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Breast Cancer

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focus on early detection

Breast is an organ paramount for the nourishment of offspring as well as it denotes female identity and beauty.

The month of October is named as Breast Cancer awareness month by the World Health organization (WHO) to make people aware of the burden of the Breast Cancer and motivate them for early detection which is the corner stone for cure of this, otherwise dreaded disease.

Annually around 4,000 women in Sri Lanka diagnosed to have Breast Cancer and unfortunately a third of them succumb in a year, mainly because of the advance of the disease at the time of seeking medical advice.

The main reasons behind the reluctance of seeking medical advice are fear of losing the breast, side effects of Radiotherapy & Chemotherapy, stigma associated with breast cancer and cultural backwardness to reveal private parts of the body for edical examination.

This article focuses on the following main areas,

1. The importance of early detection

2. Diagnosis of Breast Cancer

3. Novel modalities of treatment available in Sri Lanka

Importance of early detection of Breast Cancer

A Cancer cell must divide on average 30 times before it forms a mass that can be felt in the breast. Since tumor cells multiply and divide exponentially – one cell become two, two cells become four and so on- a tumor will increase more rapidly in size the larger it is.

Longer one waits larger it gets and further away spreads from the place of origin (metastasis) leading to incurable systemic disease.

How do we detect a Breast Cancer early?

1. Self-Breast Examination

2. Screening Mammogram

3. Medical Breast Examination

Self-Breast Examination (SBE)

SBE is a simple technique to master by all females over the age of 20 to check their own breasts monthly.

Salient features of SBE are;

Regular Examination,

Fix a date convenient to remember; usually a menstruating female can perform these 7-10 days after each menstruation. Others can fix an easy date to remember, e.g. 1st of the month etc.

Repeated practice makes you master the technique, initially you may not feel much but when it is repeated monthly one become aware of the normal consistency, shape & contour of the breast so when there’s slightest change, can be discovered easily.

Privacy & Place

SBE takes 5-10 minutes, and must be done in a properly covered & secure place with a mirror.

Inspection

Undress the upper body and stand in front of a mirror and observe any changes of color, shape, size of breasts; inspecting by keeping arms by the side of the body, pressed at hip and raised above the head.

Palpation

This can be done standing or lying down, the left breast is examined by the right hand and vice versa. Start at the periphery of the breast and proceed in a circular manner, like a mosquito coil; at the end squeeze the nipple to see whether any discharges occur.

Once you finish with the breast feel under the armpit for any lumps.

I hope you will surf the internet to find out many educative videos on SBE to master the technique today itself.

Screening Mammogram

Mammogram is similar to a X-ray film but with very low radiation. It can detect cancers very early which are not felt by the hand.

‘Screening’ means it performs in healthy individuals who have a higher risk of the disease; some western countries screen their entire female population at the age of 45-years and every 3-5 yrs thereafter. In Sri Lanka there are no such guidelines but if you fall in the high risk category (Table 1) it is advisable to undergo screening mammogram periodically .Your first mammogram is considered a baseline mammogram against which all future tests will be compared to look for changes in your breast tissue.

Mammograms are not performed below the age of 35 yrs due to difficulties in interpreting when the breast tissues are dense.

Table No 1

Risk factors for Breast Cancer

Non-Modifiable risk factors

1. Advanced age

2. Family history of Breast Cancer

3. Radiation exposure

4. Family History of early Ovarian Cancer, Uterine Cancer, Colon Cancer

5. Certain inherited genes (BRCA 1, BRCA2, TP53, Atm, CDH1)

6. First pregnancy after 35yrs of Age

7. Early Menopause

8. Late Menopause

9. Nulliparity

10. Never breast fed a child

Modified Risk Factors

1. Hormone replacement therapy

2. Obesity

3. Alcohol consumption

4. Type 2 Diabetes Mellitus

5. Tobacco Use

6. Sedentary lifestyle

Even though many are not aware, risk of Breast Cancer development can be reduced on your own, see modifiable risk factors

Medical Breast Examination

This will be done by a consultant or a medical doctor to detect any abnormality or problems as well as to address any concerns arisen from the SBE.

This is more advanced than SBE as it will be performed by a trained and experienced professional who can determine features suggestive of Cancer in order to proceed with further investigations.

Diagnosis of Breast Cancer

Early detection and confirmation pave the way for early treatment. Diagnosis of Breast Cancer is achieved through three stages referred as Triple assessment.

