BREAST CANCER COMPLICATIONS AND PROGNOSIS

Prepared byDr. Adil AlalmaiMBBS, ABFM Specialist of Family Medicine

BREAST CANCER COMPLICATIONS AND PROGNOSISObjectives:To know common complications of breast cancer.

To know prognostic factors of breast cancer.

To know staging system of breast cancer.COMPLICATIONSComplications:Organic:1)Local.2) Systemic.Psychosocial:Local Complications

Cosmetic disfiguration: Destruction of the breast, destruction of the chest wall surrounding the breast.

. Nipple discharge

Mastitis:Patient present with tenderness and erythema, accompanied by a fever of 101F (38.5 C).

Chest Pain:

about 70 to 90 percent of those with advanced solid tumors, experience chronic pain.Appropriate treatment of pain can result in 90 percent of cancer patients achieving adequate relief.There are many choices to treat cancer pain starting from non opioid such as acetaminophen to opioid(narcotics) such as morphine.Systemic:Fatigue:Cancer-related fatigueNational Comprehensive Cancer Network as a persistent, subjective sense of tiredness related to cancer or cancer treatmentthat is not proportional to recent activity and interferes with usual functioning.It has been shown that exercise, including walking and aerobic and resistance training, have beneficial effects on some symptoms related to cancer, including fatigue, distress, anxiety, and depressive symptoms.

metastsisCommon Sites of Metastsis:BONE>LUNG>LIVER>BRAIN

Complications of metastasis include:Pneumonia.Collapsed lung.Respiratory failure.Liver failure.Bone fractures.Hip fractureWrist fracture

Radiation therapyside effects

Skin burnsConfusion(with radiation to the brain)Difficulty swallowingFatigueHair lossHeadaches(with radiation to the brain)Nausea and vomitingOthercancersRashesand skin changes (discoloration)Weight loss

Side effects ofchemotherapyinclude:Anorexia.Bone marrow damage.Constipationanddiarrhea.Hair loss.Increased risk of infection.Mouth sores(mucositis).Nausea and vomiting.Weakness or fatigue.

Psychosocial:Studies have shown an increased prevalence of depression in cancer patients.

Depression has been linked to a reduced chance of survival in breast cancer patients.

Physicians may accept affective symptoms as normal and may underestimate the severity of depressive symptoms.

PrognosisprognosisDefintion:is the doctors best estimate of how cancer will affect a person, and how it will respond to treatment.The following are prognostic and predictive factors for breast cancer:

AgeStageLymph node statusTumour sizeType of tumourLymphatic and vascular invasionHormone receptor statusHER2 statusAge:Younger women (under 35 years of age) usually have a greater risk of recurrence and a poorer overall prognosis than older, post-menopausal women.

Younger women with breast cancer tend to have more aggressive, higher-grade cancer and more advanced breast cancer at the time of diagnosis.

Lymph node status:The most important prognostic factor for breast cancer is whether axillary lymph nodesinvolved or not.

Breast cancer that has spread to the lymph nodes has a higher risk of recurring and a less favourable prognosis than breast cancer that has not spread to the lymph nodes.

Breast cancer may also spread to the internal mammary lymph nodes, without having spread to the axillary lymph nodes. In this situation, the risk of recurrence is high, even though the axillary lymph nodes are negative.

The number of positive lymph nodes is also an important prognostic factor.The greater the number of positive lymph nodes, the higher the risk of recurrence.The highest risk of recurrence is for breast tumours with 4 or more positive lymph nodes.Tumour sizeThe size of a breast tumour is the second most important prognostic factor for breast cancer. The tumour size is an independent prognostic factor, regardless of the lymph node status.

The size of the tumour increases the risk of recurrence. Large breast tumours (5 cm or greater) have the greatest risk of recurrence.

Breast tumours smaller than 1 cm with no positive lymph nodes have the most favourable prognosis.

Type of tumourThetype of breast cancer tumourcan affect the prognosis.For invasive ductal carcinoma, the tubular, mucinous, medullary and papillary types have a more favourable prognosis and a better overall survival than invasive ductal carcinoma, not otherwise specified (NOS).Inflammatory breast cancer has a less favourable prognosis.Lymphatic and vascular invasionCancer cells that have spread from the breast tumour into the lymphatics or blood vessels in the breast tissue around the tumour have a greater risk of recurrence and a less favourable outcome.

Hormone receptor statusHormone receptor statusis a predictor of whether or not a tumour will respond to hormonal therapy.

Breast tumours that are hormone receptor positive (HR+) are more likely to respond tohormonal therapy.

Estrogen receptorpositive (ER+) and progesterone receptorpositive (PR+) tumours are often less aggressive, low-grade tumours that are less likely to spread than tumours that are hormone receptor negative (HR).

HER2 statusHER2 statusis another prognostic factor and may also be used to predict response to certain therapies.Tumours that overexpress HER2 (HER2-positive tumours) tend to be higher grade tumours that are more likely to spread than tumours that do not overexpress HER2.Women with HER2-positive tumours may not respond well to hormonal therapies like tamoxifen (Novadex, Tamofen) and are likely to respond well to trastuzumab (Herceptin).

Tumour recurrence or metastasis after primary treatment:There are some factors that may affect prognosis of recurrent breast cancer:

length of time from treatment to recurrencetype of recurrencetype of metastasis

length of time from treatment to recurrenceWomen whose cancer comes back more than 5 years after their diagnosis have a better outcome than those who have a recurrence less than 2 years after diagnosis.The longer period of time a woman is disease-free, the better the outcomeType of Recurrencelocal recurrence after a lumpectomy and radiation therapy has a more favourable prognosis than cancer that recurs in other organs (distant recurrence or metastases).A recurrence in the chest wall sometimes indicates a higher chance of distant metastases, although sometimes a single recurrence occurs without distant disease.Type of MetastasisLiver, lung or brain metastases have a poorer outcome than local metastases in the breast, chest wall or axilla.

Bone metastases have an intermediate prognosis, in between that of liver, lung and brain metastases and local or chest wall metastases.Staging systemTNM - systemMost common

Based on : T extent of the tumor N extent of spread to the lymph nodes M presence of metastasis

AJCC Staging System T N M Stage100I0-20-10IIa2-30-10IIb0-31-20IIIa4 or 0-11-20IIIbAny30IIIcanyany1IV

Roles and Responsibilities of the Primary Care Physician After the Diagnosis of Cancer

Be a case manager.Maintain regular contact.Be available.Have knowledge of community resources.Address ongoing health maintenance needs.Provide appropriate pain management.Assess for pathologic depression and other psychiatric pathology.Be aware of therapeutic options.Communicate with and support the patient.

QUESTIONSReferences:American Cancer Society www.cancer.orgAmerican academy of family physician.Uptodate .NICE guidelines.National Cancer Institute http://cancer.gov

THANK YOU