Professor Emeritus of Surgery, UWI
Consultant Surgeon, Medical Associates Hospital
Breast cancer is the commonest cause of death from cancer in Trinidad and Tobago.
In addition, the diagnosis and treatment have major physical, psychological, social, domestic and economic implications. A woman may lose her breast or part of it, have chemo and radiotherapy and have to live through significant alterations in body image associated with breast asymmetry, skin scarring, nail discolouration, hair loss and the psychological sequelae of these and other factors.
Many women become social recluses and limit their previous normal recreational activities.
These implications are more significant in the younger patients. Unfortunately, in T&T, 34% of breast cancers are seen in the under 50 age group.
Thus, apart from the adverse implications mentioned above, the effect on their young children, spousal and family relations, employment and finances can be very serious.
In addition to diagnosis under age 50, about one-third of deaths from breast cancer occur in this age group.
In spite of advances in treatment, there is also an increasing mortality from breast cancer in T&T. While mortality has been decreasing in the developed world (for example, USA, UK, Canada) it is increasing here.
Although genetic factors may play a small part, limitation in early diagnosis and prompt appropriate treatment may be more significant although there is no hard data to establish this.
A major problem here is an overemphasis on mammography. There is much data and sharing significant limitations of mammography especially in the developing world.
In T&T, as many as 20% of women with breast cancer have negative mammograms. Although this may be explained by the large number of younger patients, other factors may be involved.
Data from our National Cancer Registry also document a disproportionate preponderance of the disease among blacks.
Data from the USA and other Caribbean territories suggest that this is likely to be genetic. It is important for women to recognise that breast cancer is painless in over 90% of cases.
Thus, a painless lump could be very significant and should be assessed by a professional, not just a mammogram.
It is also known that the bra is likely to leave a more marked skin impression on the side with breast cancer (bra sign) – so if this is observed, expert help should be sought.
Skin tethering, nipple retraction, alteration in skin appearance and texture, ulceration, axillary mass (under the armpit) are generally later signs and it is hoped that diagnosis will be made before these findings.
Diagnosis involves clinical examination, imaging (Ultrasound, mammogram, CT, MRI) and biopsy. Confirmation by microscopy is essential for diagnosis, planning treatment and assessing prognosis.
Although surgery is an essential part of treatment, chemo, radio and hormone therapy are major determinants of long term recurrence and survival; thus, follow-up treatment, though tedious and time consuming, is essential.