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Ismail Munir

Early Menarche And Breast Cancer

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Pap Smear – A Crucial Step Towards Preventing Cervical Cancer

Introduction

After cancers of the mouth and <a href="https://merisehat.pk/disease/breast-cancer">breast cancer</a> of all age groups, cervical cancer is the third most prevalent disease in women under 50. Despite being a preventable disease, it unfortunately often does not receive due attention in Pakistan.&nbsp;Pakistan is in dire need of raising awareness in the masses on this pertinent issue while promoting screening and HPV vaccination.&nbsp; &nbsp;

This is important because invasive cervical cancer has an extremely high fatality rate. Every year, nearly 500,000 women worldwide are diagnosed annually, of which 273,000 women die.&nbsp;The majority of cervical cancer-affected females live in developing nations<a href="#accordion">[1]</a>. It&rsquo;s imperative that these countries practice the WHO policy for prevention with HPV vaccination, and set up scheduled Pap smear screening programs nationwide.&nbsp;

The Pap smear or Pap smear test, which changed how we view cervical cancer, was named after its founder Dr. Georgios Papanikolaou.

<div>&nbsp;</div>

Understanding The Importance Of A Pap Smear Test

A Pap test, also commonly known as a Pap smear, is a procedure the doctor uses to check for cervical cancer in female patients. It can also be used to check for alterations in the cervical cells that would later develop into cancer.

Your cervix&#39;s cells are gently and carefully removed during the procedure and checked for suspicious changes. This procedure takes place in a proper healthcare environment with specialized tools. Although it could be moderately painful, it typically doesn&#39;t result in any permanent pain.

&nbsp;

<ul>
	<li>You will feel more positive and reassured when the results of a Pap test are normal.</li>
	<li>By identifying cervical cell abnormalities, routine Pap screenings assist in prompt treatment and/or exploring reasons for the abnormal cell presentation.</li>
	<li>A Pap test aids in the early detection of cervical cancer before any symptoms even appear. The early detection of cervical cancer makes it more manageable to treat. Also, early diagnosis may result in fewer treatments and a quicker recovery.</li>
	<li>Your probability of survival improves with earlier cervical cancer detection. 
	&nbsp;</li>
</ul>

<ul>
	<li>A Pap test could indicate cervical cell abnormalities even though there are none. This is called a false positive.</li>
	<li>At the other end of the continuum, a Pap test might not find abnormal cervical cells even if they do exist. This is called a false negative.</li>
	<li>Some forms of cervical cancer do not result in death and they don&rsquo;t even impact the quality of life. This identification of cervical cells is called overdiagnosis.</li>
	<li>Several women with cervical anomalies might be recommended for additional examinations or treatment for a disease that might not have progressed to cancer.&nbsp;</li>
</ul>

&nbsp;

A pap smear test&#39;s primary goal is to find precancerous changes, i.e., cellular abnormalities in the cervix that might lead to cervical cancer, whereas the HPV test looks for the human papillomavirus that can cause these changes. These tests can be done separately but it is also possible to test for HPV using a sample from a pap smear. This is called co-testing.

A pap smear can identify cervical cancer cells early, so the individual can begin therapy before the disease spreads and becomes more serious. One of the leading causes of cervical cancer is HPV, which can be acquired during intercourse. While using a condom or another barrier technique when practicing intercourse reduces your risk of catching the virus, nevertheless, all sexually active women should undergo a pap smear every 3 years at least since they risk getting HPV. 
&nbsp;

A pap test shouldn&#39;t be done while you are menstruating. The accuracy of the test is impacted by severe bleeding. Ask your doctor if you can reschedule the test if your test date falls during that time of the month.

Experts advise following these measures 48 hours before your test for the most reliable Pap smear:

<ul>
	<li>Avoid lubrication.</li>
	<li>Abstain from sexual activity.</li>
	<li>Keep sprays and powders away from the vagina.</li>
	<li>Tampons, tablets, creams, suppositories, and other items must not be placed within the vagina.</li>
	<li>Avoid washing the genital region with any liquid, including water, vinegar, or alcohol (douche). 
	&nbsp;</li>
</ul>

The exam is completed at a clinic or your doctor&rsquo;s office. It takes 10-20 minutes. You won&#39;t feel pain during the Pap test, although you might feel a slight pinch or pressure.

&nbsp;

1. As you lay on a table, your feet will be firmly secured in stirrups.

&nbsp;

2. Your doctor will ask you to spread your legs&nbsp;

&nbsp;

3. Then your doctor will gently insert a metal or plastic instrument (speculum) into your vagina. This is when you might feel a sensation of pain and discomfort and it&#39;s best to relax at this stage.

&nbsp;

4. The speculum helps in keeping the walls of the vagina apart to enable a clear view of&nbsp; the cervix.

&nbsp;

5.&nbsp;Samples from your cervix will be taken and your doctor can obtain this sample in a few different ways:

<ul>
	<li>Some doctors use a spatula.</li>
	<li>Some doctors use a brush and a spatula at intervals.</li>
	<li>Some doctors use a cytobrush, which combines the functions of a spatula and a brush.</li>
	<li>Some doctors use a swab.</li>
</ul>

&nbsp;

6. You might experience a small push and discomfort during the sampling.

&nbsp;

7. Your cervix&#39;s sample of cells will be kept intact and transported to a lab to examine the presence of abnormal cells.

&nbsp;

8. After the exam, you might experience some minor scraping discomfort or slight cramping. Additionally, minor vaginal bleeding could occur just after the test. Let your doctor know if pain or bleeding persists beyond the test day. 
&nbsp;

Your test result will arrive at your doctor&#39;s office within a few days. It would either be negative (normal) or positive (abnormal).

&nbsp;

<h5>1. Normal Outcome</h5>

A normal outcome is actually a positive thing. According to your doctor, this indicates that there aren&#39;t any cancerous or precancerous cells on your cervix. Until your next scheduled Pap is due, you won&#39;t require another one.&nbsp;

&nbsp;

<h5>2. Abnormal Outcome</h5>

Your Pap smear test might show abnormal cells due to:

<ul>
	<li>Mild inflammation or minor cell changes (dysplasia)</li>
	<li>HPV or other infection</li>
	<li>Cancer or pre-cancer</li>
	<li>Lab test error</li>
</ul>

&nbsp;

<h5>3. Atypical Squamous Cells Of Undetermined Significance (ASCUS)</h5>

Squamous cells are thin and flat and grow on the surface of a healthy cervix. In the case of ASCUS, the Pap smear reveals slightly abnormal squamous cells, but the changes don&#39;t necessarily suggest that precancerous cells are present.

Your doctor can go for a liquid-based test to reanalyze the sample to check for the presence of viruses known to promote cancer development, such as some types of human papillomavirus (HPV). If no high-risk viruses are present, the abnormal cells found as a result of the test aren&#39;t of great concern. If worrisome viruses are present, you&#39;ll need further testing.

&nbsp;

<h5>4. Squamous Intraepithelial Lesion</h5>

This term indicates that the cells collected from the Pap smear may be precancerous. If the changes are low grade, it means that the cells&#39; size, shape, and other properties indicate that if a precancerous lesion is present, it would take years to develop into cancer. On the other hand, if the changes are high grade, there&#39;s a greater chance that the lesion may develop into cancer sooner; additional diagnostic testing would be necessary in this instance.

&nbsp;

<h5>5. Atypical Glandular Cells</h5>

Glandular cells produce mucus and grow in the opening of your cervix and within your uterus. Atypical glandular cells may appear to be slightly abnormal, but it&#39;s unclear whether they&#39;re cancerous or not. Further testing is needed to determine the abnormal cells&#39; source and significance.

&nbsp;

<h5>6. Squamous Cell Cancer Or Adenocarcinoma Cells</h5>

This result means the cells collected for the Pap smear appear so abnormal that the pathologist is almost certain a cancer is present. &quot;Squamous cell cancer&quot; refers to cancers arising in the flat surface cells of the vagina or cervix. &quot;Adenocarcinoma&quot; refers to cancers arising in epithelial cells. If such cells are found, your doctor will recommend a prompt evaluation.

&nbsp;

<h5>7. Cervical Cancer (Or Pre-Cancerous Stage) 
&nbsp;</h5>

It is important to note that not all positive tests equate to cervical cancer. Additional testing is usually done to rule out other causes before a definitive diagnosis of cervical cancer is made. For example, your doctor can decide to &quot;wait and see&quot; if you experience inflammation or moderate cell abnormalities. Or they could advise that you get a second Pap test in a few months. If the abnormal cells still exist, your doctor might suggest more tests. One of these could be a technique known as colposcopy. 
&nbsp;

A colposcopy is used to diagnose genital warts, cervicitis (inflammation of the cervix), and precancerous changes in the cervix, vulva, and vagina.&nbsp;Similar to the Pap test, a speculum is inserted into your vagina during a colposcopy by your doctor. The colposcope is used to examine the cervix. The device with its particular lens and a strong light enables your doctor to see your cervix more clearly. Your doctor then swabs your cervix with vinegar or another liquid substance, which highlights the suspicious regions. Your doctor can see them due to the colposcope&#39;s lens.

Samples are collected from these suspicious areas (biopsy) and are sent to a lab for additional analysis. Multiple biopsy samples can be taken if there are multiple suspicious areas.&nbsp;

After the colposcopy, if there&rsquo;s any bleeding then the doctor would swab your cervix with a chemical solution to limit the bleeding. 
&nbsp;

If you are anywhere between 21 and 65 years of age, the test should be taken every 3 years.&nbsp;

Starting at age 30, you can decide to get both a Pap test and an HPV test. It is recommended to repeat these combined tests every 5 years instead of 3. Alternatively, women aged 30 and above could also opt for HPV testing instead of the Pap smear, this is because HPV is a known risk factor for cervical cancer.

&nbsp;

Your doctor could advise more frequent Pap tests if you have certain health issues, including:

<ul>
	<li>A diagnosis of cervical cancer or an abnormal Pap smear result&nbsp;</li>
	<li>&nbsp;HIV infection</li>
	<li>&nbsp;A weakened immune system due to chemotherapy, organ transplant, or chronic use of corticosteroids</li>
	<li>&nbsp;Exposure to diethylstilbestrol (DES) before birth</li>
</ul>

Note: Inform your doctor of any of the above conditions when considering getting a Pap smear test done.&nbsp; 
&nbsp;

Pap tests are quite precise. Routine Pap tests decrease the incidence of cervical cancer and associated mortality by at least 80%. Although it could be difficult initially, your health will benefit from the short-time pain you endure during the procedure. The Pap smear process is safe and reliable. However, it&#39;s possible that some aberrant cells or cervical malignancies could be missed by the test (false negative).&nbsp;

Note: Discuss getting a Pap smear test done at your next visit with the doctor.&nbsp;&nbsp;

<div>&nbsp;</div>

<ul>
	<li>In addition to your yearly gynecological checkup, you can schedule a Pap smear separately by calling your gynecologist. Most insurance plans cover Pap smears, but you might have to make a co-payment.</li>
	<li>Your doctor might want to reschedule your Pap smear if you are menstruating on the day of the test because then the results would not be as reliable.</li>
	<li>The day before your test, try to avoid having sex, douching, or using spermicidal products as these could affect your results.</li>
	<li>A Pap smear is typically safe to have in the first 24 weeks of pregnancy. It becomes difficult after that. Additionally, you ought to hold it off until 12 weeks after giving birth to improve the accuracy of your findings.</li>
	<li>Maintaining your composure and breathing throughout the Pap smear procedure is crucial since your body will function more efficiently if you are comfortable.</li>
</ul>

&nbsp;

You and your doctor can mutually decide to discontinue Pap smears.

