Breast Cancer

1

• Breast Cancer

2
BREAST CANCERWorldwide incidence in females
Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 19994933-64.
3
BREAST CANCERAge-specific incidence (per 100,000)
New Horizons in Cancer Management, SRI
International, 1990.
4
BREAST CANCERCumulative probability of
developing breast cancer
Feuer EJ, et al, JNCI. 1993.
5
BREAST CANCERStage at diagnosis by race
Categories do not total 100 because staging
information is not available for all cases.
Greenlee RT, et al. CA Cancer J Clin.
20015115-36.
6
BREAST CANCER5-year relative survival rate by
ethnicity
Greenlee RT, et al. CA Cancer J Clin.
20015115-36.
7
BREAST CANCERNatural history

• Highly variable course
• Relatively slow growth rate
• Generally present several years before time of
  diagnosis
• Long preclinical period potentially enables early
  detection
• Median survival gt2 years in patients receiving
  conventional treatment for metastatic disease

Osteen RT. American Cancer Society Textbook of
Clinical Oncology. 3rd ed. 2001251-268.
8
BREAST CANCERRisk factors

• Age
• Family history of breast cancer
• Prior personal history of breast cancer
• Increased estrogen exposure
• Early menarche
• Late menopause
• Hormone replacement therapy/oral contraceptives
• Nulliparity
• First pregnancy after age 30
• Diet and lifestyle (obesity, excessive alcohol
  consumption)
• Radiation exposure before age 40
• Prior benign or premalignant breast changes
• In situ cancer
• Atypical hyperplasia
• Radial scar

Osteen RT. American Cancer Society Textbook of
Clinical Oncology. 3rd ed. 2001251-268.Winer
EP, et al. Cancer Principles Practice of
Oncology. 6th ed. 20011651-1717.
9
BREAST CANCERRisk factors
Breast self-examination Examination Mammographyth
e by physician only modality shown to
decrease mortality
10
BREAST CANCERScreening (high-risk)

• Annual mammography, beginning 5 yrs before age
  of youngest affected relative at time of
  diagnosis
• Target population
• ) High familial risk
• ) BRCA 1/2-positive

Tripathy D, Henderson IC. Current Cancer
Therapeutics. 3rd ed. 1999123-129.
11
BREAST CANCERBreast inspection

• Skin dimpling

12
BREAST CANCERBreast palpation
13
BREAST CANCERRegional node assessment
14
BREAST CANCERScreening mammography

• Reduces mortality by approximately
• 25-30 in women in their 50s
• 18 in women in their 40s
• Supports view that early diagnosis and treatment
  can prevent metastases
• ACS recommends annual mammogram starting at age
  40

Rimer BK, et al. Cancer Principles Practice of
Oncology. 6th ed. 2001627-640. Smith RA.
American Cancer Society Textbook of Clinical
Oncology. 3rd ed. 200175-121.
15
BREAST CANCERHorizontal mammography
16
BREAST CANCERVertical mammography
17
BREAST CANCERSigns and symptoms at presentation
18
BREAST CANCER
19
BREAST CANCERMammography
20
BREAST CANCERUltrasonography
21
BREAST CANCERLiver metastases
22
BREAST CANCERMRI scanBone metastasis
23
BREAST CANCERDiagnostic pathway
24
BREAST CANCERBiopsy techniques for palpable and
mammographically detected masses

• Excisional biopsy (usually outpatient)
• Tumor size and histologic diagnosis
• Core-cutting needle biopsy (in-office)
• Histological diagnosis
• Fine-needle aspiration (in-office)
• Cytological diagnosis

Winer E, et al. Cancer Principles Practice of
Oncology. 6th ed. 20011651-1717.
25
BREAST CANCERFine-needle aspiration biopsy
26
BREAST CANCERPathology

• Non-invasive carcinoma in situ
• Ductal carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS)
• Invasive carcinoma
• Infiltrating ductal or lobular carcinoma
• Medullary, mucinous, and tubular carcinomas
• Uncommon tumors
• Inflammatory carcinoma
• Pagets disease

