Breast Cancer A Family Medicine Perspective

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Breast CancerA Family Medicine Perspective

• By Robert R. Zaid, DO
• PrimeCare of Novi

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Overview

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

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Breast CancerEpidemiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Incidence
• Invasive breast cancer 1
• 1.4 million new cases in 2008
• Incidence rates for 2002 varied internationally
• 3.9 cases per 100,000 in Mozambique
• 101.1 cases per 100,000 in the United States
• Past 25 years
• Breast cancer incidence rates have risen globally
• Highest rates occurring in the westernized
  countries
• Change in reproductive patterns
• Increased screening
• Dietary changes
• Decreased activity
• Mortality
• Mortality has been decreasing
• Especially in industrialized countries.

1 American Cancer Society
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Breast CancerEpidemiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Projection (2009)
• United States
• Estimated 192,370 new cases in women
• 1,910 cases in men
• Incidence rates
• 70s to 90s had increasing incidence
• 1999-2005
• Decreased by 2.2 per year
• Why?
• Reduced use of hormone replacement therapy (HRT)
• Womens Health Initiative in 2002

Swart, R Downey, L, www.emedicine.com, Breast
Cancer
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Breast CancerEpidemiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Lifetime Risk of Breast Cancer
• All Women
• 12.7
• Non-Hispanic Whites
• 13.3
• African American Women
• 9.98
• More likely to be diagnosed with larger, advanced
  stage tumors (gt5 cm)

Swart, R Downey, L, www.emedicine.com, Breast
Cancer
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Breast CancerEpidemiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Death rates
• Steadily decreased since 1990
• Estimated 40,610 breast cancer deaths for 2009
• Women lt 50 years
• Largest decrease in mortality
• 3.3 per year
• Thought to represent
• Earlier detection
• Improved treatment modalities

Swart, R Downey, L, www.emedicine.com, Breast
Cancer
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Breast CancerEtiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mechanism-
• Current understanding of breast tumorigenesis
• Molecular alterations at the cellular level
• Outgrowth and spread of breast epithelial cells
• Immortal features
• Uncontrolled growth
• Genomic profiling
• Demonstrated the presence of discrete breast
  tumor subtypes
• Luminal A
• Luminal B
• Basal
• HER2
• The exact number of disease subtypes and
  molecular alterations from which these subtypes
  derive remains to be fully elucidated
• Generally align closely with the presence or
  absence of hormone receptor and mammary
  epithelial cell type (luminal or basal).

Swart, R Downey, L, www.emedicine.com, Breast
Cancer
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Breast CancerEtiology

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

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Breast CancerRisk Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Risk factors found by studies
• Many of these factors form the basis for breast
  cancer risk assessment tools.
• Common denominator
• Level and duration of exposure to endogenous
  estrogen
• Increase lifetime exposure to estrogen
• Premenopausal women
• Early menarche
• Nulliparity
• Late menopause
• Postmenopausal women
• Obesity and hormone replacement therapy

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Breast CancerRisk Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Family History of breast cancer
• 1st degree relative
• Risk 5 times greater in women with 2 or more
  first-degree relatives
• A family history of ovarian cancer in a
  first-degree relative
• Especially if the disease occurred at an early
  age (lt 50 years old)
• Associated with a doubling of risk of breast
  cancer

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Breast CancerRisk Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Exogenous hormones
• Oral contraceptives (OCs)
• Hormone replacement therapy (HRT)
• 1.25 increased risk among current users of oral
  contraceptives
• Risk appears to decrease
• As age and time from oral contraceptive
  discontinuation increases
• Breast cancer risk returns to that of the average
  population after approximately 10 years following
  cessation of oral contraceptives

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Breast CancerRisk Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• HRT
• Consistent epidemiologic data support an
  increased risk of breast cancer incidence and
  mortality (2003) with the use of postmenopausal
  HRT
• Directly associated with length of exposure
• Lobular (relative risk RR2.25, 95 confidence
  interval CI 2.00-2.52)
• Mixed ductallobular (RR2.13, 95 CI 1.68-2.70)
• Tubular cancers (RR2.66, 95 CI 2.16-3.28).