<ul>
	<li>Ask your doctor if you need to continue obtaining Pap smears after a total hysterectomy, which involves the surgical removal of the uterus and the cervix.</li>
	<li>You might be eligible to stop getting Pap smears regularly if your hysterectomy was done to treat uterine fibroids or another non-cancerous condition.</li>
	<li>However, your doctor could advise continuing routine Pap tests if your hysterectomy was performed because of a precancerous or cancerous disease of the cervix.</li>
	<li>Doctors generally concur that if a woman&#39;s previous tests for cervical cancer were negative, she could think about quitting regular Pap tests when she turns 65.</li>
	<li>Together, you may determine what is best for you based on your risk factors. Your doctor might advise continuous Pap testing if you engage in sexual activity with many partners. 
	&nbsp;</li>
</ul>

Cervical cancer can be screened safely by using a Pap smear. A Pap smear is not 100% accurate, though. False-negative results are possible, which means that even though you have abnormal cells, the test shows no abnormality. False-negative results don&#39;t necessarily indicate that something went wrong.

&nbsp;

The following variables can result in a false-negative outcome:

<ul>
	<li>An Inadequate Collection Of Cells: An insufficient amount of collected cells may give false results.</li>
	<li>A Small Number Of Abnormal Cells: Sometimes a doctor is unable to conclude the results because of an insufficient quantity of collected abnormal cells.</li>
	<li>Blood Or Inflammatory Cells Obscuring the Abnormal Cells: Unknown inflammatory conditions and blood accumulation may cause hindrances in identifying results.</li>
</ul>

&nbsp;

Note: Please remember that if one test doesn&#39;t detect the abnormal cells, the next test most likely will. Hence repeated testing is necessary so that if abnormal cells go undetected in the first test, they will most likely be detected in any of the subsequent tests. Repeated testing is also necessary since cervical cancer takes several years to develop and regular pap smear tests allow for early intervention. 
&nbsp;

Conclusion

The incidence of cervical cancer in Pakistan is lower than in other western countries, but the mortality rate is high due to scarcity of awareness, unavailability of Pap smear tests, lack of follow-up, and late presentation of cervical cancers.To curb the late-stage presentation of the disease, implementation of the screening program on the national level is imperative. This would reduce the burden of disease on the health care sector while saving the lives of countless Pakistani women.Even though some specific dos and don'ts must be followed, Pap smear is still a valuable procedure. Healthcare experts must also encourage patients to take the test by alleviating their fears and anxiety associated with the procedure.&nbsp;

Key Points

<ul><li>The Pap smear test is a quick and effective way to test for cervical cancer in women&nbsp;</li><li>Although the procedure is short, Pap smears can be a little painful and tricky.</li><li>This procedure takes place in a proper healthcare environment with specialized tools.</li><li>Pap tests decrease at least 80% of cervical cancer incidence and mortality.</li><li>Women between 21 and 65 years of age are advised to go for a pap smear every 3 years. However starting from age 30 and onwards, it is possible to get either a combined Pap smear and an HPV test OR HPV testing every 5 years.</li><li>It is important to note that not all positive tests equate to cervical cancer. Additional testing is usually done to rule out other causes before a definitive diagnosis of cervical cancer is made. </li></ul>

[1] Syeda Asma Batool (Department of Zoology, L. C. f. W. U. L. P.)., 2017. JPMA. [Online]

[2] WHO, 2003. WHO. [Online]

Neelam Asad

Humza Khizer

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How Can I Better Support A Breast Cancer Survivor?

In 2020, <a href="https://merisehat.pk/disease/breast-cancer">breast cancer</a> accounted for 28.7% of new cancer cases in Pakistani women of all ages<a href="#accordion">[1]</a>. With the highest incidence in Asia, the country continues to struggle with increasing morbidity and mortality rates, especially among young females<a href="#accordion">[2]</a>.&nbsp;

As per a Pakistani study, 89% of breast cancer patients are diagnosed at a later stage while 59% present at an advanced stage<a href="#accordion">[3]</a>. This delay in diagnosis can reduce survival rates and cause an increased mortality rate among patients. Researchers believe that a lack of awareness and a combination of sociocultural and personal factors contribute to the delay. Furthermore, a delayed diagnosis also translates into a poor prognosis and the need for more aggressive treatments.&nbsp;

Treatments such as chemotherapy, radiation, and mastectomy can affect an individual&#39;s physical and mental health. The fear of side effects of chemotherapy such as loss of hair and eyebrows often causes women to delay seeking help. Moreover, mastectomy is often associated with body image issues that can be extremely challenging in a world where a woman&#39;s attractiveness is solely based on her physical appearance.&nbsp;

However, <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer</a> can have an implication on the lives of both survivors and their friends and family. Thus, it is important to identify the challenges they face and effectively address them to improve their overall quality of life.&nbsp;

&nbsp;

Understanding How To Support A Breast Cancer Survivor

A UK study looked at more than 50,000 breast cancer survivors and a control group consisting of over 200,000 women with no history of cancer. The results revealed a higher risk of anxiety, depression, fatigue, pain, and sexual dysfunction among the survivors<a href="#accordion">[4]</a>. This is similar to the results of a Pakistani study in which 74% of survivors reported feeling varying levels of anxiety. Moreover, 83% complained of fatigue, 75% of body pain or headache, 77% had reduced appetite, 63% had weight loss, and 77% reported sleep disturbances<a href="#accordion">[5]</a>. The fear of the recurrence of cancer is believed to further add to the anxiety. Thus, breast cancer can take a physical and psychological toll on the survivors.

In a society where physical beauty is often given preference over everything else, it is no surprise that breast surgery can elicit depression and anxiety in breast cancer patients. Across all cultures and countries, including Pakistan, a woman&#39;s breasts are considered a symbol of femininity, sexual beauty, and motherhood. Thus, the physical change associated with breast surgery or mastectomy can significantly lower a woman&#39;s self-esteem<a href="#accordion">[5]</a>. They may develop a negative image of their bodies, leading to lowered self-confidence and mental health problems. Furthermore, hairlessness, loss of eyelashes and eyebrows, and skin discoloration associated with cancer treatment also take a toll on the person&#39;s mental health.&nbsp;

The combination of all these factors may lead to the survivors feeling stigmatized. This can lead to many women never seeking help or talking about their concerns and self-isolation in some cases.&nbsp;

&nbsp;

The following are some of the ways one can help breast cancer survivors with their physical and mental health:

<ul>
	<li>
	<h5>Breast Reconstructive Surgery </h5>
	</li>
</ul>

Many women opt for reconstructive surgery following mastectomy or lumpectomy. A plastic surgeon may use an implant, a flap tissue from another part of the patient&#39;s body, or both to create a breast shape. However, if you don&#39;t want to go for reconstructive surgery, there are other options such as a breast form or prosthesis that one can wear under the bra.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Wigs And Accessories</h5>
	</li>
</ul>

​​​​​​​Women dealing with hair loss can wear a wig, hat, or scarves while they wait for the hair to grow back. Or you may feel comfortable flaunting the baldness which is just a reminder of the challenges you&#39;ve overcome as a survivor.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Cognitive Behavioral Therapy (CBT) </h5>
	</li>
</ul>

​​​​​​​CBT can prove beneficial in treating mental disorders among breast cancer survivors. It can also help them deal with the fear of recurrence.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Acceptance And Commitment Therapy (ACT)</h5>
	</li>
</ul>

​​​​​​​Unlike CBT which aims to change one&#39;s unhealthy thoughts and feelings, ACT teaches skills that help people accept their realities and live with them.

&nbsp;

<ul>
	<li>
	<h5>Mindfulness-Based Therapy</h5>
	</li>
</ul>

​​​​​​​Mindfulness meditation helps people become aware and accepting of their thoughts and feelings, without any judgment. In breast cancer survivors, it can help improve fatigue, stress, and symptoms of depression and anxiety.

&nbsp;

<ul>
	<li>
	<h5>Medication</h5>
	</li>
</ul>

​​​​​​​Some patients may also benefit from anti-anxiety pills and anti-depressants. However, professional help should be sought before starting any medication.

&nbsp;

<h4>"Supporting cancer survivors can lower their stress levels. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> to monitor your stress level today!" </h4>

While cancer is a challenging time for the patient, it also takes a toll on one&#39;s family and friends who are helping them through the disease. Moreover, it can often put a strain on people&#39;s relationships with their partners. According to research, anxiety, and depression more commonly affects long-term cancer survivors and their spouses compared to healthy controls<a href="#accordion">[6]</a>.&nbsp;

If a friend or family member is a breast cancer survivor, the following can help you deal with the emotional and psychological toll:

<ul>
	<li>Support Groups - Online or in-person support groups can help people realize that they are not alone. It allows you to talk about your feelings in a safe space and trade advice with others going through similar experiences. There are also many support groups for family members of survivors on social media.&nbsp;</li>
	<li>Couples Therapy - Cancer can often affect one&#39;s personal relationships. Many partners may benefit from couple&rsquo;s therapy to improve their family and marriage relationships.&nbsp;</li>
</ul>

&nbsp;

While a cancer diagnosis and going through treatment is emotionally and physically exhausting, the post-cancer period is often what really tests the person. Both cancer survivors and their family members go through a period of psychological distress. Therefore, there is a need for programs and interventions that target both patients and their caretakers and family. Moreover, early screening breast cancer patients for mental health disorders can also help provide timely intervention and reduce the disease burden.

<ul>
	<li>A combination of physical, cultural, and social factors contributes to a delayed diagnosis of breast cancer among women. This leads to a poor prognosis and the use of aggressive treatments.</li>
	<li>Breast cancer survivors often report fatigue, pain, sleep disturbances, <a href="https://merisehat.pk/disease/depression">depression</a>, and <a href="https://merisehat.pk/disease/anxiety">anxiety</a>. Moreover, post-mastectomy or breast surgery, women report lower self-esteem and body image issues as breasts are considered a symbol of femininity, beauty, and womanhood.&nbsp;</li>
	<li>Breast reconstructive surgery, cognitive behavioral&nbsp;therapy, mindfulness meditation, acceptance and commitment therapy, and medications can help breast cancer survivors improve their overall quality of life.</li>
	<li>Partners of breast cancer survivors also report similar levels of anxiety and depression as them. Therefore, there is a need for effective programs that target both survivors and their families to help provide them timely support.&nbsp;</li>
</ul>

&nbsp;

[1] International Agency for Research on Cancer, 2021. Pakistan Globocan 2020. [Online]

[2] Sohail, S. & Alam, S. N., 2007. Breast cancer in pakistan - awareness and early detection. Journal of the College of Physicians and Surgeons Pakistan, 17(12), pp. 711-2.

