BREAST CANCER

Dr Alex Mogere
Consultant physician
Defn,
• Breast cancer is a malignant proliferation of epithelial cells lining the
ducts or lobules of the breast.
Cont. incidence/epidemiology
• Account for 20% of female cancer death
• Epithelial malignancies of the breast are the most common cause of cancer
in women (excluding skin cancer), accounting for about one third of all
cancer in women.
• Women without functioning ovaries who never receive estrogen
replacement therapy do not develop breast cancer(breast ca is hormone
dependent).
• The female-to-male ratio is about 150:1
• The 3 dates in a woman’s life that have a mjr impact on breast Ca
incidence:age at menarche, age at 1st full-term prgncy, and age at
menopause.
Cont. incidence/epidemiology
• Increased caloric intake contributes to breast cancer risk in multiple ways:
• central obesity is both a risk factor for occurrence and recurrence of
breast cancer.
• Moderate alcohol intake also increases the risk by an unknown
mechanism.
• Recommendations favoring abstinence from alcohol must be weighed
against other social pressures and the possible cardioprotective effect of
moderate alcohol intake.
• Chronic low-dose aspirin use is associated with a decreased incidence of
breast cancer
Cont. incidence/epidemiology
• Depression is also associated with both occurrence and recurrence of
breast cancer.
• OCPs-these agents cause a small increased risk of breast cancer
• By contrast, OCPs offer a substantial protective effect against ovarian
epithelial tumors and endometrial cancers
• Radiation is a risk factor in younger women
• SITE: commonest in upper outer quadrant-60%
Genetic considerations
• Human breast Ca is a clonal disease; a single transformed cell
• Breast cancer may exist for a long period as either a noninvasive
disease or an invasive but nonmetastatic disease
• BRCA1-Women who inherit a mutated allele of this gene from either
parent have at least a 60–80% lifetime chance of developing breast
cancer and about a 33% chance of developing ovarian cancer.
• A p53 mutation is present in nearly 40% of human breast cancers as
an acquired defect.
The palpable breast mass
• BSE(Breast Self examination)
• Elicit nipple discharge
• Examine all regional LNs
• Lesions with certain features are more likely to be cancerous (hard,
irregular, tethered or fixed, or painless lesions).
• A negative mammogram in the presence of a persistent lump in the
breast does not exclude malignancy
• Palpable lesions require additional diagnostic procedures, including
biopsy.
Cont. palpable breast mass
• Solid lesions that are persistent, recurrent, complex, or bloody cysts
require mammography and biopsy,
• In selected pts the so-called triple diagnostic technique (palpation,
mammography, aspiration) can be used to avoid biopsy .
• FNA should be used only in centers that have proven skill in obtaining
such specimens and analyzing them.
• The likelihood of cancer is low in the setting of a “triple negative”
(benign-feeling lump, negative mammogram, and negative fine-
needle aspiration), but it is not zero
The “triple diagnosis” technique
Mx of a breast cyst
The abnormal Mammogram
• Diagnostic mammography is aimed at evaluating the rest of the breast
before biopsy is performed
• Subtle abnormalities that are 1st detected by screening mammography
should be evaluated carefully by compression or magnified views
• The abnormalities include clustered microcalcifications, densities
(especially if spiculated), and new or enlarging architectural distortion
• For some nonpalpable lesions, ultrasound may be helpful either to
identify cysts or to guide biopsy
• In the presence of a breast lump a negative mammogram does not rule
out cancer.
The abnormal Mammogram
• If a nonpalpable mammographic lesion has a low index of suspicion,
follow-up in 3–6 /12 is reasonable.
• Stereotactic biopsies: indicated for lesions that require biopsy but are
likely to be benign—for cases in which the procedure probably will
eliminate additional surgery.
• When a lesion is more probably malignant, open biopsy should be
performed with a needle localization technique.
Breast mass in pregnancy/lactation
• In Pg, the breast grows under influence of estrogen, progesterone,
prolactin, and human placental lactogen.
• Lactation is suppressed by progesterone, which blocks the effects of
prolactin.
• After delivery, lactation is promoted by the fall in progesterone levels,
which leaves the effects of prolactin unopposed
• A dominant mass must be treated with the same concern in a
pregnant woman as any other.
Breast mass in pg/lactation
• Pg women often have more advanced disease because the
significance of a breast mass was not fully considered and/or because
of endogenous hormone stimulation.
Benign breast masses
• Only about 1 in every 5–10 breast biopsies leads to a diagnosis of
cancer,
• The vast majority of benign breast masses are due to “fibrocystic”
disease(small fluid-filled cysts and modest epithelial cell and fibrous
tissue hyperplasia)
Clinical presentation
• Painless lump
• Pain
• Nipple discharge
• Skin manifestations:retracted nipple, dimpling,redness/rash, nipple
discharge,tethering, puckering,ulceration, fungation,peau d’orange,satellite
nodules, dilated veins
• Paget’s disease of the nipple
• Mastitis carcinomatosa(inflammatory carcinoma); pg and lactation
• Metastatic presentation(if this is the only presentation-occult presentation):
regional axillary or supraclavicular LN, distant mets,
• Asymptomatic: incidental finding during routine screening
INVXs
mammogram
Cont invxs.
U/S
Cont . Inxs
Biopsy
Cont. Invxs:
Core biopsy
Invxs for Mets
• Bone-bone survey
• Lung –CXR ,CT scan
• Liver –Lfts, U/S scan, CT scan
• Brain- Ct scan
TNM Staging
• Tumor size
• Node involvement
• Metastasis
Tumor involvement
Node involvement
Overall Staging
Screening for breast Ca
• Breast Ca is virtually unique among the epithelial tumors in adults in
that screening (in the form of annual mammography) improves
survival
• There is 25–30% reduction in the chance of dying from breast cancer
with annual screening after age 50 years;
• While controversy continues to surround the assessment of screening
mammography, the preponderance of data strongly supports the
benefits of screening mammography
• It seems prudent to recommend annual or biannual mammography
for women past the age of 40 year
Screening for breast Ca
• Screening by any technique other than mammography is not
indicated.
• Screening by any technique other than mammography is not
indicated.
MRI screening
• Younger women who are BRCA1 or BRCA2 carriers or untested first-
degree relatives of women with cancer;
• women with a history of radiation therapy to the chest between ages
10 and 30 years;
• women with a lifetime risk of breast cancer of at least 20%;
• women with a hx of Li-Fraumeni, Cowden, or Bannayan-Riley-
Ruvalcaba syndromes
• (the higher sensitivity may outweigh the loss of specificity.)
Breast Cancer Tx
• Combination of :
• Chemotx -neoadjuvant(preoperative),adjuvant(post operative)
• Hormonal Tx
• Surgery
• Radiation – eg after lumpectomy, local tx
Early Breast Ca Tx