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Breast CancerRisk Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Combo estrogen plus progestin
• Increased risk as compared to estrogen only
• Not statistical significance (p0.06)
• Womens Health Initiative (WHI)
• Indicate that the adverse outcomes associated
  with long-term use outweigh the potential disease
  prevention benefits particularly for women older
  than 65 years
• Protective factors
• Late menarche
• Anovulation
• Early menopause (spontaneous or induced)
• Lowering endogenous estrogen levels
• Shortening the duration of estrogenic exposure. 

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Breast CancerRisk Factors
Advanced age Family history   Two or more relatives (mother, sister) One first-degree relativ Family history of ovarian cancer in women lt50y Personal history  Personal history  Positive BRCA1/BRCA2 mutation  Breast biopsy with atypical hyperplasia  Breast biopsy with LCIS or DCIS Reproductive history Early age at menarche (lt12 y) Late age of menopause Late age of first term pregnancy (gt30 y)/nulliparity Use of combined estrogen/progesterone Current or recent use of oral contraceptives Lifestyle factorsAdult weight gainSedentary lifestyleAlcohol consumption gt4 gt5 gt2 gt2 3-4 gt4 4-5 8-10 2 1.5-2 2 1.5-2 1.25 1.5-2 1.3-1.5 1.5

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

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Breast CancerRisk Assessment Tools

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Multivariate Methods for estimating breast cancer
• 2 types
• Estimate absolute risk of developing cancer
• Estimate likelihood that an individual is a
  carrier of a gene mutation
• BRCA1
• BRCA2

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Breast CancerRisk Assessment Tools

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• BRCA screens
• BRCAPRO
• Identifies 50 of mutation negative families
• Fails to screen 10 of mutation carriers
• Myriad I, II
• Manchester
• Ontario Family History
• U.S. Preventive Services Task Force (USPSTF)
• Does not specifically endorse any of these
  genetic risk assessment models because of
  insufficient data to evaluate their applicability
  to asymptomatic, cancer-free women.
• USPSTF does support the use of a greater than 10
  risk probability for recommending further
  evaluation with an experienced genetic counselor
  for decisions regarding genetic testing.

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Breast CancerRisk Assessment Tools

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Risk Prediction Models
• Gail Model (1989)
• Made from data from Breast Cancer Detection and
  Demonstration study
• Probability of developing breast cancer over a
  defined age interval
• Intended to improve screening guidelines
• Gail Model 2
• Includes history of first-degree affected family
  members
• Used extensively in clinical practice
• Most accurate for non-Hispanic White women who
  receive annual mammograms
• Tends to overestimate risk in younger women who
  do not receive annual mammograms
• Reduced accuracy in populations with demographics
  (age, race, screening habits) that differ from
  the population on which it was built
• http//www.cancer.gov/bcrisktool/

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Breast CancerRisk Assessment Tools

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Care
• Address concerns regarding applicability of the
  Gail Model to African American women
• Data from a large case control study of African
  American
• CARE Model demonstrated high concordance between
  the numbers of breast cancer predicted and the
  number of breast cancers observed among African
  American women when validated in the WHI cohort.

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Breast CancerGenetic Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Heredity
• 5-10 of women have an identifiable familial
  predisposition
• 20-30 of women with breast cancer have a
  relative with history
• BRCA1 and BRCA2 mutations
• Responsible for 3-8 of all cases of breast
  cancer
• 15-20 of familial cases
• Gene mutation on Chromosome 17 and 18
• Account for majority of inherited disease
• Believed to be tumor suppressor genes
• Rare mutations are seen in the PTEN, TP53, MLH1,
  MLH2, and STK11 genes.