[3] Gulzar, F. et al., 2019. Identifying the reasons for delayed presentation of Pakistani breast cancer patients at a tertiary care hospital. Cancer management and research, Volume 11, pp. 1087-1096.

[4] Carreira, H. et al., 2021. Associations between breast cancer survivorship and adverse mental health outcomes: A matched population-based cohort study in the United Kingdom. PLOS Medicine, 18(1).

[5] Azam, M. et al., 2021. An empirical study on quality of life and related factors of Pakistani breast cancer survivors. Scientific Reports, Volume 11.

[6] Mitchell, A. J. et al., 2013. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis. The Lancet Oncology, 14(8), pp. 721-732.

Nimrah H. Sattar

Medilink Consultant clinic

Saad Ullah Siddiqui

Menopause And Breast Cancer

According to research, in all of Asia, Pakistan has the highest rate of breast cancer, with 1 in 9 women at risk of getting diagnosed with breast cancer<a href="#accordion">[7]</a>&nbsp;<a href="#accordion">[6]</a>. This is usually because of the myths associated with the condition. Delayed screening means the cancer is diagnosed when it has advanced and there is little chance of survival.

Understanding the link between Menopause and Breast cancer

Age is one of the major risk factors for developing breast cancer. The likelihood of being diagnosed with a malignant tumor in the breast is greatest between the ages of 45 and 55. Unless an individual has previously undergone chemotherapy, surgeries such as hysterectomy or oophorectomy, or possesses a genetic predisposition to experience early menopause, this is when a natural decline in hormone levels occurs.

The decreased production of estrogen and progesterone leads to irregular menstrual periods before they eventually cease. During this phase, one may experience hot flashes, sexual difficulties, insomnia, memory problems, osteoporosis, and anxiety.

However, menopause itself is not our concern here. Menopause itself is not related to a higher risk of getting cancer. It&rsquo;s the fact that 1 out of 8 cases of breast cancer occur during their lifetime, mostly in women over 50, that&rsquo;s worrisome<a href="#accordion">[8]</a>. This is why the age factor is important &ndash; a girl who starts menstruating before 12 and/or experiences menopause after 55 will have an increased number of ovulations and, thereby, increased exposure to hormones like estrogen.

And then there&rsquo;s the issue of medications or treatments like hormone replacement therapy one may be taking to manage the menopausal symptoms, which increases the risk of breast cancer. 
&nbsp;

While menopause is a risk factor for breast cancer, interestingly, breast cancer can also induce menopause. Treatments like chemotherapy, ovarian suppression (through surgery, hormone therapy, or radiotherapy), and hormone therapy (e.g., anastrozole, exemestane, letrozole, and tamoxifen) cause menopausal symptoms<a href="#accordion">[9]</a>.&nbsp; While each woman reacts differently to therapy, premature menopause due to breast cancer may be permanent (rather than temporary) if they&rsquo;re closer to the natural age of experiencing it. 
&nbsp;

Menopausal signs that are frequently experienced include:

<ul>
	<li>Joint pain</li>
	<li>Night sweats</li>
	<li>Anxiety and irritation</li>
	<li>Mood change</li>
	<li>Heart palpitations</li>
	<li>Change in libido</li>
	<li>Hot flushes</li>
	<li>Changes to hair and skin</li>
	<li>Weight gain, especially around our waist</li>
	<li>Difficulty sleeping</li>
	<li>Memory issues</li>
	<li>Vaginal dryness 
	&nbsp;</li>
</ul>

The onset of these symptoms can be gradual or sudden. It is worth mentioning that not all individuals experience all the listed symptoms, and the severity of symptoms can vary among individuals. 
&nbsp;

The estrogen-driven breast cancers, also known as estrogen-receptor-positive cancers, are a more common occurrence than aggressive cancers. They tend to develop gradually and have a lower mortality rate. In other words, they require less aggressive therapy and have a better outlook and reduced chance of recurrence.

According to studies, if you&rsquo;re overweight or obese post-menopause, you have a 20-60% greater risk of developing breast cancer than those who are lean<a href="#accordion">[10]</a>. This extra fat is the main source of estrogen at that time. It also produces proteins that increase inflammation throughout the body, which causes breast cancer to recur. 
&nbsp;

<h5 style="text-align:justify">Medications</h5>

There are two distinct kinds of drugs, and they both function differently. Aromatase inhibitors (AIs) reduce or halt the body&#39;s production of estrogen, which causes the tumors to die. Tamoxifen prevents estrogen from acting on breast cancer cells.

Both tamoxifen and an aromatase inhibitor can be used to treat postmenopausal individuals with estrogen-positive breast cancer. However, aromatase inhibitors are generally more effective and do not increase the risk of blood clots or uterine cancer<a href="#accordion">[10]</a>. 
&nbsp;

Exercising, a balanced diet, quitting smoking (including avoiding passive smoking) and drinking alcohol, and relieving stress can help breast cancer patients deal with the symptoms. 
&nbsp;

Menopause can be a risk factor for breast cancer and vice versa. However, you can overcome both issues with a balanced diet, a healthy lifestyle, proper checkups, and the right therapy.

[1]Sohail S, Alam SN. Breast cancer in Pakistan-awareness and early detection.

[2] Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International journal of cancer. 2010 Dec 15;127(12):2893-917

[3] Clemons M, Simmons C. Identifying menopause in breast cancer patients: considerations and implications. Breast cancer research and treatment. 2007 Aug;104:115-20.

[4] Biglia N, Bounous VE, Sgro LG, D'Alonzo M, Pecchio S, Nappi RE. Genitourinary syndrome of menopause in breast cancer survivors: are we facing new and safe hopes?. Clinical Breast Cancer. 2015 Dec 1;15(6):413-20.

[5] De Villiers TJ, Pines A, Panay N, Gambacciani M, Archer DF, Baber RJ, Davis SR, Gompel AA, Henderson VW, Langer R, Lobo RA. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2013 Jun 1;16(3):316-37.

[6] Academic.oup.com.

[7] Khan NH, Duan SF, Wu DD, Ji XY. Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women. Cancer Manag Res. 2021;13:2125-2129. Published 2021 Mar 2. doi:10.2147/CMAR.S270671

[8] NHS choices.

[9] Menopausal symptoms and breast cancer. Breast Cancer Now.

[10] Stepko B, En español , español E, 03 O. Dealing with breast cancer after menopause. AARP

Syeda Qurat-ul-Ain

Obesity And Breast Cancer

However, the relationship between obesity and breast cancer is not straightforward. Research indicates that gaining weight as an adult increases the risk, but being overweight since childhood does not have the same effect. Additionally, excess fat around the waist will pose a greater risk than having it around the hips or thighs<a href="#accordion">[1]</a>. 
&nbsp;

Understanding of the link between Obesity and Breast Cancer

A study using BMI and cancer incidence data found that around 37,670 new cases of cancer in men and 74,69 new cancer cases in women between 2011 and 2015 were due to excess body weight (i.e. overweight, obese, or morbidly obese)<a href="#accordion">[2]</a>.

The percentage of cases due to excess weight varied across different types of cancer, with the highest number of cases of liver/gallbladder and endometrial cancers in women and esophageal adenocarcinoma in men. 
&nbsp;

Obesity is a well-established risk factor for various cancers in women. For instance, obese women are at a high risk of developing breast cancer. Moreover, they experience different treatment outcomes due to their body weight.

Both pre-and postmenopausal women are at an increased risk of developing breast cancer due to increased body weight. However, it is believed that this risk may be lower in very young premenopausal women who have no family history of breast cancer and live in developed countries. Nevertheless, obese women, regardless of age, generally have poorer survival rates. 
&nbsp;

Obesity increases the risk of some cancers in the following ways<a href="#accordion">[2]</a>:

<ul>
	<li>Fat tissue produces excess estrogen, which is associated with increased risks of breast, endometrial, ovarian, and some other cancers.</li>
	<li>Obese people usually have increased blood levels of insulin and insulin-like growth factor-1, which is responsible for the development of colon, kidney, prostate, and endometrial cancers.</li>
	<li>Obesity combined with chronic inflammatory conditions, such as gallstones or non-alcoholic fatty liver disease, can cause oxidative stress and increase the risk of the biliary tract and other cancers.</li>
	<li>Fat cells produce hormones called adipokines that can stimulate or inhibit cell growth, with high levels of leptin promoting aberrant cell proliferation and low levels of adiponectin having antiproliferative effects that protect against tumor growth.</li>
	<li>Obesity increases risk through impaired tumor immunity and changes in the mechanical properties of the scaffolding tissue that surrounds developing tumors.</li>
	<li>A poor diet is also linked to obesity since it lacks essential nutrients for maintaining healthy cells and preventing cancer.</li>
	<li>Sedentary behavior and lack of physical activity are associated with an increased risk of obesity and breast cancer.</li>
	<li>Certain genetic factors make individuals more susceptible to obesity and breast cancer.</li>
	<li>Obesity can lead to difficulties in cancer screening and management. For instance, screening for cervical cancer is not very effective in obese women. 
	&nbsp;</li>
</ul>

Note: While obesity is a risk factor for breast cancer, not all obese individuals develop breast cancer. Other factors, such as age, family history, and lifestyle choices, can also influence an individual&#39;s risk of breast cancer. 
&nbsp;

Observational studies suggest that obese people losing excess weight can reduce the risk of certain types of cancer, such as breast, endometrial, colon, and prostate cancers. However, these studies cannot prove that obesity causes cancer, and caution should be exercised in interpreting their findings.

In a study of postmenopausal women, intentional weight loss of more than 5% of body weight was associated with a lower risk of obesity-related cancers, especially endometrial cancer. 
&nbsp;

Bariatric surgery among obese people, particularly women, was associated with reduced risks of cancer overall, hormone-related cancers, and obesity-related cancers such as postmenopausal breast cancer, endometrial cancer, and colon cancer.

