(2nd Edition) - moh.gov.my

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(2 ND EDITION)

Transcript of (2nd Edition) - moh.gov.my

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(2nd Edition)

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

KEY MESSAGES

• Breastcanceristhecommonestcancerinallethnicgroupsandinallagegroupsinfemalesfromtheageof15yearsonwards.TheoverallAge-Standardised IncidenceRate(ASR)was39.3per100,000populationsin2006inMalaysia.

• Ofthecasesdiagnosedin2003,33.6%werewomenbetween40and49yearsofage.

• All Chinese women had the highest incidence with an ASR of 46.4 per 100,000population.

• Tripleassessmentwhichconsistsofclinicalassessment,imaging(ultrasoundand/ormammography)andpathology(cytologyand/orhistology)isanestablishedmethodforthediagnosisofbreastcancer.

• TheAmericanJointCommitteeonCancer(AJCC)CancerStagingManual(7thEdition)hasbeenusedforstagingofcancersintheseguidelines.

• Surgery is themainstayof treatment for earlybreast cancerandconsists of eitherbreast conserving surgery (BCS) or mastectomy, and assessment of axillary lymphnode.

• Breastcancerisrecognisedasasystemicconditioneveninearlystageofthedisease,withasignificantriskofdistantmicro-metastases.Asaresult,adjuvantchemotherapyhasanestablishedroleineradicatingthesemicro-metastases,thusimprovingsurvival.

• The diagnosis of breast cancer is undeniably distressing. In addition to the normalreactionstosuchadiagnosis,manywomenexperienceelevatedlevelsofdistressastheillnessprogresses.

• Palliativecareaimstomaximisethequalityoflifeinthetimeremainingforthepatientwithbreastcancer.

This Quick Reference provides key messages and a summary of the main

recommendations in the Clinical Practice Guidelines (CPG) Management

of Breast Cancer (2nd Edition) November 2010.

Detail of the evidence supporting these recommendations can be found in

the above CPG, available on the following websites:

Ministry of Health Malaysia : h t t p : / / w w w . m o h . g o v . m y

Academy of Medicine Malaysia : h t tp : / /www.acadmed.org.my

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

STRATIFICATION OF RISK FACTORSLow Risk Moderate Risk High Risk

•Alcoholconsumption •Increasingagefrom40yearsold

•Personalhistoryofinvasivebreastcancer

•Reproductivefactors:o Increasingageatfirstfull

termpregnancy>30yearo Hormonereplacement

therapyo Oralcontraceptivepill

usage

•Reproductivefactors:oEarlymenarche

(<12yearold)oLatemenopause

(>55yearold)oNulliparity

•LobularCarcinomaInSitu(LCIS)andDuctalCarcinomaInSitu(DCIS)

•Obesity •Benignbreastdiseasewithproliferationwithoutatypia

•Benignbreastdiseasewithatypicalhyperplasia

•Densebreast •Ionisingradiationfromtreatmentofbreastcancer,Hodgkin’sdisease,etc.

•CarrierofBRCA1and2geneticmutation

•Significantfamilyhistoryi.e.1stdegreefamilywithbreastcancer

SCREENING

Mammographymaybeperformedbienniallyinwomenfrom50–74yearsofage

Breastcancerscreeningusingmammographyinlow&intermediateriskwomenaged40–49yearsoldshouldnotbeofferedroutinely

Womenaged40–49yearsshouldnotbedeniedmammographyscreeningiftheydesiretodoso

BSEisrecommendedforraisingawarenessamongwomenatriskratherthanasascreeningmethod

CRITERIA FOR EARLY REFERRAL

• Age>40yearsoldwomenpresentingwithabreastlump

• Lump>3cmindiameteratanyage

• Clinicalsignsofmalignancy

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

PATHOLOGY REPORTING

Anadequatepathologyreportforbreastcancermusthavethefollowingminimumparameters:

• Location(sideandquadrant),maximumdiameter,multifocality

• Tumourtype(histology)

• Histologicalgrade

• Lymphnodeinvolvementandtotalnumberofnodesexamined

• Resectionmargins

• Lymphovascularinvasion

• Non-neoplasticbreastchanges

• Hormonereceptorstatus[estrogen-receptor/progesteronereceptor(ER/PR)]

• HER-2assessment

CONTRAINDICATIONS OF BREAST CONSERVING SURGERY (BCS)

• Theratioofthesizeofthetumourtothesizeofthebreastandlocationofthetumourwouldnotresultinacceptablecosmesis

• Presenceofmultifocal/multicentricdiseaseclinicallyorradiologically

• Conditionswherelocalradiotherapyiscontraindicated(suchaspreviousradiotherapyatthesite,connectivetissuediseaseandpregnancy)

SENTINEL LYMPH NODE BIOPSY (SLNB)

SLNBshouldnotbecarriedoutinwomenwithclinicallyinvolvednodes.Thesafetyandefficacyoftheprocedureforbreastcancer>3cmormultifocaldiseasehasyettobedemonstratedinrandomisedcontrolledtrials

SLNBmaybeofferedtothefollowing:

• Unifocaltumourof≤3cm

• Clinicallynon-palpableaxillarynodes

SLNBshouldonlybeperformedbysurgeonstrainedandexperiencedinthetechnique

DualtechniquewithisotopeandbluedyeinperformingtheSLNBispreferred

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

SYSTEMIC THERAPYAdjuvantchemotherapyshouldbeconsideredinallpatientswithearlybreastcancer

