Breast cancer

by Dr Kris Chatamra
Breast cancer

Professor Dr Kris Chatamra M.B., B.S. (London), F.R.C.S., (England), M.D. (London), Fellow of the Royal Society of Thailand, Hon. Director Queen Sirikit Centre for Breast Cancer (Thai Red Cross), and Queen Sirikit Centre for Breast Cancer Foundation

Professor Dr Kris Chatamra was educated in the UK and came back to Thailand after thirty years as a senior clinician and an examiner for the Royal College of Surgeons of England. He was also awarded the prestigious, Buckstone Brown Award for medical research on the liver, in addition to the Cutler’s Award for surgical research. (His post-doctoral thesis, M.D. London, was on the regeneration of the liver. He is now the Honorary Director and founder of the Queen Sirikit Centre for Breast Cancer, (QSCBC) a centre of excellence for breast cancer which cares for all women but primarily the underprivileged. He extended the project to form the Queen Sirikit Centre Foundation which raises funds to organise breast and cervical cancer screening projects in the slum communities; research and treatment at the Queen Sirikit Centre and the ‘Pink Park’ project, a convalescence, cancer rehabilitation and end of life care home for the poorest cancer patients in Thailand.

His interest in surgical oncology began in 1979 when he was a clinician and lecturer at the Royal Marsden Hospital, the UK’s premier cancer hospital and his main interest has remained upper gastrointestinal and breast cancer. His research interests have included, introducing breast conservation for breast cancer 29 years ago in Thailand; initiating intra-operative radiotherapy for breast cancer in SE Asia and the treatment of locally advanced breast cancer using the omentum. His latest research work is the use of immunotherapy to treat breast cancer. His vision is to always maintain the highest level of diagnosis and treatment, for example, the introduction of 3D mammography and CT mammography were the first non-prototype equipment installed in the world. The dedicated MRI machine remains the first and only equipment available of its kind in Thailand. Nano String PAM 50 technology is also available to evaluate patient gene profile and risk level for each individual patient so that treatment can be adjusted accordingly. He remains committed to trying to provide the best services that are available to the underprivileged. He is also a Fellow of the Royal Society of Thailand.

As time progresses the equipment and techniques to diagnose and treat breast cancer are improving dramatically. At the Queen Sirikit Centre for Breast Cancer (QSCBC) we continually raise funds to provide the best possible facilities for patients, although open to all women, we focus on the poorest women in society. The centre has begun trials in immunotherapy which encourages the body to eliminate cancer cells. There are many approaches to immunotherapy research, but the aim is to use the patient’s immune system to fight cancer, firstly by teaching the immune system to recognise and then attack cancer cells. At the QSCBC in 2019, we have embarked on a new immunotherapy research trial. The QSCBC, thanks to donations, has been using the PAM 50 test (Prediction Analysis of Microarray 50), which shows whether some cancers have a higher probability of spreading to other organs in the body. The test particularly looks at oestrogen receptor – positive (ER positive) and HER-2 negative breast cancers. PAM 50 is a tumour profiling test, which will give information about the genes in cancer cells. A biopsy of the tumour is taken from the patient and a group of 50 genes are sampled and tested. Every cell of the body has genes that contain the blueprint for each individual’s body; their genetic code. Likewise, every cell in a breast tumour has genes, these genes contain the blueprints for the tumour.

There has been a lot of concern that mammography is a risk to patients. Modern mammography gives out very little radiation, compared with the equipment from 10-15 years ago. Mammography plus breast ultrasound, if carried out by an experienced breast radiologist and a good standard of equipment, are still the best screening investigations for breast cancer. It is also essential to have a thorough clinical examination by an experienced surgeon. They claim that only 85% of lesions can be identified by the most modern mammography is not accurate if the most modern methods of examination are adhered to. At the QSCBC we have raised funds to provide the most modern equipment for patients, (primarily the poorest), including digital mammography and ultrasounds. The centre has now acquired a CT Mammography which allows the patient to lie down and is pain-free; the equipment looks rather like a ‘doughnut’. A CT scan or computed tomography scan makes use of many X-ray measurements from different angles, rather like a cake sliced up into many pieces, so there is a cross-sectional image. *Research comparing the various diagnostic imaging equipment is ongoing at the QSCBC.