Nevertheless, more research is needed to fully understand the relationship between weight loss and the risk of cancer among obese people<a href="#accordion">[2]</a>. 
&nbsp;

Losing weight can improve overall health:

<ul>
	<li>Reduces risk of chronic diseases, such as type 2 diabetes, heart disease, and certain types of cancer</li>
	<li>Lowers blood pressure and improves cholesterol levels</li>
	<li>Decreases strain on joints, hence, reducing pain and improving mobility</li>
	<li>Improves sleep quality and reduces the risk of sleep apnea</li>
	<li>Improves mood and decreases risk of depression and anxiety</li>
	<li>Increases energy levels and improves physical performance</li>
	<li>Reduces risk of pregnancy complications and infertility</li>
	<li>Improves immune function and reduces inflammation</li>
	<li>Improves brain function and cognitive performance 
	&nbsp;</li>
</ul>

An effective way to reduce weight includes a combination of a healthy diet, regular exercise, and lifestyle changes. Here are some specific tips that can help<a href="#accordion">[3]</a>:

Eat A Balanced And Nutritious Diet: It&rsquo;s important to eat a balanced diet, which includes plenty of fruits and vegetables, whole grains, lean proteins, and healthy fats. Avoid processed and high-calorie foods.

Control Portion Sizes: Use smaller plates and cups, and measure the portions to avoid overeating.

Stay Hydrated: Drink plenty of water and avoid sugary drinks.

Exercise Regularly: At least 30 minutes of moderate-intensity exercise every day, such as brisk walking, cycling, or swimming, is recommended.

Be Active: Find ways to stay active throughout the day. For instance, take the stairs instead of the elevator or walk during lunch breaks.

Get Enough Sleep: Aim for at least 7-8 hours of sleep every night, as lack of sleep can affect weight loss.

Manage Stress: Stress can contribute to weight gain, so find ways to manage stress, such as meditation or deep breathing exercises.

Seek Support: A registered dietitian or a personal trainer can help develop a personalized weight loss plan and provide support and accountability. 
&nbsp;

Obesity has been linked to an increased risk of breast cancer in postmenopausal women. This is thought to be because adipose tissue produces estrogen, which can promote the growth of estrogen-sensitive breast cancer cells. Additionally, obesity can lead to chronic inflammation and insulin resistance; both increase the risk of breast cancer. 
&nbsp;

However, the relationship between obesity and breast cancer is complex and not fully understood. Other factors, such as age, family history of breast cancer, and hormone therapy use, can also affect a woman&#39;s risk of developing breast cancer. Therefore, women should maintain a healthy weight and engage in regular physical activity to reduce their risk of breast cancer and other health problems. Additionally, regular breast cancer screening, such as mammograms, can help detect breast cancer early when it is most treatable. 
&nbsp;

Key Takeaways

<ul>
	<li>Obesity is a major risk factor for breast cancer, especially in postmenopausal women.</li>
	<li>Excess body fat can cause hormonal imbalances that increase the risk of breast cancer.</li>
	<li>Obesity can also lead to inflammation, which can promote the development of breast cancer.</li>
	<li>Obese women are more likely to have larger tumors and more aggressive forms of breast cancer.</li>
	<li>Obesity can reduce the effectiveness of breast cancer treatment and increase the risk of recurrence.</li>
	<li>Losing weight can reduce the risk of developing breast cancer in postmenopausal women.</li>
	<li>Maintaining a healthy weight through a balanced diet and regular exercise can reduce the risk of breast cancer.</li>
	<li>Obese women may have difficulty detecting breast cancer through self-examination or mammography.</li>
	<li>Breast cancer survivors who are overweight or obese have a higher risk of recurrence and lower survival rates.</li>
	<li>Addressing obesity through lifestyle changes and medical interventions can improve overall health and reduce the risk of breast cancer. 
	&nbsp;</li>
</ul>

[1] How your weight may affect your risk of breast cancer. American Cancer Society.

[2] Obesity and cancer fact sheet. National Cancer Institute.

[3] Health effects of overweight and obesity. Centers for Disease Control and Prevention.

[4] Clinics in oncology research article.

Sarah Mhowwala

Is A Family History Of Ovarian Cancer A Risk Factor For Breast Cancer?

Inherited mutations in the BRCA1 and BRCA2 genes are known to increase the risk of both breast and ovarian cancers. About 3% of breast cancers and 10% of ovarian cancers are caused by inherited mutations in these genes1. Other inherited mutations can also increase the risk of developing breast and ovarian cancers, but BRCA1 and BRCA2 are the most common.

Even though breast cancer is more common in women, men with these mutations are also at an increased risk of developing breast cancer. Additionally, BRCA mutations can also increase the risk of pancreatic cancer and, in men, high-grade prostate cancer.

Genetic counseling and testing can help you determine if you are at increased risk for these cancers and allow you to take steps to prevent them or detect them earlier when they are more treatable.

This article explores the link between breast and ovarian cancer, and how your family health history can help you assess your risk for these cancers. 
&nbsp;

Understanding the link between Ovarian Cancer and Breast Cancer

Ovarian cancer is a term used to describe a group of diseases that begin in the ovaries, fallopian tubes, or the peritoneum, which is the lining of the abdominal cavity.

In women, the reproductive system includes two ovaries in the pelvis, one on each side of the uterus. Ovaries don&rsquo;t just produce eggs. They are also responsible for the female sex hormones estrogen and progesterone, which play an important role in the development of female reproductive organs and the regulation of the menstrual cycle.

Ovarian cancer affects their ability to function properly and causes a range of symptoms, including abdominal pain, bloating, and changes in bowel habits. Successful treatment and survival depend on early detection and treatment of cancer. 
&nbsp;

Hereditary Breast and Ovarian Cancer (HBOC) is a genetic condition that is passed down from one generation to another within a family. It is caused by mutations in two genes, called BRCA1 and BRCA<a href="#accordion">[2]</a>. 
&nbsp;

These genes play a crucial role in regulating the growth and repair of cells in the body, including breast and ovarian cells. Women who carry a harmful mutation in either BRCA1 or BRCA2 have an increased risk of developing breast and ovarian cancers during their lifetime.

The risk of developing breast cancer is estimated to be between 40-85% for women with a BRCA1 mutation. BRCA2 carriers have about the same risk of breast cancer<a href="#accordion">[2]</a>. The risk of developing ovarian cancer is 39-44% for BRCA1 mutations and 11-17% for BRCA2 mutations<a href="#accordion">[3]</a>. 
&nbsp;

HBOC is usually considered in case of a personal or family history of any of the following:

<ul>
	<li>Women diagnosed with breast cancer at the age of 45 or younger</li>
	<li>Women diagnosed with breast cancer at the age of 46-50 or younger, along with at least one close blood relative with breast cancer at any age or limited family history</li>
	<li>Women diagnosed with triple negative breast cancer at the age of 60 or younger</li>
	<li>Men diagnosed with breast cancer at any age</li>
	<li>Individuals diagnosed with ovarian, fallopian tube, or primary peritoneal cancer</li>
	<li>Individuals diagnosed with cancer in both breasts</li>
	<li>Individuals diagnosed with pancreatic cancer or prostate cancer with a Gleason score of 7 or higher</li>
	<li>Individuals with a family history of breast, ovarian, pancreatic, or prostate cancer among multiple blood relatives</li>
	<li>Individuals with Ashkenazi (Eastern European) Jewish ancestry</li>
	<li>Individuals with a known BRCA mutation in the family 
	&nbsp;</li>
</ul>

Individuals at high risk should consider genetic counseling and testing to determine if they carry a harmful mutation in one of these genes, and to explore options for managing their cancer risk, such as increased surveillance or risk-reducing surgeries. 
&nbsp;

Yes, women with a family history of ovarian cancer should consider undergoing breast cancer screening at an earlier age than women without a family history.

The American Cancer Society recommends that women with a family history of breast or ovarian cancer consider genetic counseling and testing to determine if they have a higher risk of developing cancer<a href="#accordion">[4]</a>. 
&nbsp;

Women with a BRCA1 or BRCA2 mutation have the following screening options:

<ul>
	<li>Monthly breast self-examinations beginning at 18 years</li>
	<li>Bi-annual clinical breast examinations beginning at 25 years</li>
	<li>Annual MRI scans of both breasts between ages 25 and 29</li>
	<li>Annual breast MRI and mammogram between ages 30 and 75</li>
	<li>Bi-annual pelvic exam, a transvaginal ultrasound, and CA-125 blood test beginning at age 30-35</li>
	<li>Prophylactic salpingo-oophorectomy between ages 35 and 40 and after the woman is done giving birth to children 
	&nbsp;</li>
</ul>

Men with a BRCA1 or BRCA2 mutation have the following screening options:

<ul>
	<li>Monthly breast self-examinations beginning at 35 years</li>
	<li>Annual clinical breast examinations beginning at 35 years</li>
	<li>Baseline mammogram beginning at age 35 (in case of BRCA2 mutation along with gynecomastia)</li>
	<li>Annual prostate cancer screening, PSA blood test, and digital rectal exam beginning at 45 years 
	&nbsp;</li>
</ul>

Note: Talk to your doctor about your screening options as each person is different and also because, with new methods being developed, these options may change over time. 
&nbsp;

The following lifestyle changes can help reduce the risk of breast cancer in women with a family history of ovarian cancer<a href="#accordion">[5]</a>: 
&nbsp;

<h5>Maintaining A Healthy Weight</h5>

Studies have shown that women who are overweight or obese are more likely to develop breast cancer, particularly after menopause. Therefore, women with a family history of ovarian cancer should maintain a healthy weight through a healthy diet and regular exercise. 
&nbsp;

<h5>Sticking With Your Exercise Program</h5>

Regular physical activity can help reduce the risk of breast cancer in women, including those with a family history of ovarian cancer. Studies have shown that women who engage in regular physical activity have a lower risk of developing breast cancer than those who lead a sedentary lifestyle. It is recommended that women engage in at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week. 
&nbsp;

<h5>Quitting Alcohol</h5>

Alcohol consumption has been linked to an increased risk of breast cancer. Women with a family history of ovarian cancer should quit alcohol to reduce their risk of breast cancer. 
&nbsp;

<h5>Eating A Healthy Diet</h5>

A healthy diet, which is rich in fruits, vegetables, and whole grains, may help reduce the risk of breast cancer. Additionally, it is recommended that women limit their intake of processed and red meats to further reduce their risk. 
&nbsp;

Note: These lifestyle changes may not eliminate the increased risk associated with a family history of ovarian cancer. However, they can still be beneficial in reducing the risk of breast cancer and improving overall health. 
&nbsp;

A family history of ovarian cancer is a risk factor for breast cancer. Women with a first-degree relative (mother, sister, or daughter) with ovarian cancer have a higher risk of developing breast cancer than women without a family history. Additionally, women with a family history of both breast and ovarian cancer have an even higher risk of developing breast cancer. 
&nbsp;

Women with a family history of ovarian cancer need to undergo breast cancer screening at an earlier age and consider genetic counseling and testing to determine if they have a higher risk of developing cancer.

