MDT or Multidisciplinary team management involves a 360-degree assessment of the patient clinical condition and involves the medical, surgical and radiation oncology specialities apart from the radiology, oncopathology, physiotherapy and palliative care units. The best multimodality treatment options for the patient are decided upon the inputs from these specialities to provide the best treatment plan for the patient.

Approximately 80 percent of women who develop breast cancer have no known risk factor. Some risk factors make women more prone to developing breast cancer and this is associated with prolonged exposure to the hormone oestrogen. However, one must keep in mind that just because one or two of these factors may be present, it does not necessarily mean that this is the cause for the cancer

• Early menarche
• Late menopause
• No pregnancies
• Late first childbirth
• Lack of breastfeeding
• Use of OCP (oral contraceptive pills) or HRT ( hormone replacement therapy)
• Obesity

Nearly 5 percent of breast cancers are genetic and have a strong family history of cancers. Certain genetic mutations like BRCA, P53, can increase the risk of getting cancer.

The presentation of breast cancer can be varied. The following symptoms should raise awareness and one must see a doctor for the same

• New-onset change in the size of one breast
• Lump in the breast
• Skin thickening or ulceration
• Redness in the breast
• Nipple discharge
• Nipple inversion
• Puckering or dimpling, particularly while raising the arms above the head
• Lump in the underarm area
• Any new or unusual change in the breast.

In Western countries, owing to the higher incidence of breast cancer, screening strategies are employed. By this, all patients above the age of 40 years are advised to have a mammogram either yearly or once in two years.

In India, while a formal screening programme does not exist, it is advisable for adults above the age of 40 years, especially those with a family history of breast cancer, to get themselves tested with a baseline mammogram and then a decision of how frequently it needs to be done can be discussed on a case-by-case basis with your doctor.

The best investigations to help diagnose breast cancer is a mammogram combined with an ultrasound. A mammogram is an x-ray of the breast and the breast is flattened in different positions between two plates for compression. An ultrasound of the breast is many times done in addition to the mammogram and is a painless procedure which not have any radiation. Some jelly is placed on the breast a probe is used to visualize all areas of the breast systematically.

If there is an abnormality or lesion detected in one of these reports, then it is recommended to undergo a core needle biopsy. This helps to confirm as to whether the lump is cancerous or not. It is a small procedure that takes less than 5-10 minutes and is done under local anaesthesia. A small needle is used to get tissue from the lump that can then be sent to the pathologist for testing. The report usually takes a couple of days and hormone receptor testing (including ER/PR/ Her 2) can be done on this sample to give us more information regarding the tumour.

Depending on the stage of the disease, a PET CT may be asked to check for a spread of cancer to other parts of the body.

If an operation is being planned, some more tests may be necessary to decide the fitness of the patient for general anaesthesia.

Breast cancer is the commonest in the 40-70-year age bracket, however, it is known to occur in women in their teens as well as in women older than 70 years.

Breast cancer starts as an uncontrolled division of cells which then increases in number to form a tumour/lump. Each cell of the body carries a “program “inside its nucleus in the form of DNA. One or more mutations in the DNA, a cell may become trigger this uncontrolled growth.

By the time a breast lump becomes palpable, it has been present in the body for several years. However, lumps can be detected before they become palpable, by screening normal women using a mammogram, which is a soft X-ray of the breast.

Cancer can spread locally to infiltrate the skin or the muscles of the chest. Also, it can spread to glands that lie in the armpit, above the collar bone and behind the breast bone. It can also spread to other organs; the common organs that breast cancer metastasizes to i.e. spreads to are liver, lungs, bones and brain.

The stages of breast cancer can broadly be divided into 4 based on the extent of the lump in the breast, the involvement of the glands that the breast drains into, as well as the presence of disease outside the breast.

Stage I: A small lump with no disease elsewhere except for tiny deposits in the glands in the armpit. In this stage, there is an excellent chance of long-term control subject to the grade of the lesion.

Stage II: In this stage, the patient has either a small cancerous lump with a few affected glands or a large lump with no affected glands. Patients with stage II breast cancer have an excellent chance of cure.

Stage III: Implies the presence of a large lump with affected glands in or the presence of 4 or more involved glands in the underarm.

Stage IV: Indicates advanced disease, such as infiltration of the skin, chest wall, or involvement of glands in the armpit and also centrally. Spread of disease to other distant organs is also termed stage IV cancer.

Ductal carcinoma in situ (DCIS): most common precursor stage of breast cancer that means it is localised and do not spread to nodes or distant sites. It is usually asymptomatic but may present as a swelling. 30 -50% of DCIS can develop into invasive breast cancer later. Tamoxifen 5mg daily for 3 years have shown to reduce the chances of developing invasive cancers.

Inflammatory breast cancer:
Inflammatory breast cancer is a rare and very aggressive disease in which cancer cells block lymph vessels in the skin of the breast. This type of breast cancer is called “inflammatory” because the breast often looks swollen and red, or inflamed.