The QSCBC uses Breast Thermography for research projects. The principle of thermography is the differential in heat between the skin overlying a tumour and the surrounding areas. Thermography shows the difference in the heat with a form of ‘heat camera’. The Magnetic Resonance – dedicated to breast uses radio waves and strong magnets to create an image of the breast from a multitude of angles to create a very detailed image. It is used to compliment the mammography and ultrasound but is not used at the QSCBC for normal screening. MRI-Dedicated Breast can find cancers not seen on a mammogram, however, it can discover lesions which are not tumours, namely false – positives. False – positive findings need to be checked out to ensure the lesion is not cancer; so It tends to lead to unnecessary tests or biopsies and extra stress for the patient. MRI is therefore not used for normal screening in women who have an ‘average risk’ of getting breast cancer. The MRI Dedicated Breast is used with patients who have a higher risk of breast cancer, for example, patients who have a family history of breast cancer.

Breast CancerThe technique is also used with women who already have been diagnosed with breast cancer, to help measure the size of cancer; look for other tumours in the breast and to check for tumours in the opposite breast as well as for MRI-guided biopsies. Scalp cooling is a technique used during chemotherapy to reduce the loss of hair during treatment. Many women find the loss of hair as one of the most distressing side-effects of treatment. The scalp cooling treatment, however, did not work for the SE Asian patients, whilst it was effective with the Caucasian patients. The QSCBC embarked on a nursing team project to discover why and to correct the problem. As a result, a new design of scalp cooling cap and equipment was produced and the results have been very positive, with women having minimal hair loss. The scalp cooling is used under warm air blankets in the newly designed chemotherapy suite, again gratefully received from donations from donors and the QSCBC Patient Support Group, Bangkok Breast Cancer Support Group. The QSCBC uses intraoperative radiotherapy for patients as part of an international trial. It allows patients to have one dose of radiotherapy in the operating theatre rather than weeks of 5-minute doses. For a patient coming to form a rural or upcountry area, it is far easier to have one dose rather than a multitude of radiotherapy doses over a long period of time.

Male Breast Cancer

Male breast cancer is rare but 1% of breast cancer is reported to be found in men. The most common form is invasive breast cancer carcinoma – no special type. Breast cancer in males has been found in the milk ducts, known as ductal carcinoma in situ. Tumours can also be situated in the milk producing glands, lobular carcinoma, although this type of cancer is less common because men have fewer lobules in their breast tissue. Risks for men include age, more breast cancers are diagnosed in men between the ages of 60 and 70. All men produce small amounts of oestrogen, this is perfectly normal, however, high levels of oestrogen have been linked to a higher risk of breast cancer. Men who are obese, have chronic liver conditions, such as cirrhosis and some genetic diseases, are reported to have an increased risk of getting breast cancer.

There is evidence to suggest men who have close relatives with breast cancer like a mother or sister will have an increased risk of breast cancer. If these relatives are diagnosed early, below the age of 40, the risk of male breast cancer in the family increases. Men can inherit faulty genes, like women, the BRAC 2 faulty gene is more commonly found than the BRAC 1 faulty gene in male breast cancer. Male breast cancer is rare but usually presents as a painless lump. Other symptoms could be a rash on the nipple; ulcers on the skin of the breast; lumps under the arm; oozing from the nipple, (a discharge), which may be blood stained; a nipple which is pulled into the breast, known as a retracted nipple and evidence of breast swelling. If in doubt or concerned about breast symptoms, a man should always consult a doctor.

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