While lifestyle changes such as maintaining a healthy weight, engaging in regular physical activity, and quitting alcohol can help reduce the risk of breast cancer, they may not eliminate the increased risk associated with a family history of cancer. Therefore, early detection through regular screening and genetic counseling is important to manage the risk of breast cancer in women with a family history of ovarian cancer. 
&nbsp;

<ul>
	<li>Family history of ovarian cancer is a risk factor for breast cancer. Women with a first-degree relative with ovarian cancer have a higher risk of developing breast cancer than women without a family history.</li>
	<li>Women with a family history of both breast and ovarian cancer have a higher risk of developing breast cancer.</li>
	<li>Women with a family history of ovarian cancer should consider undergoing breast cancer screening at an earlier age than women without a family history.</li>
	<li>Early detection through regular breast cancer screening and genetic counseling is important to manage the risk of breast cancer in women with a family history of ovarian cancer. 
	&nbsp;</li>
</ul>

[1] The BRCA1 and BRCA2 genes. Centers for Disease Control and Prevention.

[2] Pruthi S, Gostout BS, Lindor NM. Identification and Management of Women With BRCA Mutations or Hereditary Predisposition for Breast and Ovarian Cancer. Mayo Clin Proc. 2010;85(12):1111-1120. doi:10.4065/mcp.2010.0414

[3] Walker M, Jacobson M, Sobel M. Management of ovarian cancer risk in women with BRCA1/2 pathogenic variants. CMAJ. 2019;191(32):E886-E893. doi:10.1503/cmaj.190281

[4] Hereditary breast and ovarian cancer. Cancer.Net

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

Breast Self-Exam: The Hows and Whys

In Pakistan, 1 in every 9 women is at risk of developing <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer</a><a href="#accordion">[1]</a>.. Moreover, breast cancer is also the most frequent cancer among both men and women in the country, accounting for 14.5% of new cases in 2020<a href="#accordion">[2]</a>. Moreover, the country continues to have a high mortality rate from the disease.&nbsp; 
&nbsp;

Developing countries like Pakistan, despite the lower incidence, have a higher morbidity and mortality rate of breast cancer than developed Western nations. This contrast is due to a myriad of reasons namely: less number of screening and treatment facilities, women are often unaware of <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer symptoms</a> or treatments and delay seeking help. As a result, many are diagnosed at a later stage and have higher mortality rates. The situation can be reversed with increasing awareness and the widespread availability of&nbsp; breast cancer screening programs.&nbsp; 
&nbsp;

Although mammograms can help detect breast cancers even before one feels a lump, breast self-exams allow you to become more familiar with the anatomy of your breasts and identify any changes.&nbsp;

&nbsp;

Understanding how to perform a self breast exam

Before you begin a breast self-exam, it is always good to discuss the correct technique with a doctor and ask for a demonstration. 
&nbsp;

Since hormonal changes can cause breast changes, a breast self-exam should be conducted a few days after the end of your menstrual cycle. However, post-menopausal women can choose any day of the month. The exam should be done while standing and lying down. It typically begins with a visual inspection.&nbsp; 
&nbsp;

<ul>
	<li>Look In The Mirror: The first step of a breast self-exam is to stand in front of a mirror without your shirt and bra and look for any changes. The arms should be hanging by the sides while you assess the breasts for any swelling, skin changes, nipple changes, dimpling of the skin, redness, or nipple discharge. The same should be repeated with the arms raised overhead. Next, press your hands firmly on your hips to flex the chest muscles as you examine for any breast changes. Remember to visually inspect both the breasts. 
	&nbsp;</li>
	<li>In The Shower: Lathering the fingers with soap and water helps them glide better over the skin. Using the pads of your three middle fingers, press with different levels of pressure on each part of the breast and feel for any lumps or thickening. Next, massage the fingers in a circular motion as you move from one spot to another. The last step is to squeeze the nipples and check for any discharge. The entire breast should be examined from the collarbone to the armpit. You can use the right hand for the left breast and vice versa.&nbsp; 
	&nbsp;</li>
	<li>Lying down: The same steps should be repeated while lying down on the back with one arm under the head. In all positions, it is important to check under the areola and the armpit.&nbsp;</li>
</ul>

&nbsp;

The following signs and symptoms are often associated with breast cancer: 
&nbsp;

<ul>
	<li>painless lump near the breast or underarm</li>
	<li>the skin over the breast thickens or becomes red</li>
	<li>breast swells, becomes painful, or develops a pitted appearance like an orange peel</li>
	<li>a recent change in nipples (become inverted)</li>
	<li>nipples or areola become scaly, sore, or develop a rash</li>
	<li>bloody or clear nipple discharge 
	&nbsp;</li>
</ul>

Don&#39;t panic if you feel a lump or find any other abnormality. Several conditions can also cause breast lumps such as fibroadenoma, and fibrocystic breast disease, both of which are benign. However, do not ignore the lump and instead make an appointment with an expert to gain a professional diagnosis. 
&nbsp;

<h4>"An early diagnosis is vital to improving one’s quality of life. Head on over to our <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> and check your stress level today!" </h4>

In Pakistan, 1 in 4 cases of hereditary breast cancer and 1 in 5 cases of male breast cancer is a result of the BRCA1/2 gene mutation<a href="#accordion">[3]</a>,&nbsp;Moreover, women with a BRCA gene mutation also have a higher risk of ovarian and other cancers. On the other hand, men with genetic changes are at a higher risk of prostate and other cancers. Therefore, if a family member has a gene mutation or a history of breast cancer, it is best to consult a genetic counsellor. They might suggest genetic testing to look for various gene mutations associated with breast cancer.&nbsp;

According to the American Cancer Society, the 5-year survival rate for all women diagnosed with breast cancer is almost 91%<a href="#accordion">[4]</a>. However, the survival rates are highly dependent on the stage one is diagnosed at, the type of cancer, the person&#39;s age, and several other factors. Early-stage diagnosis can help increase the five-year survival among these patients. Although the ACS does not recommend breast self-exams for cancer detection, researchers predict that a simple breast exam can detect around 60% of cases<a href="#accordion">[5]</a>. Hence, women are often advised to conduct regular breast self-exams to reduce their risk of delayed diagnosis. 
&nbsp;

In Pakistan, most women are unaware of breast self-exams. A study done in Islamabad, among newly diagnosed breast cancer patients, found that none of the patients with stage III and IV cancer had any concept of self-exams<a href="#accordion">[6]</a>. A lack of knowledge among women is one of the major reasons behind these statistics. Therefore, there is a need for widespread breast cancer awareness programs for women to reduce the disease burden among the population. 
 
&nbsp;

<ul>
	<li>In Pakistan, breast cancer is the most frequent cancer among both men and women and accounted for 14.5% of all new cancer cases in 2020.</li>
	<li>Breast self-exams can help women understand their breasts better and timely identify any pre-cancerous changes. The examination should be done monthly while standing and lying down.</li>
	<li>While conducting a breast self-exam, one should look out for signs such as a painless lump near the breast or armpit, skin changes, breast swelling or redness, nipple changes, and any bloody nipple discharge.&nbsp;</li>
	<li>The majority of women in Pakistan are unaware of breast self-exams or breast cancer symptoms; therefore, there is a need for effective screening and health awareness programs for the population.&nbsp;</li>
</ul>

&nbsp;

[1].Sohail, S. & Alam, S. N., 2007. Breast cancer in pakistan - awareness and early detection. Journal of the College of Physicians and Surgeons Pakistan, 17(12), pp. 711-2.

[2].International Agency for Research on Cancer, 2021. Pakistan Globocan 2020.

[3].Rashid, M. U. et al., 2019. Spectrum and prevalence of BRCA1/2 germline mutations in Pakistani breast cancer patients: results from a large comprehensive study. Hereditary Cancer in Clinical Practice, 17(27).

[4].American Cancer Society, n.d. Breast Cancer Facts & Figures 2019-2020. , Atlanta: American Cancer Society.

[5].Weiss, N. S., 2003. Breast cancer mortality in relation to clinical breast examination and breast self-examination. The Breast Journal, Volume 9, pp. 86-9.

[6].Manzoor, A., Waqar, S. H., Janjua, A. & Shah, S. A., 2017. Breast Self-Examination Knowledge and Practice Among Newly Diagnosed Patients of Carcinoma Breast. J. Soc. Obstet. Gynaecol. Pak., 7(3).

Nipple Discharge

While it sounds strange, nipple discharge is actually an occurrence that affects both males and females. However, it affects women more than men, with 50-80% of women experiencing it during their reproductive years<a href="#accordion">[1]</a>.

It is the third most frequent breast complaint, after breast pain and breast mass. 97% of cases have a benign origin and nearly 6.8% of cases in women are referred to a breast surgeon<a href="#accordion">[1]</a>. 
&nbsp;

Understanding the causes of nipple discharge

The most common types of nipple discharge are: 
&nbsp;

<ul>
	<li>Milky Discharge - The most prevalent kind of nipple discharge. This occurs in women for various reasons. For instance, if you&rsquo;re a premenopausal woman experiencing hormonal changes or if you&rsquo;ve recently stopped breastfeeding, you&rsquo;ll most likely get a milky discharge.</li>
	<li>Bloody Discharge - Blood discharge can be induced by a papilloma, a noncancerous tumor that can agitate the tissue on the inside of a breast duct. However, this occurs only in rare circumstances.</li>
	<li>Clear Discharge - Bloody or clear nipple discharge can be an indication of breast cancer, particularly if it originates from a single breast. Individuals experiencing nipple discharge related to cancer often detect a lump on the affected breast as well. Clear discharges can happen in papilloma too.</li>
	<li>Green-Tinged Discharge - This mostly indicates that there&rsquo;s a cyst beneath the areola or nipple which is draining.</li>
	<li>Brown Or Cheese-Like Discharge - This is a sign of mammary duct ectasia, which is a blocked milk duct. 
	&nbsp;</li>
</ul>

Please Note: Seeking medical consultation is essential for any nipple discharge. At the very least, it can aid in the early detection of underlying conditions or help exclude potential diseases<a href="#accordion">[2]</a>. 
&nbsp;

Common causes of normal nipple discharge are: 
&nbsp;

<ul>
	<li>Pregnancy - During the early stages of pregnancy, women often have clear discharge coming from their nipples. In later stages, the discharge becomes watery or milky.</li>
	<li>Ending Breastfeeding - A milk-like fluid continues to be discharged from the breasts for a while after discontinuing breastfeeding. This can go on till 2-3 years after breastfeeding is stopped.</li>
	<li>Stimulation - Nipple discharge due to arousal is common. Natural nipple discharge can also happen when the bra rubs against the nipples frequently or when the individual engages in strenuous exercise like jogging.</li>
	<li>Hormones - Nipple discharge occurs due to fluctuation of hormones during menstruation<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

Please Note: Seeking medical consultation is essential for any nipple discharge. At the very least, it can aid in the early detection of underlying conditions or help exclude potential diseases. 
&nbsp;

Common causes of abnormal nipple discharge are: 
&nbsp;

