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Breast Cancer

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About 2,030 new male cases of breast cancer were expected in 2007. Background. The incidence of breast cancer rises after age 40. ... – PowerPoint PPT presentation

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Title: Breast Cancer


1
Breast Cancer
  • Adapted From
  • SEERs Training Web Site
  • http//training.seer.cancer.gov.index.html
  • MCR Staff
  • Supported by a Cooperative Agreement between DHSS
    and the Centers for Disease Control and
    Prevention (CDC) and a Surveillance Contract
    between DHSS and MU

2
Background
  • Excluding cancers of the skin, breast cancer is
    the most common type of cancer in women in the
    United States.
  • Accounts for one of every three cancer diagnoses.
  • An estimated 174,480 new invasive cases of breast
    cancer were expected to occur among women in the
    United States during 2007.
  • About 2,030 new male cases of breast cancer were
    expected in 2007.

3
Background
  • The incidence of breast cancer rises after age
    40.
  • highest incidence (approximately 80 of invasive
    cases) occurs in women over age 50.
  • 62,030 new cases of in situ breast cancer were
    expected to occur among women during 2007.
  • Approximately 88 will be classified as ductal
    carcinoma in situ (DCIS).

4
Background
  • 2007 - estimated 40,910 deaths (40,460 women, 450
    men)
  • Ranks second among cancer deaths in women.
  • Mortality rates steadily decreased since 1990
  • Larger decrease in women under 50
  • Due to combination of earlier detection
    improved treatment

5
Five-Year Survival Rates
  • (ACS Relative)

http//www.cancer.org/docroot/CRI/content/CRI_2_4_
3X_How_is_breast_cancer_staged_5.asp 9/13/2007
6
Risk Factors
  • Agemore prevalent in older women
  • Exposure to natural estrogens
  • First childbirth after age 30
  • Age at menopause
  • Obesityestrogens stored in body fat
  • Affluence
  • High-fat diet
  • Alcohol consumption
  • Genetics/family history

7
Reducing Risk
  • Having children at early age
  • Breast feeding
  • Healthy body weight
  • Exercise
  • Anti-estrogens

8
Symptoms
  • New lump or mass
  • painless, hard, uneven edges
  • sometimes tender, soft, or rounded
  • Swelling
  • Skin irritation or dimpling
  • Nipple pain or nipple turning inward
  • Redness or scaliness of the nipple or breast skin
  • Nipple discharge (other than milk)
  • A lump in the underarm area

9
Breast Anatomy
  • Breast
  • Made up of milk-producing glands
  • Supported and attached to the chest wall by
    ligaments
  • Rests on pectoralis major muscle
  • No muscle tissue
  • Layer of fat surrounds the glands and extends
    throughout breast
  • Three major hormones affect the breast
  • Estrogen, progesterone, and prolactin

10
Breast Anatomy
11
Breast Anatomy
  • Breast contains 1520 lobes
  • Fat covers the lobes and shapes the breast
  • Lobules fill each lobe
  • Sacs at the end of
  • lobules produce milk
  • Ducts deliver milk to the
  • nipple

12
Anatomy the lymphatic system
  • Important to know if cancer has spread to the
    lymph nodes
  • The more nodes involved, the more likely it is
    that the cancer may involve other organs.
  • Affects treatment plan.

13
Anatomy the lymphatic system
  • Most lymphatic vessels in the breast connect to
    lymph nodes under the arm (axillary)
  • Also internal mammary nodes
  • Supraclavicular or infraclavicular nodes

14
Types of Breast Cancer
  • The earliest form of the disease is ductal
    carcinoma in situ,
  • comprises about 15-20 of all breast cancers and
    develops solely in the milk ducts.
  • Invasive ductal carcinoma,
  • develops from ductal carcinoma in situ,
  • spreads through the duct walls, and
  • invades the breast tissue.
  • Most common 70-80 of cases

15
Types of Breast Cancer contd.
  • Cancer that begins in the lobes or lobules is
    called lobular carcinoma.
  • more likely to be found in both breasts.
  • accounts for 1015 of invasive breast cancers.
  • Both ductal and lobular carcinomas can be either
    in situ, or self-contained or infiltrating,
    meaning penetrating the wall of the duct or lobe
    and spreading to adjacent tissue.

16
Types of Breast Cancer contd.
  • Less common types of breast cancer include the
    following
  • Inflammatory
  • Medullary carcinoma (originates in central breast
    tissue)
  • Mucinous carcinoma (invasive usually occurs in
    postmenopausal women)
  • Paget disease of the nipple
  • Phyllodes tumor (tumor with a leaf-like
    appearance that extends into the ducts rarely
    metastasizes) and
  • Tubular carcinoma (small tumor that is often
    undetectable by palpation)

17
Inflammatory Carcinoma
  • frequently involves entire breast
  • characterized by reddened skin and edema caused
    by tumor spread to lymphatic channels of skin of
    breast
  • usually without an underlying palpable mass
  • Is a clinical diagnosis verified by biopsy of the
    tumor and overlying skin.
  • Key words lymphatic involvement of skin, peau
    d'orange, orange-peel skin, en cuirasse

Image source National Cancer Institute
18
Pagets disease
  • Crusty tumor of nipple and areola, which may be
    associated with underlying tumor of the ducts.

www.sunmed.org/cbesk2.jpg
19
DCIS
  • In Situ Abnormal cells that have not escaped the
    part of the body where they developed
  • For Breast abnormal cells in the lining of a
    milk duct that have not invaded surrounding
    breast tissue
  • Appearance of being precancerous when viewed
    under a microscope, but
  • No ability to spread as cancer cells would
  • After DCIS, increased risk of invasive breast
    cancer from 2 to more than 8 times higher than
    the risk found in general population