Dollinger M, et al. Everyones Guide to Cancer
Therapy. 1997356-384.
27
BREAST CANCERPathology Non-invasive DCIS LCIS
DCIS LCIS Abnormal mammogram Microscopic
characterization on biopsy Clustered
microcalcifications Solid proliferation of small
or non-palpable masses cells with uniform
round to oval nuclei 30 risk of invasive
cancer 37 chance of subsequentat 10 years at or
near invasive cancer original biopsy site
DCIS ductal carcinoma in situ. LCIS lobular
carcinoma in situ.
Winer E, et al. Cancer Principles Practice of
Oncology. 6th ed. 20011651-1717. Love S, Barsky
SH. Cancer Treatment. 4th ed. 1995337-340.
28
BREAST CANCERIncidence of major histologic types
Percent of all invasive carcinomas
Hendersn IC. American Cancer Society Textbook
Clinical Oncology. 2nd ed. 1995198-219.
29
BREAST CANCERInvasive ductal carcinoma
30
BREAST CANCERAnatomical site
31
BREAST CANCERSpread to lymph nodes
32
BREAST CANCERSites of distant metastases
33
BREAST CANCERTNM stage grouping
Note T1 includes T1 mic. Note The
prognosis of patients with N1a is similar to that
of patients with pN0.
AJCC Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers,
Philadelphia, Pennsylvania.
34
BREAST CANCERTumor definitions

• TX Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• Tis Carcinoma in situ Intraductal carcinoma,
  lobular carcinoma in situ, or Pagets disease
  of the nipple with no tumor
• T1 Tumor 2 cm or less in its greatest
  diameter T1mic Microinvasion more than 0.1 cm or
  less in its greatest diameter
• T1a Tumor more than 0.1 cm but not more than
  0.5 cm in its greatest diameter
• T1b Tumor more than 0.5 cm but not more than 1
  cm in its greatest diameter
• T1c Tumor more than 1 cm but not more than 2 cm
  in its greatest diameter
• T2 Tumor more than 2 cm but not more than 5 cm in
  its greatest diameter
• T3 Tumor more than 5 cm in its greatest diameter
• T4 Tumor of any size with direct extension to (a)
  chest wall or (b) skin, only as described below
• T4a Extension to chest wall
• T4b Edema (including peau dorange) or
  ulceration of the skin of the breast or
  satellite skin nodules confined to the same
  breast
• T4c Both (T4a and T4b)
• T4d Inflammatory carcinoma

AJCC Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers,
Philadelphia, Pennsylvania.
35
BREAST CANCERStage I
T1 N0 M0
T1a T ? 0.5 cm T1b 0.5 cm lt T ? 1 cm T1c 1
cm lt T ? 2 cm
T1
T ? 2 cm
N0 no regional lymph node metastasisM0 no
distant metastasis
36
BREAST CANCERStage IIA
37
BREAST CANCERStage IIB
38
BREAST CANCERStage IIIA
39
BREAST CANCERStage IIIB
40
BREAST CANCERStage IV
41
BREAST CANCERCommonly assessed prognostic factors
Nuclear grade Estrogen/progesteronereceptors HER2
/neu overexpression
Number of positive axillary nodes Tumor
size Lymphatic and vascular invasion Histologic
tumor type Histologic grade
Slamon DJ. Chemotherapy Foundation.
199946. Winer E, et al. Cancer Principles
Practice of Oncology. 6th ed. 20011651-1717.
42
BREAST CANCER5-year survival as function of the
number of positive axillary lymph nodes
Harris J, et al. Cancer Principles Practice of
Oncology. 5th ed. 19971557-1616.
43
BREAST CANCERHER-2/neu overexpression

• HER-2/neu gene is overexpressed in 25 to 30 of
  breast cancer patients
• There is a significant decrease of 5-year
  survival in breast cancer patients whose tumors
  overexpress HER-2/neu
• This decrease in 5-year survival is significant
  for both node-positive and node-negative patients
  
• In vitro studies show that HER-2/neu
  overexpression increases the following cell
  activities in malignant breast epithelial cells
• DNA synthesis
• Cell growth
• Anchorage-dependent growth
• Tumorgencity
• Metastatic potential

Slamon DJ. Chemotherapy Foundation Symposium.
199946. Abstract 39. Goldenberg MM. Clinical
Therapeutics. 199921(2)309-318.