<ul>
	<li>Fibrocystic Breast Changes - The term &quot;fibrocystic&quot; describes the growth or presence of fibrous tissue and cysts. In this case, your breast tissue will develop lumps or thicken as a result of fibrocystic alterations and these alterations will occasionally result in the emission of clear,&nbsp;yellow, white,&nbsp;or green nipple discharge in addition to pain and itching. However, they do not suggest malignancy.</li>
	<li>Galactorrhea - You might have galactorrhea if you have a milky nipple discharge even though you are not pregnant or breastfeeding. Relax, this is not a disease. There can be multiple reasons for this condition, including:</li>
</ul>

<ol>
	<li>Tumors of the pituitary gland</li>
	<li>Medications, like psychotropic drugs or certain hormones</li>
	<li>Herbs, such as fennel or anise</li>
	<li>Hypothyroidism</li>
	<li>Illegal drugs, like marijuana</li>
</ol>

<ul>
	<li>Infection - Pus-filled nipple discharge is a sign that your breast is infected. You will also notice that your breast is tender, red, or heated to the touch if you have an infection or abscess there. This inflammation of breast tissue that occasionally involves infection is known as mastitis. Even though the condition is typically diagnosed in nursing mothers, it can also occur if you are not nursing.</li>
	<li>Mammary Duct Ectasia - It is the second most common reason for abnormal nipple discharge. It typically happens to women who are near menopause. The condition will cause inflammation and blockage of the ducts below your nipple. When these ducts are blocked, it can cause an infection, which will present as a thick, green nipple discharge.</li>
	<li>Intraductal Papilloma - These are benign or noncancerous tumors in the breast&#39;s ducts. They are the most frequent cause of abnormal nipple discharge in women. When inflamed, intraductal papilloma will cause a bloody or sticky kind of nipple discharge<a href="#accordion">[3]</a>. 
	&nbsp;</li>
</ul>

Nipple discharge is also possible in men. Some of the most common causes are:

<ul>
	<li>Deficiency of testosterone</li>
	<li>Gynecomastia, i.e., breast enlargement or tenderness</li>
	<li>Pituitary tumor</li>
	<li>Breast cancer</li>
</ul>

Nipple discharge is less common in men. Hence, they should see a doctor when and if they experience it. 
&nbsp;

Yes, you read it right &ndash; nipple discharge can also occur in babies! But don&rsquo;t be alarmed; the condition is usually NOT a cause for concern.

Nipple discharge in newborns is often related to the mother&#39;s hormones that they are exposed to during pregnancy and childbirth. Irrespective of gender, the baby will most likely have swollen breast tissue and will experience discharge from their nipples due to the presence of hormones in the mother&#39;s body, particularly estrogen. These hormones tend to stimulate the baby&#39;s breast tissue, causing it to become enlarged and sometimes produce milk.

An older name for this condition is &ldquo;witch&rsquo;s milk&rdquo; because people of the 17th century believed that witches would come and steal this milk from the baby to use in black magic! So, elders would squeeze the fluid out themselves to prevent that from happening. The practice continued until the 19th century when doctors began to discourage it as it would often result in abscesses and inflammation. Thank God for science, right?

A more medical name for the condition is neonatal galactorrhea, and it is usually harmless and goes away on its own within a few weeks to months after birth. However, parents should consult a healthcare provider if they notice any unusual or persistent symptoms, such as redness, warmth, or tenderness in the breast area, or if the discharge is accompanied by a fever<a href="#accordion">[4]</a>. 
&nbsp;

According to the International Journal of Preventive Medicine, nipple discharge can be a symptom of breast cancer. According to the same study, 7-15% of women who report nipple leakage with an unclear origin tend to develop breast cancer.

The most frequently identified diseases in women with malignant nipple&nbsp;discharge are ductal carcinoma in situ or papillary carcinoma.

Another rare kind of cancer that could result in nipple discharge is Paget&rsquo;s disease of the breast, a condition that develops in the ducts of the breasts and later moves to the nipple. 
&nbsp;

Note:&nbsp;If your doctor is unable to identify a clear benign underlying cause for nipple discharge, they&nbsp;will usually propose an imaging scan to confirm the absence of a possibly malignant lesion<a href="#accordion">[2]</a>. 
&nbsp;

Doctors use the patient&rsquo;s medical history and physical exam to diagnose nipple discharge. Some tests that are useful in diagnosing the cause of nipple discharge are:

<ul>
	<li>Imaging - mammography (X-ray of the breast), ultrasound, and MRI are recommended.</li>
	<li>Biopsy - if there is any abnormality in the previous tests, a sample of the breast tissue is taken.</li>
	<li>Blood Tests - hormone levels are measured by taking a sample of blood. 
	&nbsp;</li>
</ul>

Treatment involves eliminating the causative factor:

<ul>
	<li>Stopping or changing a medication that may be causing the discharge</li>
	<li>Removal of a cyst or lump</li>
	<li>The surgical removal of a milk duct that contains any abnormality or pathology.</li>
	<li>Treating any underlying disorders 
	&nbsp;</li>
</ul>

If you experience any of the following symptoms, visit your doctor immediately:

<ul>
	<li>A palpable lump in the breast</li>
	<li>A change in the shape or size of the breast</li>
	<li>Discharge from only one nipple</li>
	<li>Blood-colored discharge</li>
	<li>Discharge that goes on for days</li>
	<li>Swelling around the collarbone or under the armpit</li>
	<li>Nipple discharge in males</li>
	<li>Nipple discharge in females over the age of 40</li>
	<li>Smelly discharge</li>
	<li>Changes in the nipple shape, color, or texture (crusting) 
	&nbsp;</li>
</ul>

In conclusion, nipple discharge is a common condition that affects both men and women. While it can be a symptom of breast cancer, the vast majority of cases are not cancerous and can be treated easily.

It is important to seek medical attention, though, if you notice any changes in your nipple discharge, such as a change in color or consistency, or if it is accompanied by other symptoms like a lump in the breast, pain, or swelling.

Your healthcare provider will be able to diagnose the cause of your nipple discharge and recommend the appropriate treatment. Remember, early detection is key to the successful treatment of breast cancer, so it is important to stay vigilant and monitor any changes in your breast health. 
&nbsp;

<ul>
	<li>While it sounds strange, nipple discharge is actually an occurrence that may affect both males and females. </li>
	<li>The most prevalent kind of nipple discharge is white or milky. This can happen to women for a variety of reasons, including hormonal changes in premenopausal women or recently stopping breastfeeding.</li>
	<li>During the early stages of pregnancy, women often have clear discharge coming from their nipples. In later stages, the discharge becomes watery or milky. </li>
	<li>Nipple discharge in babies can also occur and is usually not a cause for concern. It is often related to the mother&#39;s hormones that the baby is exposed to during pregnancy and childbirth.</li>
	<li>According to the International Journal of Preventive Medicine, nipple discharge can be a symptom of breast cancer. According to the same study, 7-15% of women who report nipple leakage with an unclear origin tend to develop breast cancer</li>
	<li>Early detection is key to the successful treatment of breast cancer, so it is important to stay vigilant and monitor any changes in your breast health. 
	&nbsp;</li>
</ul>

[1] Sajadi-Ernazarova KR, Sugumar K, Adigun R. Breast Nipple Discharge. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls

[2] Nipple discharge: Causes and treatments. Medical News Today.

[3] Breast and nipple discharge: What it could mean. WebMD

[4] Crider C. Witch's Milk: Treatment and causes of neonatal galactorrhea. Healthline.

[5] Watson S. Nipple discharge. Healthline

Mariam Chughtai

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Breast Cancer Prognosis (By Stage)

Understanding the prognosis of breast cancer is crucial for patients and their healthcare providers, as it helps guide treatment decisions. The prognosis varies greatly based on the stage at which the cancer is diagnosed, considering factors like tumor size, lymph node involvement, and molecular characteristics. 
&nbsp;

Understanding Breast Cancer Prognosis by Stage

Breast cancer staging is a critical process that helps categorize the extent of the disease. The stages range from 0 to IV, each indicating the size of the tumor and its potential spread to nearby lymph nodes or distant organs.<a href="#accordion">[1]</a> 
&nbsp;

<ul>
	<li>Stage 0: Ductal Carcinoma In Situ (DCIS)</li>
</ul>

Cancer cells are confined to the milk ducts and have not invaded surrounding tissues at this stage. The prognosis for DCIS is usually excellent, with a very low risk of recurrence after appropriate treatment.

<ul>
	<li>Stage I: Early-Stage Invasive Breast Cancer</li>
</ul>

The tumor is small and has not spread beyond the breast. The prognosis is often favorable, with a high chance of successful treatment and long-term survival.

<ul>
	<li>Stage II: Locally Advanced Invasive Breast Cancer</li>
</ul>

Stage II is divided into IIA and IIB, with varying tumor sizes and lymph node involvement. Prognosis can vary, but timely and comprehensive treatment can significantly improve outcomes.

<ul>
	<li>Stage III: Advanced Invasive Breast Cancer</li>
</ul>

Stage III breast cancer is locally advanced and may involve multiple lymph nodes. It&rsquo;s relatively more challenging to treat. However, advancements in therapies have improved survival rates for patients with Stage III disease.

<ul>
	<li>Stage IV: Metastatic Breast Cancer</li>
</ul>

At Stage IV, cancer has spread to distant organs. While metastatic breast cancer is not curable, ongoing treatments and personalized approaches can extend survival and maintain quality of life. 
&nbsp;

Several factors impact breast cancer prognosis, including:

<ul>
	<li>Tumor Size</li>
</ul>

Larger tumors often indicate a more advanced stage and a potentially worse prognosis. Early detection and treatment play a crucial role in improving outcomes.

<ul>
	<li>Lymph Node Involvement</li>
</ul>

Cancer that has spread to nearby lymph nodes suggests a higher risk of metastasis, influencing prognosis and treatment decisions.

<ul>
	<li>Hormone Receptor Status</li>
</ul>

Hormone receptor-positive tumors respond well to hormone therapy, which can positively affect prognosis.<a href="#accordion">[2]</a>

<ul>
	<li>HER2 Status</li>
</ul>

In the case of HER2-positive or HER-2 tumors, targeted therapies can help improve outcomes.

<ul>
	<li>Treatment Options</li>
</ul>

The prognosis for breast cancer is also closely tied to the treatment approach. Common modalities include surgery, chemotherapy, radiation therapy, hormone therapy, and targeted therapy. 
&nbsp;

Survivorship is an essential aspect of breast cancer prognosis. Advances in treatments and supportive care have led to increased survival rates and improved quality of life for patients post-treatment. 
&nbsp;

The term &ldquo;prognosis&rdquo; refers to the expected outcome of a disease. In the case of cancer, most doctors discuss 5-year survival rates with their patients to discuss their prognosis. This does not mean the person will survive only for 5 years. It implies that certain research studies have followed people for 5 years.

