cancer cells. It can be given:

  • Neoadjuvantly: Before surgery to shrink a large tumour.

  • Adjuvantly: After surgery to kill any remaining cancer cells and reduce the risk of recurrence.

  • Common regimens include AC (Adriamycin [doxorubicin], Cyclophosphamide), TC (Taxotere [docetaxel], Cyclophosphamide).

• Hormone (Endocrine) Therapy: For ER+ or PR+ cancers, these drugs block the body's ability to produce hormones or interfere with hormones' effects on cancer cells.

  • Tamoxifen: For pre- and post-menopausal women.

  • Aromatase Inhibitors (Anastrozole [Arimidex®], Letrozole [Femara®], Exemestane [Aromasin®]): For post-menopausal women.

  • Ovarian Suppression: Using medications (e.g., Goserelin [Zoladex®]) to temporarily stop the ovaries from producing estrogen in pre-menopausal women.

• Targeted Therapy: These drugs specifically target cancer cells, often with fewer side effects on healthy cells. The following are all used and available in Australia:

  • HER2-Targeted Drugs:

    • Trastuzumab (brand name Herceptin®)

    • Pertuzumab (brand name Perjeta®)

    • Trastuzumab emtansine (brand name Kadcyla® or T-DM1)

    • Trastuzumab deruxtecan (brand name Enhertu®)

  • CDK4/6 Inhibitors (used with hormone therapy for advanced ER+ cancers):

    • Palbociclib (brand name Ibrance®)

    • Ribociclib (brand name Kisqali®)

    • Abemaciclib (brand name Verzenio®)

• Immunotherapy: Helps your own immune system recognise and attack cancer cells. The drug Pembrolizumab (brand name Keytruda®) is now used in combination with chemotherapy for certain cases of triple-negative breast cancer.

Ongoing Research and Future Directions

Medical research is constantly evolving. One exciting area of investigation is the use of common medications, like beta-blockers (e.g., Propranolol) and COX-2 inhibitors (e.g., Celecoxib), around the time of surgery. Early studies suggest they may help reduce the risk of metastasis by altering the body's stress response and inflammation, which can affect cancer cell spread.

Prognosis and Living Beyond Cancer

A breast cancer diagnosis is a life-changing event, but it is not a journey you take alone. Your prognosis is influenced by many factors, but the overall outlook in Australia is excellent. A strong support system, including your medical team, family, friends, and support groups, is vital.

Follow-up care is essential for monitoring recovery, managing long-term side effects (like lymphoedema or the effects of hormone therapy), and watching for any signs of recurrence. Many people also find value in seeking emotional and psychological support to process their experience.

Useful Resources and Links

• National Breast Cancer Foundation (NBCF): Australia's leading community-funded organisation for breast cancer research. https://www.nbcf.org.au/

• Breast Cancer Network Australia (BCNA): Provides a network of support and information for those affected by breast cancer. https://www.bcna.org.au/

• Cancer Australia: Provides evidence-based information about cancer prevention, treatment, and care. https://www.canceraustralia.gov.au/

• Lymphoedema Education & Research Network (LEARN): An Australian resource for information on lymphoedema prevention and management. https://www.lymphoedema.org.au/

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