BREAST CANCER

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BREAST CANCER

• Curtis Tucker M.D.

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Epidemiology

• 32 of all female cancers
• 15 of cancer deaths
• 217,000 new cases per year
• 40,500 deaths per year

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Risk Factors

• FEMALE
• Increasing age very uncommon below the age of
  40, but risk increases to 1 in 8 for women living
  into their 80s
• Family history relative risk is 1.7 if women
  have a first degree relative with breast cancer
• Proliferative breast disease- ductal hyperplasia,
  sclerosing adenosis, lobular hyperplasia, LCIS
• Personal history of breast cancer (also colon,
  ovarian, endometrial)
• Reproductive factors
• Radiation exposure, especially at early age
• ?? HRT
• Alcohol, high fat diet, obesity

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Genetic Risk Factors

• Hereditary forms of breast cancer account for
  only 5 of breast cancer cases
• BRCA1 mutation inherited AD fashion with a
  lifetime risk of breast cancer of 55 - 85 and
  ovarian cancer risk of 15 45
• BRCA2 mutation 6 lifetime risk of breast cancer

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Screening

• Breast self-exams beginning in their 20s
• Clinical breast exam beginning at age 20 q 3
  yrs and annually after age 40 (15 of breast
  cancers detected only clinically)
• Mammography annually beginning at age 40 or
  5-10 yrs prior to any first degree relatives dx
  age (85 of tumors mammographically detectable)
  50 of lesions dtected by mammo only
• Screening US for dense breasts
• ?? Breast MRI

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Signs and Symptoms

• Mammo findings microcalcifications, asymmetry,
  mass, architectural distortion most DCIS found
  on mammo only
• Breast lump 65 of cases
• Eczematoid changes in the nipple (Pagets dz)
• Nipple retraction/discharge
• Skin changes/ulceration

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Pathology

• Ductal Carcinoma In Situ (DCIS) - 25 of cases
• Infiltrating Ductal Carcinoma 65 of cases
• Infiltrating Lobular Carcinoma 5-10 of cases
• Rare types medullary, tubular, lymphoma, sarcoma

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TNM Staging

• Tx tumor cannot be assessed
• T0 no evidence of primary tumor
• Tis DCIS
• T1 - tumor less than/equal to 2 cm
• T2 - tumor 2 cm but not 5 cm
• T3 tumor 5 cm
• T4 involvement of skin or chest wall or
  inflammatory carcinoma

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TNM Staging

• Nx lymph nodes (LN) cannot be assessed
• N0 No regional LN
• N1 movable axillary LN
• N2 fixed/matted axillary LN or internal mammary
  LN only
• N3 both axillary and internal mammary LN, or
  infraclavicular LN or supraclavicular LN

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TNM Staging

• Mx metastasis cannot be assessed
• M0 no distant mets
• M1 distant mets

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TNM Staging

• Stage 0 DCIS
• Stage I T1 N0 M0
• Stage II T1 N1 M0 T2 N0-1 M0
  T3 N0 M0
• Stage III T3 N1 M0 any N2-3 M0
  any T4 M0
• Stage IV any M1

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Prognostic Factors

• TNM staging
• Lymph node status prognosis directly correlates
  with number of positive LN
• Node negative - 20 recurrence at 5 yr
• LN 10 nodes 75 recurrence rate at 5 years
• Hormone receptor status ER/PR positive is more
  favorable
• Her2/neu positive is more unfavorable

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Breast Cancer Survival Ratesat 8 years

• Stage 0 98
• Stage I 90
• Stage II 70
• Stage III 40
• Stage IV 10

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TreatmentLCIS

• Not breast cancer
• Marker for increased risk of breast cancer
• Lifetime risk of developing breast cancer 25 to
  30
• Do not need excisional bx or clear margins
• Treatment options close observation, tamoxifen,
  bilateral prophylactic mastectomies

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Treatment DCIS

• Pre-invasive cancer
• Risk of LN involvement/distant mets is 1
• Do not need met w/u or LN dissection
• Options for tx breast conserving therapy vs
  simple mastectomy
• Need clear margins for breast conservation

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BCT for DCIS

• DFS rate at 5 years 99
• Review of NSABP-06 showed no difference in
  survival for BCT vs mastectomy
• NSABP-17 prospective randomized trial lumpectomy
  vs lumpectomy and radiation at 8 yrs local
  recurrence reduced from 27 to 12 with
  radiation, no difference in survival (no boost)
• European trial prospective trial same results
• All subgroups showed decrease in local recurrence
  rate
• Addition of tamoxifen further reduced risk (6
  year FU 13 recurrence vs 8)both ipsilateral and
  contralateral
• Do patients need radiation? Yes.

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Invasive Breast CancerEarly Stage

• Treatment options include BCT vs. modified
  radical mastectomy

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BCT vs Mastectomy

• Multiple US and international prospective
  randomized trials all show equivalency of BCT
  with radiation to mastectomy (over 4000 patients
  total)
• Largest US trial NSABP-06, 1800 women randomized,
  20 year follow up no difference in either
  local/regional recurrences 15 mastectomy vs 9
  BCT, or in disease-free survival 36 mastectomy
  vs 35 BCT

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BCT vs Mastectomy

• This study included an arm with lumpectomy alone
  and although DFS was not significantly effected
  (P 0.07) local recurrence rate was 40
• Ability to have is BCT is not affected by LN
  status and in fact in women with positive LN
  after mastectomy appear to have a survival
  benefit with the addition of radiation to the
  chest wall
• Current radiation techniques yield a failure rate
  in the breast of 4 at 5 years

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Breast Conserving TreatmentCriteria

• Typically less than 5 cm lesion
• No multicentric dz/calcifications
• Must have negative margins (1mm) this includes
  DCIS
• No Scleraderma/autoimmune dz
• Breast/tumor proportion cosmetic outcome

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Early Stage Breast CancerAdjuvant Treatment

• Chemotherapy
• Hormonal therapy tamoxifen, arimidex, femara,
  aromasin, raloxifene
• Herceptin monoclonal antibody to her2/neu receptor

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Advanced Stage Work Up

• CBC, CMP
• CT chest and upper Abd
• Bone scan
• Consider PET scan

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Advanced StageTreatment

• Typically includes surgery, chemotherapy,
  radiation, and if possible hormonal therapy

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Inflammatory Breast Carcinoma

• Can present with a cellulitis type picture and
  usually arises very quickly
• Does not typically have a dominant mass
• Poor prognosis and must be treated very
  aggressively
• Treated with chemotherapy followed by mastectomy
  then radiation and more chemotherapy

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