While breast cancer is challenging to live with, the good news is that the condition has one of the highest 5-year survival rates compared to other cancers, given that it&rsquo;s diagnosed early. However, these numbers don&rsquo;t predict what will happen to you. The outlook is different for everyone and depends on a lot of other factors.

Don&rsquo;t be afraid to have an open conversation with your doctor. The survival rates have improved so much over the past few years. More people now have a better understanding of the disease and, from screening to treatment options, are adopting a positive approach to it regardless of the stage of cancer. 
&nbsp;

<ul>
	<li>Breast cancer prognosis varies significantly by stage and individual characteristics.</li>
	<li>Early detection, personalized treatment plans, and ongoing research play pivotal roles in improving outcomes.</li>
</ul>

[2] Breast Cancer Treatment (PDQ) - Health Professional Version. (2021). National Cancer Institute.

[1] Breast Cancer Stages. (2021). American Cancer Society.

Staff Writer

Breast Cancer Screening

Overview

Breast cancer screening refers to a set of tests and procedures used to detect breast cancer in women who do not have any symptoms of the disease. The risk of breast cancer increases with age.

Note: The condition rarely occurs in men. Also, given that it&rsquo;s easy to feel the characteristic lump in men, screening tests are probably not helpful in their case<a href="#accordion">[6]</a>. 
&nbsp;

Understanding the Importance of Screening for Breast Cancer

<h5>Mammography Test</h5>

Mammography is a low-dose X-ray test used to detect breast cancer early, i.e., before any symptoms are apparent. During a mammogram, the breast is compressed between two plates, and X-ray images are taken. The images are then examined by a radiologist to detect any abnormalities.

Mammography is the most commonly used screening test for breast cancer. The American Cancer Society (ACS) recommends that women who are at risk of breast cancer should begin getting yearly mammograms at age 45. Women between the ages of 40 and 44 should have the option to start screening with a mammogram every year, while women 55 and older should switch to mammograms every 2 years or have the choice to continue yearly screening<a href="#accordion">[2]</a>.

However, women with a higher risk of breast cancer need to start screening earlier or have additional tests.

The accuracy of mammography in detecting breast cancer varies depending on the woman&#39;s age, weight, breast density, size and type of tumor, and where the tumor developed in the breast. Mammography is less accurate in women with dense breasts, as dense breast tissue can hide small tumors. Therefore, some women with dense breasts may need additional tests, such as ultrasound or MRI, to detect breast cancer. 
&nbsp;

There are 3 types of mammograms:

<ol>
	<li>Film mammography</li>
	<li>Digital mammography</li>
	<li>Digital breast tomosynthesis (3D mammography)</li>
</ol>

3D mammography usually costs more than 2D mammograms. 
&nbsp;

<h5>Breast Ultrasound</h5>

Breast ultrasound uses high-frequency sound waves to produce images of breast tissue.

Ultrasound is often used as a follow-up test after a mammogram when a suspicious area is detected. It can also be used for breast cancer screening in women with dense breast tissue or women who are at high risk of breast cancer.

Breast ultrasound is a non-invasive test that is painless and does not expose the patient to radiation. However, it is less accurate than mammography in detecting breast cancer, and it may lead to more false-positive results, which can cause anxiety and additional testing. 
&nbsp;

Some people are more likely to get breast cancer. It can be moderate or high risk.

The risk is greater if the individual has:

<ul>
	<li style="text-align:justify">A genetic mutation, including BRCA1, BRCA2, TP53 (based on genetic testing)</li>
	<li style="text-align:justify">A close relative who has been diagnosed with either breast or ovarian cancer, or both</li>
	<li style="text-align:justify">Had radiation therapy to the chest when they were 10&ndash;30-year-old</li>
	<li style="text-align:justify">Cowden syndrome, Li-Fraumeni syndrome, Bannayan-Riley-Ruvalcaba syndrome, or a close loved one has been diagnosed with one of this syndromes<a href="#accordion">[2]</a> 
	&nbsp;</li>
</ul>

<h5 style="text-align:justify">Pro Of Breast Cancer Screening</h5>

Reportedly, breast screening saves nearly 1,300 lives every year in the UK<a href="#accordion">[7]</a>. This is because screening helps spot cancer that is too small to see or feel, thereby, helping with early diagnosis.

Early diagnosis means there is:

<ul>
	<li style="text-align:justify">A greater chance of treatment being successful</li>
	<li style="text-align:justify">A reduced chance of aggressive treatments, like mastectomy (breast removal surgery) and chemotherapy</li>
	<li style="text-align:justify">A greater chance of being cured 
	&nbsp;</li>
</ul>

<h5 style="text-align:justify">Cons Of Breast Cancer Screening</h5>

<ul>
	<li style="text-align:justify">Overdiagnosis And Overtreatment: Finding breast cancer early doesn&rsquo;t necessarily mean that it would improve the patient&rsquo;s life or even help them live longer. The biggest risk, especially with mammography, is that it diagnoses problems in the breast that wouldn&rsquo;t cause any negative consequences. This &lsquo;overdiagnosis&rsquo; eventually leads to &lsquo;overtreatment&rsquo; that can be potentially harmful. 
	&nbsp;</li>
	<li style="text-align:justify">False-positive Test Results: This refers to abnormal screening test results even though there&rsquo;s no cancer present. As a result of the screening, a doctor will order diagnostic tests such as a biopsy, which is a risky business.</li>
</ul>

False-positive usually occur if the woman:

<ol>
	<li style="text-align:justify">Is under 50</li>
	<li style="text-align:justify">Has a family history of breast cancer</li>
	<li style="text-align:justify">Has had previous breast biopsies</li>
	<li style="text-align:justify">Has taken hormones for menopause</li>
	<li style="text-align:justify">Is getting mammography for the first time; for every 10 women who have a single mammogram, 1 will have a false-positive result</li>
</ol>

Also, the skill of the radiologist can affect the result. Besides, the chance of having a false-positive increase with the number of mammograms a woman has.

Psychologically, a false-positive test and the need to get more tests can increase anxiety during diagnostic testing. Moreover, these tests can be invasive, expensive, and time-consuming. 
&nbsp;

<ul>
	<li style="text-align:justify">False-negative Test Results: This refers to the normal test results even though breast cancer is present. This would delay the necessary treatment and care the patient needs at the time. 1 in 5 cancers is missed due to mammography.</li>
</ul>

False-negative usually occur if the woman:

<ol>
	<li style="text-align:justify">Is young</li>
	<li style="text-align:justify">Has cancer that is not dependent on estrogen and progesterone hormones</li>
	<li style="text-align:justify">Has dense breast tissue</li>
	<li style="text-align:justify">Has fast-growing cancer 
	&nbsp;</li>
</ol>

<ul>
	<li style="text-align:justify">Discomfort: Pain or discomfort during a mammogram screening usually depends on the woman&rsquo;s anxiety level and the phase of the menstrual cycle.</li>
	<li style="text-align:justify">Radiation Exposure: Even though the radiation dose of a screening mammogram is very low, it nevertheless exposes the breast to radiation.</li>
</ul>

<ol>
	<li style="text-align:justify">Having a mammogram every 3 years for 20 years increases the risk of getting cancer over a lifetime</li>
	<li style="text-align:justify">Women with breast implants or large breasts are exposed to slightly higher radiation doses during the mammography</li>
</ol>

That said, the benefits of breast screening outweigh the risk of the procedure, which is why it&rsquo;s not recommended for anyone to skip it.

Early detection of breast cancer is crucial for successful treatment and survival. Women should talk to their healthcare providers about their risk factors for breast cancer and when to start screening. Typically, women with a family history of breast cancer or other risk factors are advised to start screening earlier or have additional tests. 
&nbsp;

Some screening tests that are still being studied in clinical trials include:<a href="#accordion">[6]</a> 
&nbsp;

<ul>
	<li>Thermography</li>
</ul>

A special camera is used to record the temperature of the skin over the breast. Tumors cause temperature changes that can be detected during the procedure.

<ul>
	<li>Tissue Sampling</li>
</ul>

A sample of the cells from breast tissue is taken for microscopic evaluation. 
&nbsp;

Breast cancer is the most common cancer among women globally, including in Pakistan. In Pakistan, breast cancer is the leading cause of cancer-related deaths among women. Unfortunately, due to a lack of awareness and resources, many cases of breast cancer in Pakistan are diagnosed at an advanced stage, which leads to lower survival rates.

In recent years, though, there has been some progress in breast cancer awareness and screening programs in Pakistan. Various non-profit organizations, such as the Pink Ribbon Pakistan and Shaukat Khanum Memorial Cancer Hospital and Research Centre, have been working tirelessly to raise awareness about breast cancer and provide access to breast cancer screening and treatment for women in Pakistan.

The Pink Ribbon Pakistan is a non-profit organization that has been working towards breast cancer awareness and screening in Pakistan since 2004. The organization aims to educate women about breast cancer and the importance of early detection through various awareness campaigns and programs. Pink Ribbon Pakista<a href="#accordion">[5]</a>.

The Shaukat Khanum Memorial Cancer Hospital and Research Centre is another non-profit organization in Pakistan that is dedicated to providing cancer treatment and care to patients, including breast cancer patients. The hospital offers breast cancer screening services, including mammography and ultrasound, as well as breast cancer treatment services such as surgery, chemotherapy, and radiation therapy.

Apart from non-profit organizations, the government of Pakistan has also taken some steps toward breast cancer awareness and screening. The government has launched various programs to raise awareness about breast cancer and provide access to breast cancer screening for women in Pakistan. The government has also provided funding for breast cancer screening and treatment services at public hospitals.

Despite the efforts of non-profit organizations and the government, breast cancer awareness and screening programs in Pakistan still face many challenges. One of the biggest challenges is the lack of resources and facilities for breast cancer screening and treatment, particularly in rural areas of the country. Many women in rural areas do not have access to mammography or ultrasound facilities, which are essential for breast cancer screening. 
&nbsp;

Another challenge is the lack of awareness and education about breast cancer among women in Pakistan. Many women do not know about the importance of breast cancer screening or are hesitant to undergo screening due to social and cultural barriers.