Adjuvant chemotherapy shouldbeoffered toallwomenwithanyof the following risk factorsespeciallyinpre-menopausalwomen:

• Oneormorepositiveaxillarylymphnodes

• ERandPRnegativedisease

• HER23+disease

• Tumoursize>2cm

• Grade3disease

ENDOCRINE THERAPY

TamoxifenshouldbeofferedtoallwomenwithERpositiveinvasiveearlybreastcancer

RADIOTHERAPYAdjuvantradiotherapyshouldbeofferedtothefollowingpost-mastectomypatientswith:

• ≥4lymphnodes

• Positivemargin

Adjuvantradiotherapycanbeofferedtothefollowingpost-mastectomypatientswith:

• 1-3lymphnodes

• Nodenegativediseasewithhigh riskof recurrencewith twoormore risk factorssuchaspresenceof lymphovascular invasion, tumours>2cm,grade3 tumours, close resectionmargin(<2mm)andpremenopausalstatus

• T3andT4tumours

All patients with post-BCS should be offered adjuvant radiotherapy for both invasivebreastcancerandDCIS

PSYCHOLOGY SUPPORTWomendiagnosedwithbreastcancershouldbescreenedforemotionaldistress

Validated self-assessment psychological tests such asHospitalAnxiety andDepressionScale(HADS),administeredbyatrainedpersonnelmaybeusedtoscreenforemotionaldistressatthetimeofdiagnosis

Allpatientswithbreastcancershouldbeassignedtoabreastcarenursewhowillsupportthemthroughoutthediagnosis,treatmentandfollowup

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

FOLLOW UP

Regularfollowupshouldbescheduledasfollows:

• threemonthlyforthefirstyear

• thensix-monthlyforfiveyears

• thenanannualreviewthereafter

Annual mammography should be offered to all patients with early breast cancer who hasundergonetreatmenttodetectrecurrenceorcontra-lateralnewbreastcancer

LIFESTYLE MODIFICATIONDiethighinfibreandlowinfattogetherwithphysicalactivityshouldbeadvisedinwomenafterdiagnosisofbreastcancer

FAMILIAL BREAST CANCER

Womenwhose familyhistory isassociatedwithan increased risk fordeleteriousmutations in

BRCA1, BRCA2 orTP53 genes should be referred for genetic counselling and evaluation for

genetic testing. This includes individuals with affected blood relatives with any one of the

followingfamilyhistorypatterns:

• 3ormoreindividualswithbreastorovariancanceratanyage

• 2ormoreindividualswithbreastcancer,1ofwhomwasdiagnosedat≤50yearsold

• 1individualwithbreastcancerdiagnosedat≤40yearsold

• 1individualwithbothbreastandovariancanceratanyage

• 1individualwithbilateralbreastcanceratanyage

• 1individualwithmalebreastcancer

• 2ormoreindividualswithovariancanceratanyage

• Family history of breast cancer in combination with other BRCA-related cancers such as

pancreas,prostateandoesophagealcancers

• FamilyhistoryofearlyonsetbreastcancerincombinationwithotherTP53-relatedcancers

suchassarcomasandmultiplecasesofchildhoodcancers

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MAnAGEMEnt oF BREASt CAnCER (2nd Edition) QUiCK REFEREnCE FoR HEALtH CARE PRoVidERS

ALGORITHM FOR TREATMENT OF OPERABLE BREAST CANCER

OPERABLE BREAST CANCER

Surgery

Breast Conserving Surgery1, axillary surgery Mastectomy Axillary surgery ± Reconstruction

Low risk1 Intermediate/high risk2

Intermediate/high risk2 Low risk

Adjuvant radiotherapy + Hormone therapy

Chemotherapy ± Herceptin Hormone therapy

Chemotherapy ± Herceptin

Adjuvant radiotherapy ± Hormone therapy

Adjuvant radiotherapy3

± Hormone therapy

1If the surgical margin is 2 mm, several factors should be cons idered in determining whether re-excision is required. These includes:

• Age

• Tumour histology (lymphovascular invasion, grade, extensive in-situ component and tumour type such as lobular carcinoma)

• Which margin is approximated by tumour (smaller margins may be acceptable for deep and superficial margins)

• Extent of cancer approaching the margin

pN0 and all of the following criteria:

• size of tumour max 2 cm

• Grade 1

• no lymphovascular invasion

• ER-/PR-positive

• HER2- negative

• age > 35 years old

pN0 and at least 1 further criteria:

• size of tumour > 2 cm

• Grade 2/3

• vessel invasion present

• HER2 over-expression

• age < 35 years old

• or pN+(N1-3) and HER2-negative

• pN+(N1-3) and HER2 over-expression

or

• pN+ (N > 4)

2Risk Stratification

Low risk Intermediate risk High risk

3 Indication for adjuvant radiotherapy

• 4 or more lymph nodes

• Positive margin

• ± 1-3 lymph nodes

• ± Node negative disease with high risk of recurrence with 2 or more risk factors such as

- presence of lymphovascular invasion, tumours greater than 2 cm, grade 3 tumours, close resection margin (< 2 mm) and premenopausal status

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