20
Behavior
  • Invasive (infiltrating)
  • In situ (15-20 of all breast cancers)
  • Synonyms for carcinoma in situ
  • noninfiltrating,
  • intraductal,
  • lobular carcinoma in situ,
  • Stage 0, TIS
  • noninvasive,
  • no stromal involvement,
  • papillary intraductal,
  • papillary non infiltrating,
  • intracystic,
  • lobular neoplasia,
  • lobular noninfiltrating,
  • confined to epithelium, intraepithelial,
  • intraepidermal,
  • DCIS, LCIS

21
Grade (differentiation)
  • Assigned by pathologist
  • How close does the bx resemble normal tissue
  • Helps predict prognosis
  • Lower number indicates slower-growing cancer that
    is less likely to spread
  • Higher number indicates a faster-growing cancer
    that is more likely to spread

22
Grades
  • Grade 1 (well differentiated) cancers have
    relatively normal-looking cells that do not
    appear to be growing rapidly and are arranged in
    small tubules. 
  • Grade 2 (moderately differentiated) cancers have
    features between grades 1 and 3. 
  • Grade 3 (poorly differentiated) cancers, the
    highest grade, lack normal features and tend to
    grow and spread more aggressively

23
(No Transcript)
24
Grade Bloom-Richardson
  • Bloom-Richardson (BR) Score
  • Frequency of cell mitosis
  • Tubule formation
  • Nuclear pleomorphism
  • Bloom-Richardson Grade
  • Low grade BR score 35 grade 1
  • Intermediate grade BR score 6, 7 grade 2
  • High grade BR score 8, 9 grade 3

25
Diagnosing Breast Cancer
  • Mammogram
  • MRI
  • Ultrasound
  • Biopsy
  • Fine Needle Aspiration
  • Core Needle Biopsy (stereotactic and other)
  • Excisional biopsy (sometimes with wire
    localization)
  • Lymph node dissection and Sentinel lymph node
    biopsy

26
Sentinel Lymph Node Biopsy
A.D.A.M. illustration used with licensed
permission.
27
Breast Cancer Staging (TNM)
Source American Joint Commission on Cancer and
International Union Against Cancer
28
Treatment
  • Surgery
  • Mastectomy
  • Lumpectomy
  • Removal of axillary lymph nodes (for invasive
    cancers)
  • Sentinel node biopsy
  • Axillary dissection
  • Radiation
  • Usually after surgery
  • Chemotherapy
  • Combinations of drugs
  • Hormone therapy
  • Tamoxifen, others

29
Estrogen Progesterone Receptor Status
  • Proteins on the surface of cells that can attach
    to substances such as hormones, that circulate in
    the blood.
  • Normal breast cells some breast cancer cells
    have receptors that attach to estrogen and
    progesterone.
  • Play a role in the growth and treatment of breast
    cancer.
  • ER-positive tumors have a better prognosis and
    are more likely to respond to hormone therapy
  • About 2/3 breast ca contain at least one of these
  • Higher percentage in older women

30
Premenopausal Tamoxifen
  • Ovaries produce estrogen, sent through
    bloodstream directly to the breast
  • Tamoxifen mimics estrogen
  • Attached to receptors, keeping real hormones out

31
Postmenopausal Aromatase inhibitors
  • Produce most of their estrogen outside the
    ovaries
  • Generated through androgen hormones store in
    fatty tissue and adrenal glands
  • In a biochemical process started by the enzyme
    aromatase, androgen is converted into estrogen,
    into bloodstream and to breast
  • Aromatase inhibitors block the process

32
Aromatase Inhibitors (AIs)
  • Steroidal AIs
  • Aromasin (exemestane)
  • Nonsteroidal AIs
  • Arimidex (anastrazole)
  • Femara (letrozole)
  • Many clinical trials showing significant results
    in both reduced breast cancer relapse, as well as
    reduced rates of metastatic disease
  • Now being studied in various scenarios with
    Tamoxifen

33
HER2/neu Status
  • human epidermal growth factor receptor 2
  • A protein involved in normal cell growth
  • Important in the control of abnormal or defective
    cells that could become cancerous
  • HER2/neu positive cancers have an excessive
    amount of the HER2/neu cancer gene protein in and
    around their cells.

34
Herceptin
  • Considered a targeted therapy or an immune
    treatment
  • Given IV, once every 2-3 weeks
  • Targets the HER2 protein production
  • Helps stop the growth of the HER2 positive cancer
    cells
  • Helps prevent recurrence
  • http//www.cancer.gov/cancertopics/factsheet/thera
    py/herceptin

35
Tests for HER2 Breast Cancer
  • IHC ImmunoHistoChemistry measures the
    production of the protein by the tumor.
  • Ranked as 0, 1, 2 or 3
  • 3 HER2 positive cancer
  • FISH Fluorescence In Situ Hybridization probes
    to look at the number of HER2 gene copies in the
    tumor cell.

36
Treatment Options are changing
  • Intraductal (in situ) no longer recommend total
    mastectomy (recent)
  • Treatment options may vary with age
  • Brachytherapy (mammosite)
  • Patients 45 or 50
  • Node negative
  • Small tumors
  • Combinations of tamoxifen/AIs
  • Avastin new class of drug
  • Blocks formation of blood vessels that supply
    tumors

37
  • Missouri Cancer Registry
  • Help Line 800-392-2829
  • Help interpreting path report for staging
  • http//mcr.umh.edu
  • For further information, please contact
  • Sue Vest, Project Manager vests_at_health.missouri.ed
    u
  • Nancy Cole, Assistant Project Manager
  • colen_at_health.missouri.edu
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