In conclusion, breast cancer screening is an essential tool to detect breast cancer when the individual does not have any symptoms. Mammography is the most commonly used screening test for breast cancer, but additional tests such as ultrasound or MRI may be needed for women with dense breasts or a high risk of breast cancer. Whether a woman should be screened for breast tests or the type of screening test to use depends on multiple facts. However, women should always talk to their healthcare providers about their breast cancer screening options and when to start screening. 
&nbsp;

<ul>
	<li style="list-style-type:none">Breast cancer is a major concern for women worldwide.</li>
	<li>According to the World Health Organization (WHO), breast cancer accounts for 16% of all female cancers and is the leading cause of cancer deaths among women.</li>
	<li>Breast cancer screening refers to a set of tests and procedures used to detect breast cancer in women who do not have any symptoms of the disease.</li>
	<li>The American Cancer Society (ACS) recommends that women who are at risk of breast cancer should begin getting yearly mammograms at age 45.</li>
	<li>Women between the ages of 40 and 44 should have the option to start screening with a mammogram every year, while women 55 and older should switch to mammograms every 2 years or have the choice to continue yearly screening.</li>
	<li>MRI is not recommended as a screening test for all women. It is used in certain situations only, such as for women with a high risk of breast cancer, women with a strong family history of breast cancer, or women with dense breasts.</li>
	<li>The American Cancer Society no longer recommends breast self-exam as a screening tool for breast cancer because studies have not shown a clear benefit.</li>
	<li>Various non-profit organizations, such as the Pink Ribbon Pakistan and Shaukat Khanum Memorial Cancer Hospital and Research Centre, have been working tirelessly to raise awareness about breast cancer and provide access to breast cancer screening and treatment for women in Pakistan.</li>
</ul>

[1] Breast cancer (no date) World Health Organization. World Health Organization

[2] ACS Breast Cancer Screening Guidelines.

[3] Breast cancer information, support & donations (2023) National Breast Cancer Foundation.

[4] Breast biopsy (no date) Biopsy Procedure for Breast Cancer.

[5] *, N. (2022) National screening, Pinkribbon.

[7] NHS choices. Accessed February 27, 2023.

[6] Breast cancer screening –patient version. National Cancer Institute.

Arbaz Ansari

Does Breast Size Affect Your Risk Of Breast Cancer?

A risk factor is something that makes getting cancer more likely. It can be a habit, drug, or some illness. Various risk factors contribute to the development of breast cancer. Given that most cases of breast cancer are found in women, it&rsquo;s often likened to the presence of female hormones progesterone and estrogen.

The condition is more prevalent in high-income nations like Canada, the USA, and some European countries. Also, the risk of getting breast cancer increases with age, with most breast cancer cases in women being diagnosed between 50 and 69 years<a href="#accordion">[3]</a>. 
&nbsp;

Understanding Breast Size and Cancer Risk

Even though some research indicates that breast size does influence the risk of breast cancer, the connection is not well known and is still being researched. Women of all breast sizes can be diagnosed with breast cancer. Since bigger breasts contain more breast tissue than smaller ones, more cells can develop into cancer.

Although breast cancer can originate anywhere in the breast, it usually begins in the milk tubes or lobules. The likelihood that some or all of the breast tissue&#39;s cells will develop abnormally, ultimately developing into cancer, increases as the number of cells increases.

Breast cancer risk is four to six times higher in women with more than 75% dense breast area as compared to women with less than 5% dense area. It is usually because the tissue in dense breasts appears whitish and tumor-like on mammography, which makes it much more difficult to find breast cancer. Additionally, the development of breast cancer in dense breasts is hereditary. This means the increased risk of breast cancer in women with dense breasts is multifactorial<a href="#accordion">[4]</a>.

However, given that there are a lot of other variables, such as exposure to specific environmental factors, age, family background, hormones and behaviors (such as drinking alcohol and smoking) that can lead to breast cancer, women with smaller breasts can also get breast cancer. 
&nbsp;

A genome-wide association study demonstrated a relationship between two single nucleotide variants (SNPs) that have previously been linked to breast cancer risk and size. Additionally, they discovered a second SNP in the same locus that is strongly linked to breast size. These findings suggest that a third SNP previously linked to breast cancer may also be related to breast size.

It should be emphasized that the similarities between breast size and breast cancer in these three areas are not significant enough to explain any potential epidemiological link between breast size and breast cancer that has been suggested in other studies<a href="#accordion">[2]</a>. 
&nbsp;

Some studies have suggested a potential link between breast size and an increased risk of breast cancer. However, it is important to note that the evidence supporting this association is limited, and further research is needed to fully understand the relationship.

The size of the breast is usually just a hereditary DNA trait. Besides, many other factors can affect a person&#39;s risk of developing breast cancer, such as age, family history, hormonal factors, lifestyle factors, and exposure to certain environmental factors.

However, all women should be aware of the signs and symptoms of breast cancer and follow recommended screening guidelines to detect any potential issues early. 
&nbsp;

[1] Lee H, Li JY, Fan JH, Li J, Huang R, Zhang BN, Zhang B, Yang HJ, Xie XM, Tang ZH, Li H. Risk factors for breast cancer among Chinese women: a 10-year nationwide multicenter cross-sectional study. Journal of epidemiology. 2014 Jan 5;24(1):67-76.

[2] Eriksson N, Benton GM, Do CB, Kiefer AK, Mountain JL, Hinds DA, Francke U, Tung JY. Genetic variants associated with breast size also influence breast cancer risk. BMC medical genetics. 2012 Dec;13(1):1-8.

[3] Lee S. Risks for breast cancer. Canadian Cancer Society.

[4] Bcrf. BCRF-supported study shows correlation between family history and breast density. Breast Cancer Research Foundation. July 8, 2022. Accessed June 22, 2023.

Let&#39;s face it, most people don&#39;t like talking about periods. But the fact is the age at which a girl starts her period, also known as menarche, has an impact on her risk of developing breast cancer later in life, making it all the more important to start a healthy discussion around periods. 
&nbsp;

The first menstrual period typically happens between the ages of 10 and 16, with an average age of 12.4 years<a href="#accordion">[2]</a>. It is linked to the development of secondary sexual characteristics and marks the onset of reproductive abilities in girls. 

Numerous factors, such as socioeconomic conditions, genetics, general health, nutritional status, exercise, seasonality, and family size, are believed to determine the age at which menarche occurs. 

Breast cancer is the most common cancer among women worldwide, accounting for approximately 12.5% of all new cancer cases globally<a href="#accordion">[1]</a>. While many factors contribute to the development of breast cancer, early menarche has been identified as a potential risk factor. 
&nbsp;

Understanding the Menarche-Breast Cancer Connection

Symptoms before the first period<a href="#accordion">[3]</a>:

<ul>
	<li>Cramping in the belly, back, or legs</li>
	<li>Bloating </li>
	<li>Tender or sore breasts</li>
	<li>Pimple or acne flare-up</li>
	<li>Mood swings</li>
	<li>Fatigue or tiredness 
	&nbsp;</li>
</ul>

The girl may notice brown or red blood on her underwear during the first period. It&rsquo;s only a few spots for some girls while others go from light bleeding to heavy to light again. 
&nbsp;

Menarche is the first menstrual cycle that typically starts during puberty, usually around age 12 but can vary by several years. Early menarche refers to menstruation that starts before the age of 12. Factors that can contribute to early menarche include:

<ul>
	<li>Increased subcutaneous fat</li>
	<li>High BMI</li>
	<li>Consuming high concentrations of fructose</li>
	<li>Geographic location</li>
	<li>Ethnicity</li>
	<li>Socioeconomic status</li>
	<li>Poverty level</li>
	<li>Family structure</li>
	<li>Living arrangements</li>
	<li>Nutrition 
	&nbsp;</li>
</ul>

Irregular menstrual cycles are common among most girls after their first period. Additionally, the shorter interval between menarche (first period) and the establishment of regular menstrual cycles can contribute to an increased risk of breast cancer. 
&nbsp;

Early menarche is linked to several health issues later in life, such as obesity, diabetes, high cholesterol, depression, and eating disorders. Research shows that early menarche is also associated with an increased risk of breast cancer. 

According to a study, girls who reach menarche before 12 have a 23% higher risk of developing breast cancer as compared to those who reach it at 15 or afterwards<a href="#accordion">[4]</a>. 

One theory is that the risk is due to prolonged exposure to cyclic hormonal stimulation of breast tissue. Additionally, there is more risk from excessive exposure to exogenous estrogen and progesterone than estrogen alone. 

However, there are some limitations and biases within these studies, e.g. small sample sizes, self-reported data, and retrospective data; even demographic limitations, such as a study with a sample group living in a more rural, lower-income area than the control group<a href="#accordion">[4]</a>. 
&nbsp;

Other risk factors for breast cancer, in addition to early menarche, include:

<ol>
	<li>Age: The risk of breast cancer increases as women get older, with most cases occurring over 50.</li>
	<li>Gender: Women are more likely to develop breast cancer than men.</li>
	<li>Family History: Women are at an increased risk if their first-degree relative (mother, sister, or daughter) has had breast cancer.</li>
	<li>Genetic Mutations: Some inherited gene mutations, such as BRCA1 and BRCA2, can increase the risk of breast cancer.</li>
	<li>Medical History: Breast cancer can recur in the same breast or the other one in women with a history of the condition.</li>
	<li>Dense Breast Tissue: Women with dense breast tissue may have a higher risk of breast cancer.</li>
	<li>Radiation Exposure: Women who have had radiation therapy to the chest area for another condition (such as Hodgkin&#39;s disease) are at an increased risk.</li>
	<li>Hormone Therapy: Women who have taken hormone therapy for an extended period, such as estrogen and progesterone for menopausal symptoms, may have an increased risk.</li>
	<li>Alcohol Consumption: Consuming alcohol also increases the risk of breast cancer. 
	&nbsp;</li>
</ol>

Note: You won&rsquo;t necessarily develop breast cancer if you have one or more of these risk factors. However, it&#39;s important for you to be aware of your risk factors and to undergo regular screening for breast cancer. 
&nbsp;

While there is no sure way to prevent breast cancer, there are several steps that women can take to reduce their risk<a href="#accordion">[5]</a>:

<ul>
	<li>It&#39;s crucial to maintain a healthy weight through regular exercise and a healthy diet since being overweight or obese increases the risk of breast cancer, especially for postmenopausal women. </li>
	<li>Avoid alcohol. </li>
	<li>Women over 50 should undergo regular breast cancer screening, such as mammograms, to detect any abnormalities early on. 
	&nbsp;</li>
</ul>

Early menarche is associated with a higher risk of several health issues later in life. The prolonged exposure to cyclic hormonal stimulation of breast tissue can result in the development of hormone receptor-positive breast cancer. 

Even though more research is required to understand the relationship between early menarche and breast cancer, girls must be aware of the potential risks. 

Regular breast cancer screening and early detection are also essential for improving outcomes and survival rates. 
&nbsp;

<ul>
	<li>Early menarche refers to menstruation that starts before a girl turns 12. </li>
	<li>It is associated with a higher risk of several health issues later in life, including obesity, diabetes, high cholesterol, depression, eating disorders, and breast cancer.</li>
	<li>One theory is that the risk is due to prolonged exposure to cyclic hormonal stimulation of breast tissue. </li>
	<li>Additionally, excessive exposure to exogenous estrogen and progesterone increases the risk of breast cancer more than estrogen alone.</li>
	<li>Regular breast cancer screenings, such as mammograms, are recommended for women over 50 or earlier for those with a family history of breast cancer.</li>
</ul>

[1] Breast Cancer. Breast cancer facts & statistics 2023.

[2] Lacroix AE, Gondal H, Shumway KR, et al. Physiology, Menarche. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.