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Breast CancerGenetic Factors

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mutation rates may vary by ethnic and racial
  groups.
• BRCA1 mutations
• Highest rates occur among Ashkenazi Jewish women
  (8.3)
• Hispanic women (3.5)
• Non-Hispanic white women (2.2)
• African American women (1.3)
• Asian American women (0.5)
• Women with BRCA1 or BRCA2 gene
• Estimated 50-80 lifetime risk of developing
  breast cancer.

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Breast CancerBreast Cancer Screening

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Early detection
• Primary defense available to patients
• Preventing the development of life-threatening
  breast cancer
• Breast tumors that are smaller or nonpalpable
• Treatable and have a more favorable prognosis
• Survival benefit of early detection
• Early detection is widely endorsed
• Women younger than 40 years
• Monthly breast self-examination practices
• Clinical breast exams every 3 years are
  recommended, beginning at age 20 years.

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Breast CancerBreast Cancer Screening

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mammography
• Annual screening mammography beginning at age 40
  years
• Widely recommended approach in the United States
• U.S. Preventive Services Task Force (USPSTF) Nov
  2009
• Updated breast cancer screening guidelines
• Recommend against routine mammography before age
  50 years
• 40 to 49 years of age
• USPSTF suggests that the decision to start
  regular screening mammography be individualized
  and should include the patient's values regarding
  specific benefits and harms
• American College of Obstetricians and
  Gynecologists (ACOG)
• Continues to recommend adherence to current ACOG
  guidelines
• Screening mammography every 1-2 years for women
  aged 40-49
• Screening mammography every year for women age 50
  or older
• ACOG notes, however, that because of the USPSTF
  downgrading, some insurers may no longer cover
  some of these studies.

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Breast CancerBreast Self Examination

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Breast self-examination
• Inexpensive and noninvasive procedure
• Evidence supporting effectiveness
• Controversial and largely inferred
• Not been found to reduce mortality
• Improvements in treatment for early, localized
  disease
• Breast self-examination and clinical breast exam,
  continues to be recommended
• Clinical trials support combining clinical breast
  exam with mammography

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Breast CancerBreast Self Examination

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Recommendations
• USPSTF
• Inadequate evidence to make a recommendation for
  teaching or performing BSE
• 2009 USPSTF guidelines recommend against teaching
  women how to perform BSE
• Resulted in additional imaging procedures and
  biopsies
• ACOG
• Continues to recommend counseling
• BSE has potential to detect palpable breast
  cancer

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Breast CancerMammography

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mammography
• Demonstrated to be an effective tool
• Prevention of advanced breast cancer in women at
  average risk
• Best available population-based method to detect
  breast cancer at an early stage
• Often reveals a lesion before it is palpable by
  clinical breast examination
• On average 1-2 years before noted by breast
  self-examination
• 20-30 of women still do not undergo screening as
  indicated
• Physician recommendation
• Access to health insurance
• Digital Mammograpy
• Allows the image to be recorded and stored
• Computer-aided diagnosis (CAD) systems
• Using an image modified to improve evaluation of
  specific areas in question.

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Breast CancerMammography

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Recommendations
• USPSTF
• Estimates benefit of mammography in women
• 50-74 years to be a 30 reduction risk of death
• 40-49 years, the risk of death is decreased by
  17
• Non-white women and those of lower socioeconomic
  status remain less likely to obtain mammography
  services and more likely to present with
  life-threatening, advanced-stage disease

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Breast CancerMammography

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Ultrasound
• Widely available and useful adjunct to
  mammography
• MRI
• Combination of T-1, T-2, and 3-D
  contrast-enhanced MRI techniques has been found
  to be highly sensitive
• Approximating 99
• Limitations
• 10-fold higher cost than mammography
• Poor specificity (26)
• Significantly more false-positive reads
• Significant additional diagnostic costs and
  procedures.