1. Clinical Assessment

2. Radiological Assessment

3. Pathological Assessment

Clinical Assessment

This is done by a Consultant doctor. Breast examination & thorough systemic examination will be performed and findings will be graded in a scale from 1-5 (5 bears most probability of Breast Cancer)

Radiological Assessment

Mainstay of radiological assessment is by ultrasound scan (USS) and diagnostic mammogram.

Diagnostic mammogram differs by screening mammogram as it is performed in patients where breast cancer is suspected. and may take more pictures in different angles than screening mammogram.

Ultrasound scan is an outpatient procedure. Below the age of 35 yrs. when the breasts are denser, it is a safer and reliable mode. It can detect lumps, cysts (water bubbles), infections etc.

USS can reveal valuable information as an adjunct to mammogram where sensitivity of picking a lesion can be as high as 98% when both are combined.

There are other advanced tools such as CT scan and MRI which are reserved for more complex and advanced cases.

After the radiological diagnosis radiologist will scale the findings in a scale of 1-5 (5 being the most probable of cancer)

Pathological Assessment

This is the most important step of confirmation of a breast cancer, where a small piece or few cells from the lump is taken out to be examined under the microscope.

Commonly known as fine needle aspiration cytology (FNAC) is performed on an outpatient basis by inserting a small needle to the mass and taking out few cells. If the lump is not readily probable this could be done under the USS guidance.

In case a larger sample of tissues are needed for confirmation a core of tissue or part of the lump is taken out and examined under the microscope.

Again, the results of pathological assessment will be graded in a scale of 1-5 (5 being the most probable of Cancer) by the Pathologist.

Once the results of above are available another set of tests will be performed to assess the spread of the disease outside the breast. These are chest X-ray, USS Abdomen, Bone scan, CT scan, MRI Scan, PET Scan and the most appropriate of these will be selected by the clinician according to the disease & the patient.

When the results of above tests are available he/she will summon a multidisciplinary team meeting (MDTM) to decide the best treatment option for a particular patient. This will enable to tailor made the treatment for each and every individual rather to impose a set guideline for everyone. Information which needs at the MDTM are,

1. Confirmation of Cancer, its type & behavior

2. Spread to the arm pit

3. Spread to the other areas of the body

4. Proportion of cancer size compared to the breast size

5. Patient wishes and compliance

Novel modalities of treatment available in Sri Lanka

In 1894 Dr. William Stewart Halsted performed the first series of mastectomies to remove the whole diseased breast and this technique was the gold standard for the treatment of breast cancer with slight modifications until recently.

But in recent past there has been a paradigm shift of treatment modalities for the disease mainly due to the way we analyze it now.

Treatment options for Breast Cancer are subdivided as follows,

1. Treatment of Breast

2. Treatment of Armpit

3. Systemic Treatment

Treatment of the Breast

There has been a drastic change of the way we treat breast nowadays with mastectomy seldom required. Following are some approaches,

1. Wide local excision (WLE)

If the cancer is small compared to the size of the breast, it can be taken out with a clear margin of normal tissues carefully through a small incision. This will be assessed under the microscope to determine complete removal.

2. Quadrantectomy

Breast is divided arbitrarily in to four quadrants; Upper medial, Upper lateral, Lower medial & Lower lateral.

In case of a relatively large cancer which is in a quadrant can be taken out along with this entire quadrant. And the resulted defect can be filled with fat from under the armpit. (Li cap)

In some cases, it is necessary to remove more than one quadrant, in these cases resultant defect can be filled with fat & muscles taken out from the arm pit and back.

3. Skin and nipple sparing mastectomy

When the tumor is much bigger or it is in several different places, whole breast tissue is taken out leaving the skin & nipple. Obviously large defects created by this surgery can be filled with silicon prosthesis which are commercially available to restore the size & context of the breast.

4. Mastectomy and reconstruction

Still mastectomy has its ground for advanced cancer when the patients presents herself late for examination. It can now be combined with immediate, early or late breast reconstruction to restore the beauty.

Treatment of the Armpit

It was customy to remove all lymph nodes under the armpit along with Mastectomy as described by the Halsted, but now mainly due to the knowledge of lymph draining pathways, we perform sentinel lymph node biopsy.

When cancer cells travel from breast to armpit it goes along the lymph channel to one lymph node first, which we call as sentry or sentinel lymph node.

When we inject a dye or radioactive particle around the cancer and nipple it drains first to the sentinel lymph node which will be identified using a gamma camera and removed through a small incision to be examined under the microscope for cancer cells. If there are no Cancer cells detected rest of the lymph nodes will not be removed. Only when there is cancer present at the sentinel node rest of the lymph nodes are cleared away.

