October is "Pink Month", the month that the WHO has designated to raise awareness among citizens of the importance of breast cancer prevention. Breast cancer is in fact the most frequent neoplasm in women in any age group and is the leading cause of death from cancer in women. The WHO estimates that breast cancer cases worldwide are more than 2.3 million per year and that in 95% of countries it is the first or second cause of cancer death in women.

How to prevent breast cancer? What therapies and treatments are currently available? What is the psychological impact of breast cancer? We talk about it in this article with Dr. Pietro Panizza, Radiologist, Head of the Breast Radiology Unit of the San Raffaele Hospital, and with Prof. Valentina Di Mattei, Associate Professor and Specialist in Clinical Psychology at UniSR, Coordinator of the Clinical Health Psychology Service of the IRCCS San Raffaele Hospital and Founder and Manager of the "Health in the Mirror" Program.

Primary and secondary prevention of breast cancer

When talking about breast cancer prevention, a distinction must be made between primary and secondary prevention.

Primary prevention

It is designed to prevent the tumor from manifesting itself and, to date, is fundamentally linked to lifestyle, nutrition and physical activity (rules also valid for the first two causes of death due to illness, i.e. tumors and cardiovascular diseases). It has been widely demonstrated that a healthy lifestyle, with a controlled diet, which limits certain foods such as animal fats, sugars, alcohol and favors fruit, vegetables, whole foods and fish, has a positive influence on reducing the incidence of tumors and specifically breast cancer, which is in fact more widespread in Western societies, i.e. richer ones.

Secondary prevention

It consists of diagnosing the tumor before it can cause damage and is essentially early diagnosis. As regards breast cancer, it has been demonstrated for over 60 years how mammographic screening can have an impact on the history of the disease, reducing mortality. Mammography, which is nothing other than an X-ray of the breast, is the only test that, to date, has shown that it can obtain this result. It has become digital, then 3D-like and now allows images to be acquired with intravenous injection of iodinated contrast medium, the same as CT (computed tomography).

The organized screening programs by the National Health System include an invitation to women to undergo a free mammogram at specialized centres, from 50 to 69 years of age and in some local health authorities from 45 to 74 years of age, annually from 45 to 49 and every two years. from 50 to 74 years old. This program, which involves the evaluation of mammographic images by 2 blind radiologists (double reading), has demonstrated, in women who respond to the invitation and undergo periodic mammography, that it can reduce mortality by up to 40%.

However, a fair percentage of women prefer to undergo a mammogram spontaneously, choosing a center where it can be performed; in this case, checks are recommended starting from the age of 40, at a personalized interval, depending on the type of breast and personal and family history.

Under the age of 40, mammography should not be considered as a screening test because in this age group the effectiveness of this test in reducing mortality has not been demonstrated. It can be considered in particular cases that must be evaluated directly by the Radiologist. Regarding the use of breast ultrasound in young, pre-mammography age women, it has not been scientifically demonstrated that this test, like self-exam, has an impact on mortality. It is advisable to carry it out in case of self-detection of alterations or when requested during a clinical visit by the general practitioner or a specialist.

Discover here the practical indications on how to carry out self-examination and the warning signs to pay attention to

Finally, we must consider women at high risk, mainly those with the BRCA genetic mutation and not only. The mutation can be transmitted from both the mother and the father, in equal measure. When the family history highlights the risk of genetic mutation, for example when there are at least 3 cases of breast cancer among 1st and 2nd degree relatives, it is necessary to request a consultation with the Geneticist who will evaluate the family history and define whether to proceed with a genetic test, which is performed with a blood sample. If the test is positive, reducing the risk through surgery, with prophylactic mastectomy, can be considered.

Alternatively, one can undergo surveillance programs, a sort of screening on a selected population, which involves annual magnetic resonance imaging alternating at 6 months with ultrasound in young people and mammography and possible ultrasound from 35/40 years of age. Women who have undergone radiotherapy of the mediastinum at a young age, for example for lymphoma, should also be included in this risk group. Another form of risk reduction is prophylactic chemotherapy, still under study, with interesting results but with a fair risk of side effects.

