Breast Cancer Management
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Breast Cancer Management Abdul Basit FRCS Keele Medical School Friday 02 March 2012
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Transcript of Breast Cancer Management
Breast Cancer
Management
Abdul Basit FRCS
Keele Medical School Friday 02 March 2012
Further Information
• Memorial Sloan Kettering Hospital• Cancer Research UK.
This presentation can be seen on Linked-inAnd
Slideshare.com
Lactational Breast Abscess
Copyright J Michael Dixon, Lucy R Khan
Abscess drainage under USS
Peri-areolar abscess incision and drainage
Copyright J Michael Dixon, Lucy R Khan
Incision & drainage under L.A.
Copyright J Michael Dixon, Lucy R Khan
Names mentioned today in breast surgery
Paget’s disease
Sir James Paget 1874Surgeon St. Barttholomew’s Hospital,London
Ligaments of CooperSir Astley Cooper 1845
Surgeon Guy’s Hospital, London
Glands of MontgomeryWilliam Montgomery 1837
Obstetrician, Dublin, Ireland
Ductal Carcinoma of no special Type
Lobular Cancer
80 %
10 %
Ductal Cancer
Age and Risk of Breast Cancer
• Up to age 25 1: 15000• Up to age 30 1: 2000
• Up to age 40 1: 200• Up to age 50 1: 50• Up to age 60 1: 22• Up to age 70 1: 14
• Up to age 80 1: 10
Life Time Risk 1: 8
Sensitivity of Mammography by Age
Age Sensitivity30 - 39 0.5840 – 49 0.7550 - 59 0.9260 - 69 0.93
70+ 0.87
Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V (1996)
Effect of age, breast density, and family history on the
sensitivity of first screening mammography. JAMA 276: 33-38
Hormones affecting the breast
<30 30-39 40-49 50-59 60-69 70-79 ≥800
50
100
150
200
250
3
26
99
186203
123
52
Age Range 692 Operated Breast Cancer patients
University Hospital of North Staffordshire 2009 -2010
OtherMesothelioma
Cervix Liver
Multiple myeloma Brain with CNS
Oral Ovary
Leukaemias Uterus
Pancreas Stomach
Oesophagus Kidney
Bladder
Malignant melanoma
N-H-LProstate
Colorectal Lung
Breast
0 10,000 20,000 30,000 40,000 50,000
Male Female
Number of new cases
Figure 1.1: The 20 most commonly diagnosed cancers (excluding non-melanoma skin cancer), UK, 2007
Breast cancer is not the number one killer
IHD
CVA
Denen
tia
Influ
enza
Lung Can
cer
Chronic
low
er R
espira
try
Breas
t Can
cer
0
5000
10000
15000
20000
25000
30000
35000
Cause of Death in Females 2009
Nu
mb
er
– 15% decrease (42-27/100,000)
Life time risk of 1:8
47,700 new cancers per annum (2008) < 50yrs 20% 50-70yrs 50% only 33% are NHSBSP detected
>70yrs 30%
Rising Incidence over 25 years
Fall ing mortality
– 50% increase (75-122/100,000)
over 550,000 ‘survivors’8 out of 10
Tamoxifen
Use of chemotherapy in pre-menopausal women and Radiotherapy in WLE
Hormonal Therapy 5 yearsTamoxifen 20mg daily for all women
Only for post-menopausal womenThere is a choice of
Aromatase Inhibitors(A.I.) Anastrazole
LetrazoleExamestane
(Primary Hormonal Therapy)
ADJUVANT
Primary Hormonal Therapy
Neo- Adjuvant
Age related breast lumps
TOTAL MASTECTOMY VERSUS
LUMPECTOMY(Wide Local Excision)
Wide Local Excision
N Engl J Med, Vol. 347, No. 16 · October 17, 2002 · www.nejm.org
ABSTRACT
In 1976, we initiated a randomized trialto determine whether lumpectomy with or withoutradiation therapy was as effective as total mastectomyfor the treatment of invasive breast cancer.
TWENTY-YEAR FOLLOW-UP OF A RANDOMIZED TRIAL COMPARING TOTAL MASTECTOMY, LUMPECTOMY, AND LUMPECTOMY PLUS
IRRADIATIONFOR THE TREATMENT OF INVASIVE BREAST CANCER
BERNARD FISHER, M.D.,
Wide Local Excision (WLE) with Sentinel Lymph Node Biopsy (SLNB)
The Volume of Heart Irradiated
J Clin Oncol 17:101-109. 1999 by Andre´ Fortin et al. American Society of Clinical Oncology.
Wide Local Excision
Management of the axilla
Diagnosis of breast cancer
Ultrasound of axilla
Suspicious Gland (S) Normal Glands
Core Needle Biopsy(USS-CNB)
Positive Gland Negative Gland Sentinel Lymph Node Biopsy(SLNB)
Positive SLNB Negative SLNB(No further axillary treatment)Axillary Clearance
Abdul Basit et alClinical Breast Cancer
March 2011
Axillary lymph Glands
Blue Sentinel Node
Breast Cancer is potentially curable
Nottingham Prognostic Index (NPI) < 4.4
Size 20 mm Grade 3 Node Negative
10 year disease free survival = over 80 %
R.W. Blamey*, S.E. Pinder, G.R. Balla, I.O. Ellis, C.W. Elston, M.J. Mitchell, J.L. HaybittleThe Breast Institute, Nottingham City Hospital, Nottingham
E U R O P E A N J O U R N A L OF CA N C E R 4 3 ( 2 0 0 7 ) 1 5 4 5 –1 5 4 7
Early Detection
Multidisciplinary Team
• Pathologist• Radiologist• Oncologist• Surgeon
• Breast Care Nurses
10 Things you must know before you can plan treatment for breast cancer
• Age• Size of tumour 1
• Type of tumour• Grade of tumour 2
• Lymph Node3 Positive NegativeIf Pos, how many nodes out of how many ?