This will greatly reduce the complications and side effects associated with arm pit clearance.

Systemic Treatment

Usually, systemic treatment is advocated for patients with advanced breast cancer. There are several modalities,

1. Radiotherapy

2. Chemotherapy

3. Hormone Therapy

4. Immune Therapy

These can be given prior to the surgery, after the surgery or both to achieve maximum effect.

Take home message

Breast Cancer is completely curable without removing the breast if treated early. SBE and Screening Mammogram are crucial in picking up early cancer.



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Giving Sri Lankan street dogs love, respect and a home

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by Zanita Careem

An epitome of courage and wisdom, she is one of the top entrepreneurs in Sri Lanka, founder of Sri Lanka’s most stylish department where she served as Managing Director. Otara Gunawardena is truly inspirational.

She has earned many awards and notched several achievements. She was awarded the best female entrepreneur award at the Seventh US Stevie awards for Women in Business and 2018 Women of the Year Award by Women in Management (WIM).

Embark has become a popular brand. How do you account for it, its beginnings and its progress?

“Back in 2007, pedigreed dogs were popularly in demand but there were countless street dogs who needed care and love. Many of them were abused and unwanted. I wanted to change their circumstance and initiated Embark with the dream of providing a better life for our Sri Lanka’s street dogs and to give them the love, respect and the home they deserve.

“The brand was set up so that the profits would support the work we do with street dogs. It was also meant to help people to live a lifestyle supporting the cause and being ambassadors for the dogs with the clothing they wear. Most of the T- shirts have slogans conveying a positive message about street dogs in a fun way and many items became popular fashion statements.”

Explain the concept behind embark and the advocacy campaign for the welfare of homeless dogs?

“The concept was to make the street dog fashionable to own. And we have succeeded in doing so as more than 6,000 street pups have been re-homed, more than 60,000 vaccinated and sterilized throughout the island. Close to 35,000 plus street dogs have been rescued and treated over the last 15 years. Many people also now do their own rescues and adoptions.

“Embark mainly provides free medical treatment for sick and injured street dogs, the majority without owners. We also help find homes for pups who are abandoned on the streets. Besides the direct rescues we do there is also a foster network who rescues these pups, looks after them temporarily whilst we provide the required medical care – vaccinations, de-worming etc. and bring them to our monthly adoption programs where they find forever homes. We carried out many sterilization programs throughout the country and ensure there is population control within the street dog population in Sri Lanka. We also have a free medical clinic weekly at our head office in Colombo where we provide vaccinations, treatments and sterilizations for street/ adopted dogs.

What is your main focus in initiating this project?

“As explained previously, the main reason behind Embark is to give our Sri Lankan street dogs the love, respect and most of all the home that they deserve.”

Don’t you ever find the work you’re doing depressing and do you find any changes for the better?

“Sadly, the situation is quite dire in Sri Lanka but it has definitely improved from the past. There is now a no kill policy and sometimes there are programs of vaccination and sterilization implemented but unfortunately not done well. There is a lot more awareness and concern with people now against cruelty and also many more helping stray animals than before. However, there is still a lot of cruelty to elephants, an increase in terrible pet shops which are filled with suffering animals, cruel pedigree breeding, inhuman zoos, animals suffering in captivity etc.

“Lack of laws is a big issue too, something that has not changed despite many governments that have come and gone. It can be quite depressing to be aware of the cruelty and see it daily in a country such as ours where the need for compassion is stressed. We just do what we can each day to make a positive difference in the current situation.”

What has been the highlight of setting up Embark?

“Well, there are many, but I can say it has been rewarding to see a paralysed dog walk again, a dog who was severely ill recover and a rescued pup finding their forever home and living the best possible life. These may seem small achievements but they are close to my heart and I am glad I am able to help these amazing beings recover and live a good life. “

What are your programs to improve and protect animals and the environment in Sri Lanka?

“Embark under, Otara Foundation has been working on improving the lives of street dogs throughout the country, conducting rescue and re-homing initiatives whilst managing the canine population and preventing rabies through sterilization and vaccination programs across the country. Most of the rescues and treating of the injured are focused in the Western Province, but we do try our best to reach as best as we can in other areas.

“Embark has been at the forefront influencing policy in relation to animals and playing a vital role in making a significant change in the lives of animals and people alike.