Currently available treatments

Once doubtful or suspicious lesions have been identified on imaging, they must be characterized by needle sampling, guided by images, mainly ultrasound but also mammographic or magnetic resonance imaging. The sampling can be cytological by fine needle aspiration or histological, with needle biopsy, following local anesthesia. They are generally simple, minimally invasive procedures.

The histological sampling, in addition to defining the nature of the lesion, provides biological information on the degree of aggressiveness of the lesion and on the presence of hormone receptors and other factors that allow defining the best treatment strategy: for example, whether to proceed with surgery or postpone it and start neoadjuvant or primary therapy, usually chemotherapy.

At San Raffaele, a Breast Unit (BU) or Senology Center has been active for several years, as required by the NHS and SNR in compliance with European regulations. The Brest Unit is a cohesive group of dedicated breast cancer specialists working together; they are a multidisciplinary team with access to all the facilities needed to provide high-quality care throughout the diagnosis, treatment and monitoring of breast cancer.

The BU include surgeons, oncologists, radiologists, pathologists, radiotherapists and radiology technicians, dedicated to the management of breast pathology, supported by nuclear doctors, geneticists, psychologists, plastic surgeons, physiotherapists and all other specialists who can make a contribution to the diagnosis, treatment and physical and mental follow-up of the patient with breast cancer.

Breast cancer in men

Breast cancer also occurs in males and constitutes 1% of all breast cancers and less than 0.5% of tumors in males. Approximately 20% of cases occur in subjects with familial cases of breast and ovarian cancer and approximately 10% have the BRCA2 genetic mutation. The tumor manifests itself exactly as in women and is treated in the same way. Given the low incidence, no screening program is planned.

In adolescent males or following pharmacological treatments, a palpable retroareolar nodularity sometimes appears, often painful and unilateral, due to the growth of the mammary gland: in young people it is evaluated with ultrasound, otherwise with mammography.

The psychological impact of breast cancer: the experience of “Health in the Mirror”

A breast cancer diagnosis can have a profound impact on an individual's psychological balance. During the course of the illness, one may experience various moments of difficulty ranging from managing the complexities related to treatments, to organizing daily life. Psychological support not only helps patients manage emotional stress, but can also have a positive impact on their quality of life, helping to improve treatment adherence and facilitate more effective communication with the medical team.

An example of this approach is represented by the "Health in the Mirror" program. Through a synergistic collaboration with a multidisciplinary team of professionals, it aims to promote the well-being and quality of life of patients throughout all the different phases of the treatment process. This occurs through supportive interventions aimed at managing the side effects of therapies, training, prevention and research moments.

References

• https://www.who.int/news-room/fact-sheets/detail/breast-cancer
• https://www.salute.gov.it/portale/tumori/dettaglioContenutiTumori.jsp?lingua=italiano&id=5538&area=tumori&menu=vuoto
• aiom.it/wp-content/uploads/2021/11/2021_LG_AIOM_Neoplasie_Mammella_11112021.pdf.pdf
• hsr.it/news/2021/ottobre/cura-prevenzione-tumore-seno-san-raffaele
• senonetwork.it
• Gao et al. Radiographics. 2018 , Lautrup et al. Acta Oncologica 2018
• Di Mattei VE, Carnelli L, Taranto P, Bernardi M, Brombin C, Cugnata F, Noviello A, Currin M, Mangili G, Rabaiotti E, Sarno L, Candiani M. "Health in the Mirror": An Unconventional Approach to Unmet Psychological Needs in Oncology. Front Psychol. 2017 Sep 21;8:1633. doi: 10.3389/fpsyg.2017.01633. PMID: 28983271; PMCID: PMC5613306.
• Dinapoli L, Colloca G, Di Capua B, Valentini V. Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment. Curr Oncol Rep. 2021 Mar 11;23(3):38. doi: 10.1007/s11912-021-01049-3. PMID: 33709235; PMCID: PMC7952347.
• Hulbert-Williams, Nicholas J.^a; Beatty, Lisa^b; Dhillon, Haryana M.^c. Psychological support for patients with cancer: evidence review and suggestions for future directions. Current Opinion in Supportive and Palliative Care 12(3):p 276-292, September 2018. | DOI: 10.1097/SPC.0000000000000360