DR A AKHATOR FWACS FICS SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH PRETEST Breast cancer is the most common cancer in women in Nigeria Breast cancer is the most common cause of cancer related deaths ID: 373944
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BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS
DR. A. AKHATOR FWACS, FICS
SENIOR LECTURER DELSU
CONSULTANT SURGEON DELSUTHSlide2
PRE-TEST
Breast cancer is the most common cancer in women in Nigeria
Breast cancer is the most common cause of cancer related deaths
Breast cancer commonly present as painful breast lump
Prognosis of breast cancer is related to the size of the breast tumor
Trastuzumab
(Herceptin
R
) is treatment for ER/PR positive tumorSlide3
LEARNING OBJECTIVES
Realize the burden of breast cancer in our environment
The importance of early diagnosis in management of breast cancer
Evaluate breast cancer symptoms and recommend appropriate managementSlide4
OCTOBER IS BREAST CANCER AWARENESS MONTHSlide5
BREASTSlide6Slide7
INTRODUCTION
Breast cancer – malignant neoplasm arising in the breast.
Most common cancer in women worldwide.
Incidence in Nigeria is 33/100,000
Incidence in males 1-9% of cases
Peak age 42 years
78% locally advanced disease
22% metastatic diseaseSlide8
THE FACTS ABOUT BREAST CANCER
APPROXIMATELY EVERY 3 MINUTES A WOMAN IS DIAGNOSED WITH BREAST CANCER
APPROXIMATELY EVERY 12 MINUTES A WOMAN DIES FROM BREAST CANCER
INCIDENCE INCREASING 5%/YEAR IN DEVELOPING COUNTRIES
A REVIEW 1991 – 33% ADVANCED DISEASE IN DEVELOPED COUNTRIES
2007 – 60-80% ADVANCED DISEASE IN DEVELOPING COUNTRIESSlide9
MORE FACTS
IN THE UK 2009
NEW CASES - 38,212 FEMALES, 250 MALES
SECOND COMMONEST CANCER DEATHS
IN US
211, 240 NEW CASES EXPECTED IN WOMEN
1,690 NEW CASES IN MEN
African-American women have a lower incidence but higher mortality
They also have higher risk for triple-negative
tumours
INCIDENCE – 128.6/100,000 POPULATION
Life time risk of 1 in 8 womenSlide10
Factors that increase risk
Family History
Lifestyle
Personal HistorySlide11
Family History
Mother
, sister, or daughter has developed breast cancer before
menopause 3 x.
If
two or more close relatives (e.g., cousins, aunts, grandmothers) have/had breast
cancer.
Mutations
in genes BRCA1 and BRCA2 increase one's susceptibility to breast cancer. Slide12
FAMILY HISTORY
SHARED GENETIC MAKEUP
SHARED LIFESTYLE
SIMILAR ENVIRONMENTAL EXPOSURE
5-10% CAUSED BY INHERITED GENETICSSlide13
PERSONAL HISTORY
Previous history of breast cancer
Previous history of benign breast disease
Menarche <12 years
Hormonal contraceptives – current and recent users
Nullipara
First delivery after 30 years
Menopause at 55 years or older
Hormonal Replacement TherapySlide14
Lifestyle
Several studies found a lower incidence of breast cancer among women who exercise regularly
Higher proportion of breast cancer among obese women.