Inflammatory breast cancer is rare, accounting for 1 to 5 per cent of all breast cancers. Most inflammatory breast cancers are invasive ductal carcinomas, which means they developed from cells that line the milk ducts of the breast and then spread beyond the ducts.

Invasive lobular carcinoma: a type of breast cancer that originates in the milk-producing glands (lobules) of the breast. They have the potential to spread to the lymph nodes and other areas of the body. Usually, they occur in later ages (above 60yrs). They are rare when compared to the invasive ductal carcinoma. They are mostly oestrogen receptor (ER) and progesterone receptor (PR) positive and HER2 negative.

Lobular carcinoma in situ (LCIS: is a type of breast changes that seen when a breast biopsy is done and is considered as precursor lesions for Invasive Lobular Carcinoma. In LCIS, cells that look like cancer cells are growing in the lining of the milk-producing glands of the breast (called the lobules), but they don't invade through the wall of the lobules. They are usually removed with an amount of normal breast tissue around (Lumpectomy). In the case of high-risk lesions, preventive mastectomy also may be done.

Male breast cancer:
Rare cancer with less than 1 % of all breast cancers and incidence in males in 0.1%. Usually presents as hard lump below the nipple-areola and usually the treatment for localised disease is mastectomy followed by systemic therapy like chemotherapy, hormonal therapy (Tamoxifen) and local radiation. The major risk factors for the development of male breast cancer include advancing age, hormonal imbalance, radiation exposure, and a family history of breast cancer. BRCA2 mutation also increases the risk for male breast cancer

Paget's disease of the breast; Paget's disease of the nipple, also known as Paget's disease of the breast presents as eczema-like changes to the skin of the nipple and the area of darker skin surrounding the nipple (areola). It's usually is associated with breast cancer in the tissue behind the nipple and is rare. Paget's disease of the breast occurs most often in women older than age 50. Most women with Paget's disease of the breast have underlying ductal breast cancer or less commonly, invasive breast cancer. Only in rare cases is Paget's disease of the breast confined to the nipple itself. It causes oozing, itching, redness and sometimes ulcers on the nipple-areola complex. The disease stage of underlying breast cancer decides on the management and usually involves surgery, radiation hormonal therapy and chemotherapy

Triple-negative breast cancer: TNBC constitutes 10-15% and is a specific subtype of breast cancer that behaves aggressively when compared to the other subtypes like hormone-positive or Her 2 positive. In these cancers, the oestrogen receptor, progesterone receptor and Her2 receptor are absent. They are mostly associated with BRCA gene mutation but can exist without mutation also. They are usually seen in young females and those with family history. The treatment includes surgery, radiation therapy and chemotherapy in early and locally advanced stages. In metastatic breast cancer, chemotherapy is the preferred treatment. Immunotherapy also has shown to have effects in TNBC.

Breast cancer in young women: Around 10-15% of all breast cancers occur in less than 45yrs of age and is considered separately as they have different biological behaviour. The risk factors include a family history of breast cancer, history of radiation in the childhood or adolescence etc. The management also includes special concerns like psychological impact, fertility issues etc. apart from surgery, chemotherapy, endocrine therapy, radiation therapy

Inherited breast cancer: BRCA1 and BRCA2: They constitute less than 15% of all breast cancers. The most common cause of hereditary breast cancer is an inherited mutation in the BRCA1 or BRCA2 gene. In normal cells, these genes help make proteins that repair damaged DNA. Mutated versions of these genes can lead to abnormal cell growth, which can lead to cancer. They are also associated with increased risk of developing uterine cancer, ovarian cancer, gastric cancer etc. The other conditions associated include hereditary diffuse gastric syndrome, Li Fraumeni syndrome etc.

Non-cancerous breast condition:
Only 1 of 10 breast lumps is cancerous. Mostly in premenopausal and perimenopausal females, there are soft to firm breast lumps which especially get noticed during the menstrual cycles called fibroadenomas. They usually resolve after menopause and don’t need any treatment apart from reassurance. Other conditions include fibrocystic disease, papilloma etc.

Metastatic Breast cancer:
Breast cancer which has spread from the involved breast to sites like lung, bone, brain, liver or any other distant part of the body is called metastatic breast cancer (MBC). They usually are seen in 5-25% cases in India due to the absence of early detection by screening. They are unlikely to be cured. However, based on the biological characteristics of breast cancer, survival varies among different types of MBC. There is no role for surgery in MBC except when there is ulcerated disease causing pain/discharge etc. The main treatment in MBC includes chemotherapy, targeted therapy (anti-HER2) and endocrine therapy based on the immunohistochemistry of the disease.

Angiosarcoma: is a rare soft tissue tumour of the breast. It occurs in both a primary form without a known precursor and a secondary form that has been associated with a history of irradiated breast tissue.