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Breast CancerMammography

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Below are the criteria for using breast MRI
  screening per the American Cancer Society (ACS).6
  
• Annual breast MRI
• Evidence based
• BRCA mutation
• First-degree relative of BRCA carrier, but
  untested
• Lifetime risk approximately 20-25 or greater as
  defined by BRCAPRO or other risk models
• Lifetime risk of breast cancer
• Radiation to chest when aged 10-30 years
• Li-Fraumeni syndrome and first-degree relatives
• Cowden and Bannayan-Riley-Ruvalcaba syndromes and
  first-degree relatives

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Breast CancerMammography

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Insufficient evidence to recommend for or against
  MRI screening
• Lifetime risk 15-20, as defined by BRCAPRO or
  other risk models
• Lobular carcinoma in situ or atypical lobular
  hyperplasia (ALH)
• Atypical ductal hyperplasia (ADH)
• Heterogeneously or extremely dense breast on
  mammography
• Women with a personal history of breast cancer,
  including ductal carcinoma in situ
• American Cancer Society does not recommend the
  use of breast MRI in women who have less than 15
  lifetime risk

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Breast CancerPresentation

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mammogram-
• Often irst detected as an abnormality on a
  mammogram
• Mammographic features
• Asymmetry
• Microcalcifications
• A mass
• Architectural distortion
• Larger tumors
• May present as a painless mass
• Pain
• 5 of patients with a malignant mass present with
  breast pain
• Other symptoms
• Immobility
• Skin changes (ie, thickening, swelling, redness)
• Nipple abnormalities (ie, ulceration, retraction,
  spontaneous bloody discharge)

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Breast CancerWorkup

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Core biopsy
• Percutaneous vacuum-assisted
• Image guided breast biopsy
• Recommended diagnostic approach
• Performed with
• Ultrasound
• Stereotactic, or MRI guidance
• Core biopsies spare the need for operative
  intervention
• Provides pathological results quicker than
  surgical excisions
• Excisional biopsy
• As the initial operative approach
• Shown to increase the rate of positive margins

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Breast CancerWorkup

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Palpation directed core biopsy
• If a breast mass may be palpable but not
  correlate with imaging
• Complications of a diagnostic core or excisional
  biopsy
• Hematoma
• Infection
• Scarring
• Re-operation
• Sampling error resulting in inaccurate diagnosis.

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Ductal Carcinoma in situ (DCIS)
• Lobular Carcinoma in situ (LCIS)
• Medullary Carcinoma
• Mucinous Carcinoma
• Tubular Carcinoma
• Papillary Carcinoma
• Metaplastic Carcinoma
• Mammary Pagets Disease

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Ductal Carcinoma in situ (DCIS)
• Identified in ducts (non-invasive)
• Identified on mammography
• Suspicious calcifications,
• Distribution
• Linear
• Clustered
• Segmental
• Focal
• Mixed
• DCIS is divided into comedo (ie, cribriform,
  micropapillary, solid) and noncomedo subtypes,
  which provides additional prognostic information
  regarding likelihood of progression or local
  recurrence

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Ductal Carcinoma in situ (DCIS)
• Standard treatment of DCIS is surgical resection
  with or without radiation
• Adjuvant radiation and hormonal therapies
• Reserved for
• Younger women
• Patients undergoing lumpectomy
• Comedo subtype
• Mastectomy
• 30 of women with DCIS in the United States
• Conservative Surgery
• 30 with conservative surgery alone
• Conservative surgery with whole breast radiation
• 40 with conservative surgery followed by
  whole-breast radiation therapy

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Ductal Carcinoma in situ (DCIS)
• Axillary or sentinel lymph node dissection is not
  routinely recommended for patients with DCIS
• Metastatic disease
• Disease to the axillary node in 10 of patients
• Whole-breast radiotherapy
• Delivered 5-6 weeks following
• Tamoxifen
• Adjuvant therapy for breast conserving surgery
• Only hormonal therapy currently approved
• Aromatase inhibitor (anastrozole)
• Currently in clinical trials