SmokingSlide15
OTHER LIFESTYLE FACTORS
ALCOHOL – one or more drinks a day increases risk
DIET – High in fruits and vegetables decreases risk
EXERCISE – Regular exercise decreases risk
WEIGHT – Maintaining healthy weight decreases riskSlide16
ENVIRONMENTAL RISK
POLYCYCLIC AROMATIC HYDROCARBONS – Chemicals produced when coal, oil, gas, garbage are burnt – increases risk
SMOKING – Passive smoking increases risk; when smoking started as teenager
ELECTROMAGNETIC FIELD – NO RISKSlide17
BREAST CANCER MYTHS
SHAMPOO – NOT TRUE
WEARING BRA – NOT TRUE
PUTTING MONEY IN BRA – NOT TRUE
RADIATION FROM CELL PHONES – NOT TRUE
ANTIPERSPERANTS/DEODORANTS – NOT TRUE
BREASTFEEDING GRANDCHILDREN – NOT TRUE
WITCHES INFLICT – NOT TRUESlide18
CLASSIFICATION
Heterogeneous disease at each stage
Early breast cancer (Tis-2/N0-1)
In situ disease
Invasive
Late
breast cancer (T3,4/N2/M1)
Locally advanced
Metastatic diseaseSlide19
STAGE GROUPING
STAGE 0 – Tis, N0,M0
STAGE IA – T1, N0,M0
STAGE 1B – T0 or T1, N1mi, M0
STAGE IIA – T0 or T1, N1, M0; T2,N0,M0
STAGE IIB – T2, N1, M0; T3, N0, M0
STAGE IIIA – T0 to T2, N2, M0; T3, N1 orN2,M0
STAGE IIIB – T4,N0-N2,M0;
STAGE IIIC – any T, N3, M0
STAGE IV – any T, any N, M1Slide20
Total Cancers
Per Cent
In Situ Carcinoma
*
15–30
Ductal carcinoma in situ, DCIS
80
Lobular carcinoma in situ, LCIS
20
Invasive Carcinoma
70–85
No special type carcinoma ("ductal")
79
Lobular carcinoma
10
Tubular/cribriform
carcinoma (
Better
prognosis than average)
6
Mucinous (colloid)
carcinoma (
Better
prognosis than average)
2
Medullary
carcinoma (
Better
prognosis than average)
2
Papillary carcinoma
1
Metaplastic carcinoma, (Squamous) Slide21
EARLY DIAGNOSIS …..
Early diagnosis leads to better prognosis
The size of the tumor and extend of spread determines the prognosis
Early stage
Better possibility for cure
Less morbidity
Less toxic treatmentSlide22
PROGNOSIS
Overall survival/Disease free interval
Quality of life
Adverse effect/toxicity of treatment
Body habitus
PsychologicalSlide23
PROGNOSTIC FACTORS
Age
Tumor size
Axillary
LN status
Histological grade
Receptor status – ER, PR
HER2-neu(C-
erb
B2)Slide24
OVERALL SURVIVAL
CURE RATES FOR BREAST CANCER
5 year cure rates of >90% obtainable for early
tumours
,
<
30% for late
tumoursSlide25
SURVIVAL RATES BY STAGE
Stage 0 – 93%
Stage I – 88%
Stage IIA – 81%
Stage IIB – 74%
Stage IIIA – 67%
Stage IIIB – 41%
Stage IIIC – 49%
Stage IV – 15%Slide26
QUALITY OF LIFE
Scars of treatment/no breast
Younger survivors face
Emotional stresses
Trouble with social functioning
Chemotherapy induced early menopause
Sexual difficultiesSlide27
DIAGNOSIS
ASYMPTOMATIC PATIENT
SCREENING
BSE
CBE
Mammography
MRI
SYMPTOMATIC PATIENT
Clinical evaluation
Diagnostic investigationsSlide28
Breast Self
Exam
Be Safe, Be SureSlide29
Advantages of BSE
It is simple and easy to perform.
It is convenient and requires little time.
It is private.
It involves no medical cost
It is safe and non-invasive.
It requires no specific equipment.Slide30
Methods of training
Pamphlets and leaflets.
Instructional videos.
Demonstrations and personal instructions.Slide31
Breast-self-examination
Breast self examination – monthly
Understand the breast and look for changes
Development of a lump.
Swelling.
Skin irritation or dimpling.
Nipple pain or retraction.
Redness or
scaliness
of the nipple or breast skin.
Discharge - other than milk.