“The Otara Foundation works with its accredited partners to promote large and medium-scale reforestation projects in the country. In addition, because it is the Foundation’s mandate that all life matters and every little effort is a step in the right direction, we support and promote smaller individual initiatives in reforestation and replanting. I personally advocate a better life for animals, speak out on behalf of the animals and participate in awareness.”

Any drawbacks?

“I can only look at the change I have been able to make for animals and the environment and be grateful for what’s been achieved. The drawbacks are knowing how much more we need to do and can be done if there was conscious caring leadership as a lot of bigger change has to be initiated from the top.”

How does it feel being a female entrepreneur?

“It has been a challenging yet enjoyable journey. I am happy to have been able to change the direction of retail and fashion in Sri Lanka and to give a lot more women hope to follow their dreams and be who they want to be.”

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Understanding fibroids

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Uterine myomas, commonly called fibroids, are very common in South Asian and African women. However, the risk of them turning malignant or cancerous is very rare. In an interview with the Sunday Island, Consultant Obstetrician and Gynaecologist and Senior Lecturer in Obstetrics and Gynaecology from the Kotelawala Defense University, Dr. Romanie Fernando throws light on the causes and treatment of fibroids which are found in 30% of Lankan women over 30 years.

by Randima Attygalle

Uterine fibroids are benign or non-cancerous muscular growths which could appear in the uterus (womb), uterine wall or on its surface. The uterine wall which is made of smooth muscle becomes harder as a result of fibroids. “There is a genetic pre-disposition involved in fibroids; South Asian and African women are at a higher risk of getting fibroids and why they are more pre-disposed is still unknown,” says Dr. Romanie Fernando.

Fibroids usually appear in women of reproductive age- generally between 30-40 years although in some, they could appear earlier than that. “They are very common, so much so, one in three Lankan women above 30 years will have fibroids. However, the risk of having a malignant change is very rare. Only less than 0.5% of uterine fibroids will have the risk of turning into cancer, hence women should not have unnecessary fears about them,” Dr. Fernando says.

Causes

Genetics and hormones largely influence fibroids and their growth. Estrogen and progesterone imbalance affect fibroid growth. When hormone production slows down during menopause, these fibroids usually shrink. “Family history, age and race are the other factors which could place a woman at a higher risk of developing them,” explains the obstetrician.

Symptoms

Symptoms depend on the size and site of the fibroid. Only about 30% of women with fibroids will have symptoms and the majority will be asymptomatic (not showing symptoms). “Some fibroids are so small and are of a size of a shirt button that they will go unnoticed and won’t cause any harm, while others grow in big masses and can affect the uterus and adjacent structures causing symptoms.”

If a fibroid is found inside the uterus or the uterine cavity, it could affect the menstrual cycle resulting in pain during menstruation, heavy periods and spotting (bleeding in between two cycles). “If a fibroid is found in a woman close to menopause and if it is not causing any menstrual or pressure symptoms, we usually wait until she reaches menopause without intervening because with low estrogen, the fibroids will naturally shrink.”

Diagnosis

Diagnosis is largely an incidental or accidental finding during a clinical examination. “During a routine pelvic exam a doctor may suspect fibroids if the shape of the uterus feels irregular or unusually large. Fibroids are also diagnosed during pregnancy when routine scans are done.”

Treatment

Treatment too depends on the age of the woman, size and site of the fibroid. The growth of most of the fibroids is very slow, usually about half a centimeter in two years, explains Dr. Fernando. “However, if the growth is very rapid within a short time, it could be worrying and we need to intervene to remove it.”

Although not a very common presentation, severe backache could also be a symptom of fibroids. “Some women with fibroids could also be anemic due to increased menstrual blood loss and in such instances, we address anemia as well.”

Fibroids are treated symptomatically. If a fibroid is found to be causing pain, heavy menstrual flow or pressure on other organs such as the bladder for example, (causing frequent urges to urinate or inability to control urine) investigations will be done to determine the best mode of treatment. “Treatment could be either with oral medication or surgery depending on the severity of each case.”

Fibroids and pregnancy

If fibroids larger than five centimeters are found in a woman before her pregnancy, they are usually surgically removed to avoid complications during pregnancy. During pregnancy, the blood supply to the womb is increased, hence removal of fibroids is very risky and is postponed until after the delivery. “After a pregnancy the hormone levels and the blood supply become less and the fibroids too tend to become smaller. There had been maternal deaths when trying to remove fibroids during cesarean operations because of the inability to control the heavy bleeding,” says the consultant.