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Lobular Carcinoma in situ (LCIS)
• Found in the lobules (or glands)
• Non-palpable mass
• Diffuse distribution throughout the breast
• Incidence
• Doubled over last 25 years
• 2.8 per 100,000 women
• Peak incidence is in women aged 40-50 years
• No consistent features on breast imaging
• Often an incidental finding
• 10-20 of women with LCIS develop invasive breast
  cancer
• Within 15 years from diagnosis.
• LCIS is considered a biomarker of increased
  breast cancer risk
• Treatment options
• Chemoprevention with a SERM
• Bilateral mastectomy
• Close observation.

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Medullary Carcinoma
• Relatively uncommon (5)
• Invasive
• Occurs in younger women
• Presentation
• Bulky palpable mass with axillary lymphadenopathy
• Diagnosis
• Sheets of anaplastic tumor cells with scant
  stroma
• Moderate or marked stromal lymphoid infiltrate
• Histologic circumscription or a pushing border
• Other findings
• DCIS may be observed in the surrounding normal
  tissues
• ER, PR, and HER2/neu are typically negative, and
  TP53 is commonly mutated.
• Roughly 30 of patients have lymph node
  metastasis.
• Prognosis
• Good

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mucinous Carcinoma
• Rare histologic type
• Fewer than 5 of invasive breast cancer
• Produces Mucin
• Usually presents during the seventh decade
• Excellent prognosis (gt80 10-year survival).

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Tubular Carcinoma
• Uncommon histologic type
• 1-2 of all breast cancers
• Single layer of epithelial cells
• Low incidence of lymph node involvement
• Very high overall survival rate

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Papillary Carcinoma
• 1-2 of all carcinomas
• Usually seen in women older than 60
• Types
• Cystic (non-invasive)
• Good prognosis
• Micropapillary ductal carcinoma (invasive)
• Poor prognosis
• Lymph node metastasis

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Metaplastic Carcinoma
• 1 of breast cancers
• Combination of adenocarcinoma plus mesenchymal
  and epithelial components
• Wide variety of histological patterns
• Spindle-cell carcinoma
• Carcinosarcoma
• Squamous cell carcinoma of ductal origin
• Adenosquamous carcinoma
• Carcinoma with pseudosarcomatous metaplasia
• Matrix-producing carcinoma
• Metaplastic breast cancer tumors
• Larger
• More rapidly growing
• Commonly node negative
• Typically ER, PR, and HER-2 negative
• Average age of onset in the sixth decade
• Higher incidence in African Americans.

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Metaplastic Carcinoma
• Demonstrated a worse prognosis for metaplastic
  breast cancer as compared to infiltrating ductal
  carcinoma
• 3-year overall survival rate of 48-71
• 3-year disease-free survival rate of 15-60
• Prognosis / predictors of poor overall survival
• Large tumor size
• Advanced stage
• Nodal status does not appear to impact survival
  in metaplastic breast cancer

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Breast CancerHistological Findings

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mammary Pagets Disease
• 1-4 of all breast cancers
• Peak incidence is seen in the sixth decade of
  life (mean age 57 y)
• Adenocarcinoma
• Localized within the epidermis of the
  nipple-areola complex
• Paget cells
• Large
• Pale epithelial cells
• Presentation
• Lesions
• Unilateral developing insidiously
• Scaly
• Fissured
• Oozing
• Erythematous nipple-areola complex
• Retraction or ulceration of the nipple is often
  noted
• Itching, tingling, burning, or pain.
• Mammary Paget disease is associated with an
  underlying breast cancer in 75 of cases.
• Overall 5-year and 10-year survival rates are 59
  and 44, respectively.