Standing and lyingSlide32
When to do a Breast Self-Exam
The best time to do breast self-exam is right after
her
period, when breasts are not tender or swollen. If
she does
not have regular periods or sometimes skip a month, do it on the same day every month.Slide33
Clinical Breast Examination
BREAST EXAM BY DOCTOR (CBE) – EVERY 3 YRS BETWEEN 20-39YRS;
YEARLY AFTER 40YRS, before mammogram
POOR SENSITIVITY - 54%
HIGH SPECIFITY – 94%
CBE-detected
tumours
has 70%
survivalSlide34
Mammogram
XRAY OF THE BREAST (MAMMOGRAM) – YEARLY AFTER 40 YRS
Mammography-detected
tumours
has 90% survival
Mammography increased detection of DCIS from 1% to 21
%
Regular screening by mammography and CBE decrease mortality by 25 – 30% in women 50years or olderSlide35
EARLY DIAGNOSIS
TRIPLE ASSESSMENT
CLINICAL EVALUATION
IMAGING
HISTOCYTOLOGYSlide36
CLINICAL EVALUATION
History
Progression of symptoms
Risk factors for breast cancer
Treatment to date
Physical examination
Local
systemicSlide37
FEATURES OF BREAST CANCER
Breast lumps – painless
Swelling of the breast
Nipple discharge – blood stained
Retraction of the nipple
Changes in the skin of the breast
Breast or nipple pain
Signs of spreadSlide38
LUMP IN THE BREASTSlide39Slide40
LUMP IN THE AXILLASlide41Slide42
RETRACTED NIPPLESlide43
RETRACTED NIPPLESlide44
INFLAMMATORY BREAST CANCERSlide45
BLOODY NIPPLE DISCHARGESlide46
BREAST ULCERSlide47
BREAST ULCERSlide48
Breast cancer in a manSlide49
IMAGING
Breast scan
Mammogram
Digital mammogram
Computer aided diagnosis (CAD)
MRI
OTHERS
Thermography
Scintimammography
Tomosynthesis
(3D Mammography)Slide50
HISTOCYTOLOGY
TYPES OF BIOPSY TECHNIQUE
FNAC
Core Needle
Vacuum assisted
Open biopsy
Incisional
excisionalSlide51
TREATMENT
SURGERY
Mastectomy + reconstruction
BCS
HORMONAL THERAPY
CHEMOTHERAPY
TARGETED THERAPY
RADIOTHERAPYSlide52
MASTECTOMY - Indications
Large tumors
Centrally located tumors
Large tumors
cf
size of breast
Multicentric
tumor – mammogram
Previous radiotherapy
Patient’s preferenceSlide53
MASTECTOMY
Simple mastectomy + SLND
Skin-sparing mastectomy
Nipple-sparing mastectomy
Modified Radical mastectomy
Breast reconstruction/breast form
Radiotherapy after mastectomy
Large tumors 5cm or larger
Deep seated tumors
4 or more positive lymph nodesSlide54
Breast conservation surgery
BCS + RT = BCT
75%
Px
in developed countries
Tumor control rate of 80-90%
5 year survival rate – 70-88%
Local recurrence rate 2-10%
Without RT – 15-40%
TYPES OF BCS
Lumpectomy
WLE
QUARTSlide55
CONTRAINDICATION TO BCT
Very small breast
Very large breast
Advanced/high grade disease
Lactating breast/pregnancy
Multicentric
disease
Contralateral
disease
Previous RT
Central tumors
Multiple tumors
Risk for 2
nd
tumorSlide56
BCS WITHOUT RADIOTHERAPY
BCS is considered without radiotherapy if all of the following are present
Patients aged 70 years or older
Tumor is <2cm and has been completely excised
Tumor is hormone receptor positive and patient is placed on hormone therapy
No positive axillary lymph nodeSlide57
CHEMOTHERAPY
Combination, sequential therapy
Adjuvant/
neoadjuvant
setting
CMF
CAF; AC, TAC
Capacitabine
Common side effects
Hair loss
Nausea and vomiting
Fatigue
Stomatitis
Anorexia
Increased susceptibility to infections
Others – menstrual, heart, hand and foot syndrome, neuropathy, bladderSlide58