1,2,3 = Nottingham Prognostic Index (NPI)
Margins of clearance Lympho-vascular invasion Immunohistochemistry - 3
ER PgR Her2 Health & Performance Status
Menopausal Status
Tumour Histological Grades
Grade 1 Grade 2 Grade 3
Ki - 67
Angiolymphatic space invasion
my Ki-67 is 98%....same thing, when my oncologist said "this is the fastest growing tumor I've ever seen"..didn't help me much considering he is now retired and a world reknown breast cancer specialist.....
I too had no node involvemnet. I was dx Jan of 08...my new oncologist wants to do preventitive chemo again in 2 yrs...I am doing it, because chemo does work great against the aggresive cells....
I am clean and clear right now....triple negative as well..
Educating health promoting behaviours
Weight reductionPhysical activity and exercise 30 minutes most days.
Having first child before the age of 30Breast feeding for 6 months during reproductive life
Diet – Less saturated and animal fat - more Fruit & Veg• Less processed and red meat - more fish• Less refined flour and sugar - more fibre
Avoiding hormones in the ‘pill’ , HRT and IVF
Stockphoto.com
Ductal Carcinoma-in-Situ (DCIS)
J Cuzick, SE Pinder, IO Ellis.Lancet Oncology 7 December 2010
The UK/ANZ DCIS trial
1694 Patients followed by yearly bilateral mammography for a median of 12 years
376 Events (22%)
tamoxifen significant reduction in all contralateral events.older women benefit more from radiotherapy than younger women.
Total events in 12 years
n =376DCIS
197 (12%)
Invasive
163 (10%)
Ipsilateral 174 (10%) 122 (10%)
Contralateral 17 (1%) 39 (2%)
Annual rate of a breast event = 2 %
ALL DIAGNOSED BY SURVELLIANCE RADIOLOGY
Risk factorsFamily history of breast cancer in
relatives Age at onset of breast cancer.
• Bilateral disease.• Degree of relationship (first or greater).
• Multiple cases in the family (particularly on one side).
• Other related early-onset tumours (for example, ovary, sarcoma).
• Number of unaffected individuals (large families with many unaffected relatives will be less likely
to harbour a high-risk gene mutation).
Known Risk Factors Gail Claus Tyrer-CuzickPrediction (Amir E, Evans . J Med Genet (2003) 0.48 0.56 0.81
Personal InformationAge 20 -70 yearsBody Mass Index (BMI)Waist to Hip RatioAlcohol Intake (0-4 units daily)
YesNoNoNo
YesNoNoNo
YesYesNoNo
Hormonal /Reproductive FactorsAge at MenarcheAge at first live birthAge at menopauseHormonal replacementOral ContraceptiveBreast FeedingPlasma Oestrogen
YesYesNoNoNoNoNo
NoNoNoNoNoNoNo
YesYesYesNoNoNoNo
Personal Breast DiseaseBreast biopsiesAtypical Ductal HyperplasiaLobular Carcinoma in situBreast Density
YesYesYesNo
NoNoNoNo
YesYesYesNo
Family history First degree relative Second degree relative Third degree relative Age of the onset of breast cancer Bilateral breast cancer Male breast cancer Ovarian cancer
YesNoNoNoNoNoNo
YesYesNoYesNoYesNo
YesYesNoYesYesYesYes
Evans and Howell Breast Cancer Research 2007 9:213
Woman's age is 39 years.
Age at menarche was 13 years.
Age at first birth was 33 years.
Person is premenopausal.
Height is 1.7 m.
Weight is 64 kg.
Woman has never used HRT.
Risk after 10 years is 11.99%.
10 year population risk is 1.472%.
Lifetime risk is 37.84%.
Lifetime population risk is 9.838%.
Probability of a BRCA1 gene is 7.418%.
Probability of a BRCA2 gene is 6.146%.
?
39 39
?
39
39 49 59 69 79 0.0%
7.5%
15.0%
22.5%
30.0%
37.5%
Personal risk
Population risk
“Lifetime risk is not very useful on itsown—after all there’s a 1 in 1 life time
chance that you will die of something or other”
On August 19, 2008, it was announced that Applegate was cancer free after a double mastectomy , even though
cancer was found in only one breast.
She has an inherited genetic fault, a BRCA1 mutation.
Christina Applegate
in 2010
Her mother, Nancy Priddy is a breast cancer survivor
wikipedia.org
TRIPLE ASSESSMENT
History and Examination
ImagingHistopathology
Diagnostic accuracy approaching 99%
Lead Time Bias
Age 50 Screen detected
10mm size
Age 55 Symptomatic presentation
25mm size
Age 80
Thank you for your attention
What are the risk factors?Known risk factors for breast cancer are:being femaleincreasing ageprevious history of breast cancerhaving proven benign breast disease in the pastnot breastfeeding long termcurrent use of hormone replacement therapyhaving a family history of breast cancerhaving no children or few childrenhaving children at late ages (especially over 30)early pubertyhaving a later menopauseobesity (for post-menopausal women only)high consumption of alcohol
If you have ESTROGEN RECEPTOR POSITIVE BREAST CANCER or a history of breast cancer in the family and have taken IVF or long-term HRT, there is a high probability that you have an estrogen metabolism impairment and were unable to process these medications
Each person processes medication differently. Some women can not process (or metabolize) estrogen
correctly so when they take certain pharmaceuticals, such as fertility drugs,
the inability to process estrogen correctly can become carcinogenic.