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Breast CancerPrognosis

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Predictors / prognostic factors of BC
• Axillary lymph node status
• Tumor size
• Lymphatic/vascular invasion
• Patient age
• Histologic grade
• Histologic subtypes (eg, tubular, colloid
  mucinous, papillary)
• Response to neoadjuvant therapy
• Estrogen receptor/progesterone receptor status
• Her2/neu gene amplification and/or overexpression
  
• Breast cancer predictive factors include the
  following
• Estrogen receptor/progesterone receptor status
• Her2/neu gene amplification and/or overexpression
  
• Lymph node status

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Breast CancerStaging

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• T- tumor size
• N- Lymph node status
• M- Metastasis
• Separated into stages 0- IV
• Survival Rates 5 year
• Stages
• 0
• 99-100
• I
• 95-100
• II
• 86
• III
• 57
• IV
• 20

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Breast CancerStaging

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• National Cancer Center Network (NCCN) guideline
• Stage I or II
• Recommends a history and physical examination
• Laboratory studies (CBC with differential, liver
  and renal function tests, and calcium levels)
• Stage III
• Chest x-ray or CT scan of the chest
• CT scan of the abdomen and pelvis
• Bone scan for evaluation of distant metastasis
• Tumor markers (CEA and CA15.3 or CA27.29) may
  also be obtained in these patients

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Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Lumpectomy
• Mastectomy
• Breast Reconstruction
• Management of Contralateral breast
• Sentinel Node Dissection
• Axillary Lymph node dissection
• Breast Conserving radiation therapy
• Adjuvant Chemotherapy
• Adjuvant Hormonal Therapy
• Behavioral therapy--- Very Important

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Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Lumpectomy
• Defined as complete surgical resection of a
  primary tumor
• Goal of achieving widely negative margins
  (ideally a 1 cm margin around the lesion)
• Synonyms for lumpectomy
• Partial mastectomy
• Segmental mastectomy
• Tylectomy
• A quadrantectomy is a type of lumpectomy
• Complete removal of the entire affected breast
  quadrant
• Performed with palpation guidance or with image
  guidance

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Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Mastectomy
• Total mastectomy
• Complete removal of all breast tissue
• Clavicle superiorly
• Sternum medially
• Inframammary crease inferiorly
• Anterior axillary line laterally with en bloc
  resection of the fascia of the pectoralis major
• The nipple-areolar complex (NAC) is resected
  along with a skin paddle to achieve a flat chest
  wall closure when performing a total mastectomy.
• No removal of any axillary nodes
• Modified radical mastectomy
• Total mastectomy with axillary lymph node
  dissection

53
Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Postmastectomy Radiation Therapy
• Positive postmastectomy margins
• Primary tumors larger than 5 cm
• Involvement of 4 or more lymph nodes
• Breast Reconstruction
• SSM
• NSM

54
Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Management of Contralateral breast
• Sentinel Node Dissection
• Technetium 99
• Methylene blue dye
• First set of nodes that drain from the breast to
  the axilla
• Lymph nodes checked for metastasis
• If positive usually recommend axillary dissection
• Axillary Lymph node dissection

55
Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Breast Conserving radiation therapy
• Used to eliminate residual subclinical disease
• Side effects
• Fatigue
• Breast pain
• Swelling
• Skin desquamation
• Late toxicity (lasting 6 mo or longer following
  treatment)
• Persistent breast edema
• Pain
• Fibrosis
• Skin hyperpigmentation

56
Breast CancerTreatment

• Epidemiology
• Etiology
• Risk Factors
• Screening
• Presentation
• Workup
• Staging
• Treatment

• Adjuvant Chemotherapy
• Adjuvant Hormonal Therapy
• Estrogen-receptor positive early stage breast
  cancer
• Hormonal therapy plays a main role
• May be used with chemotherapy
• Function to decrease estrogen's ability to
  stimulate existing micro-metastases or dormant
  cancer cells
• Can reduce the relative risk of distant,
  ipsilateral, and contralateral breast cancer
  recurrence by up to 50

57
Breast Cancer

• Any questions?
• Powerpoint can be found at www.drzaid.com/presenta
  tions