HORMONAL
Tamoxifen
;
Raloxifene
;
Toremifene
Fulvestrant
– eliminates receptor
Aromatase
inhibitiors
Letrozole
Anastrozole
exemestane
Ovarian ablation
Oophorectomy
LHRH analogs –
goserelin
,
leuprolide
Megastrol
acetate
androgensSlide59
TARGETED THERAPY
HER2/
Neu
monoclonal antibodies
Trastuzumab
(Herceptin
R
)
Lapatinib
(Tyrkeb
R
)
Angiogenesis inhibitors
Bevacizumab
(Avastin
R
)Slide60
EARLY BREAST CANCER
DCIS – BCS with 2mm margin
Pagets
disease – BCS + removal of nipple-
areolar
complex
Invasive disease – BCS + SLN biopsy/ mastectomy
Start adjuvant chemotherapy or radiotherapy as soon as clinically possible within 31 days of completion of surgery.
Endocrine therapy –
Tamoxifen
– premenopausal;
aromatase
inhibitor for post menopausalSlide61
ADVANCED BREAST CANCER
Mastectomy
Primary/adjuvant systemic therapy
Biological Rx -
trastuzamab
Uncontrolled local disease – wound management
Pain management
Lymphedema
Cancer related fatigue
Bone metastasis
Brain metastasisSlide62
BREAST CANCER IN WARRI
142 new cases presented to breast clinic (2008 -2009)
20 Were Breast Cancer (14.08%)
ONLY 1 CAME WITH EARLY DISEASE (5%)
62% PRESENT > 3 months after noticing symptoms
WHY ARE THEY COMING LATE?Slide63
WHY ARE THEY COMING LATE
Ignorance
Lack of facilities
Fear of diagnosis
Fear of the treatment
Alternative treatment options
Delay in referrals from peripheral centres
NO SCREENING PROGRAMSlide64Slide65Slide66Slide67Slide68
WAY FORWARD
NMA – active in promoting awareness of cancer especially breast cancer
NHIS – Include cancer screening as part of their healthcare provision
Provision of facilities – radiotherapy
Short trigger for referral of breast complaintsSlide69
TAKE HOME POINTS
Breast cancer is here with us.
Patients are presenting with advanced breast disease
Early breast cancer has >90% survival rate
Late breast cancer has < 30% survival rate
It is our responsibility to get these patients to present earlier
BSE
CBE
MammogramSlide70
REFERENCES
Akhator A,
Oside
CP. Breast diseases in Warri. African J of
Trop
Med & Bio. Res 2010.
Akhator A.
Clinicopathological
study of breast cancer in
Eku
. The Nigerian J of Clinical Practice 2008
Adebamowo
CA,
Ajayi
OO. Breast cancer in Nigeria. West
Afr
J Med 2000
Guideline implementation for breast health care in low and medium income countries. The Breast health global initiative 2007
Scottish intercollegiate guidelines network – management of breast cancer in women.Slide71
REFERENCES
Disease Control priorities project – Controlling Cancers in developing countries. April 2007
National Institute for Health and Clinical Excellence – Guidelines Early and Locally advanced breast. February 2009.
National Institute for Health and Clinical Excellence – Guidelines Advanced breast cancer
Cancer screening in United States, 2007; A review of current Guidelines, practices, and prospectsSlide72
THANK YOU AND GOD BLESSSlide73
POST TEST
Breast cancer patients present commonly to breast clinic with early disease in Warri
The prognosis of breast cancer is related to the grade of the tumor
Hormone receptor assay is essential in the management of breast cancer.
BSE is the most widely recommended method for screening breast cancer
Breast conservative surgery is the best treatment for stage III disease.