Fibroids can cause foetal growth restrictions and premature labour in some women. The positioning of the baby could also be abnormal in some cases. “If the fibroid is found closer to the uterine cavity, there could be a higher risk of miscarrying and after normal delivery heavy bleeding (post-partum haemorrhage) is also common.

Types of surgery

There are many ways to treat fibroids. The treatment that works best for each woman will depend on symptoms, reproductive plans, age, and the site of fibroids in the womb. “In younger women with reproductive wishes (those who hope to get pregnant in future), we usually remove the fibroids with myomectomy. This type of surgery removes them while retaining the healthy tissue. Myomectomy could be performed in many ways from abdominal surgery to laparoscopy,” remarks Dr. Fernando.

Although several other non-surgical interventions including the latest high intensity focused ultrasound (HIFU) device which was developed for treating uterine fibroid and drugs to shrink fibroids are available in other parts of the world, locally we are still limited to treating fibroids surgically with myomectomy (removal of the fibroid) or hysterectomy (removal of the uterus), says the consultant.

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Vibrant hair colours and subtle make-up for 2022 –Ramani

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by Zanita Careem

As 2022 begins, the beauty boom continues. In this article Ramani Fernando takes a daring leap into the overarching themes set to trend 2022.

How we express ourselves through products, to progress in sustainability and inclusion across the country.

Ramani Fenando’s deep passion to beauty trends in hair, and engagement with, its growing enthusiastic followers continues to dominate the beauty scene in 2022.

A beacon for new trend beauty entrepreneurs will not be short of support and guidance helping to bring a growing number of mission driven beauty brands to life and scale. My passion became my career and that’s why I also say do what you love, you never know where it will lead.

Q: The past year has witnessed a significant shift to people who discover and indulge in beauty category, what your take on it.

I want to inspire people to understand that no matter what they look like, they are people. For me beauty is timeless. We want everyone to accept and love themselves for themselves and be comfortable in their own skin.

From being a beautician and handresser to becoming the founder of many Ramani Fernando salons I have come a long way. My name in the beauty industry is most recognizable, she gets candid about her passion,her salons, her favorite make up products and share words of encouragement for women entrepreneurs.

What do you think your brand Ramani Fernando salons is synonymous to?

I’d like to think that Ramani Fernando Salons has been a pioneering, inspirational and passionate brand with more than 45 years within the hair industry, having grown from a single unit into a large chain of salons around the country.

I wouldn’t want to compare my salons to other brands in the industry as each brand or individual has their own pioneers which makes them unique in their own way.

What kind of make up do you like?

Something I live by is “Less is More” I like subtle classic looks when it comes to bridal makeup, I feel elegance and simplicity are my focus.

Have you ever faced any crticism for your work?

Yes of course, I take it very seriously and in a positive manner as constructive criticism which I feel, we all need in our lives to learn and grow from.

Your words of encouragement for women who want to have identity of themselves?

“Each of us has unsuspected power to accomplish what we demand of ourselves.”

The new trends in hair styles, hair colour and hair cuts.

Hair Styles

Ten years ago, people were just styling hair and not thinking about the haircut underneath it.” It’s a way of approaching your hair that allows you to embrace all manner of trends, from embracing your natural curls to air drying your layers, and gives your hairstyle its unique character.

For a while now, we’ve favoured hairstyles which appear artfully undone, low maintenance and effortless, but many hairstylists are predicting a return to the old-school blow-dry and a more finessed approach to hair.

Hair Cuts

Undoubtedly the haircut of 2021, the bob is going nowhere for this year. But for young teenagers the bob remains at the forefront. There are so many new variations in the hair—changes in length, shape, volume and styling—for 2022

What do you think are the new make up trends this year?

Yet another popular type of makeup application is HD makeup. This makeup is done using regular brushes but products that contain pigments with light-diffusing coatings that blur the imperfections when light reflects onto them.

Mineral makeup is all about getting that natural finish with makeup that looks like your skin, but better. The products for this type of makeup style are made using compressed minerals and they don’t have any oil. This is generally the preferred makeup technique for oily skin types, but with the rightful application can work fabulously for any skin type.

The signature products that will dominate the skin industry.

There are many products that I consider as signature products for skin car, some of the more dominant ingredients, like niacinamide, hyaluronic acid, salicylic acid (to name a few) focusing on creating healthy moisturized, blemish free, pigment free and glowing skin.

Any hair colour that will dominate the young teenagers.

At the moment we see many teenagers coming in to the salon asking for many vibrant colours like blues, greens, purples and pinks.

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