• Stage 0(Non invasive):

Surgery +/- adjuvant
• Stage 1/II : surgery + adjuvant eg, lumpectomy/mastectomy,LN
removal
Advanced Breast Ca Tx
• StageIII(locally advanced): neodjuvant tx + surgery
• Stage IV(Mets): systemic tx +/- ltd surgery
Surgical Tx
Cont . Surgical Tx
When to do conservative surgical Tx
Adjuvant Tx
Cont. Adjuvant Tx
LN(Axillary) Surgery
Stage III Breast Ca Mx
Stage IV Breast Ca Mx
Endocrine Tx(Hormone sensitive Breast Ca)
• Tumors that are positive for the estrogen receptor and negative for
the progesterone receptor have a response rate of ∼30%
• Tumors that are positive for both receptors have a response rate
approaching 70%.
• If neither receptor is present, the objective response rates are <5%.
• Due to their lack of toxicity and because some pts whose receptor
analyses are reported as neg respond to endocrine tx, an endocrine tx
should be attempted in virtually every pt with metastatic breast Ca
Cont. Endocrine Tx for breast Ca
Cont. endocrine tx
• In most postmenopausal Pts, the initial endocrine tx should be an
aromatase inhibitor rather than tamoxifen
• For the subset of postmenopausal women who are estrogen
receptor–positive but also HER2/neu-positive, response rates to
aromatase inhibitors are substantially higher than to tamoxifen
• Aromatase inhibitors are not used in premenopausal women because
their hypothalamus can respond to estrogen deprivation by producing
gonadotropins that promote estrogen synthesis.
Chemotx .
• Breast Ca responds to multiple chemotherapeutic agents, including
anthracyclines, alkylating agents, taxanes, and antimetabolites
• Although patients treated with adjuvant regimens such as
cyclophosphamide, methotrexate, and fluorouracil (CMF regimens)
may subsequently respond to the same combination in the metastatic
disease setting, most oncologists use drugs to which the patients have
not been previously exposed.
• Once pts have progressed after combination drug therapy, it is most
common to treat them with single agents.
Chemo tx. For Breast Ca
• One may use an anthracycline or paclitaxel following failure with the
initial regimen.
• One randomized study has suggested that docetaxel may be superior
to paclitaxel
• The use of a humanized antibody to erbB2 (trastuzumab [Herceptin])
combined with paclitaxel can improve response rate and survival for
women whose metastatic tumors overexpress erbB2.
Prognosis
Prognostic factors
Breast cancer surveillance guidelines
THANK YOU!