The Obstetrics amp Gynecological Society of Bhopal amp AMPOGS Research Public Welfare Society Screening tools Clinical Breast examination Breast self examination Mammography Ultrasonography ID: 529271
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Slide1
Screening for Breast cancer
The Obstetrics & Gynecological Society of Bhopal
&
AMPOGS
Research Public Welfare SocietySlide2
Screening tools
Clinical Breast examination
Breast self examination
Mammography
Ultrasonography/
elastography
FNAC
Cytology of nipple dischargeSlide3
AGE STANDARDISED (
WORLD)
BREAST AND GENITAL TRACT CANCER INCIDENCE RATES PER
100,000
FEMALES
31.3
17.4
8.3
3.2
21.2
20.1
19.3
24.6
28.2
27.5
23.3
23.2
16.6
19.3
20.2
15.7
7.6
7.2
6.5
7.2
7.2
4.8
1.3
1.4
1.6
2.3
2.5
2.4
0
5
10
15
20
25
30
35
1970
1975
1980
1985
1990
1995
2000
YEAR
RATE
BREAST
CERVIX UTERI
OVARY
CORPUS UTERISlide4
Breast and genital tract cancerSlide5
Breast cancer Incidence
Most common cancer in women
worldwide.
M
ost common cause of death from cancer among women. More than three fourths of these women in developing countries are diagnosed in advanced stage of the disease. If these lesions are detected early, most breast cancers can be effectively treated with good outcome.
In India 144,937 women were newly detected with breast cancer in 2012, of which 70,218 women died. Roughly, for every 2 women newly diagnosed with breast cancer in India, one dies of this disease.Slide6
Who to be screened
Women
between the ages of 40-60 years of age
All
women identified with a breast mass that has previously not been clinically evaluated need to be screened for breast cancerWomen with high Risk factors can be offered screening from age 30 years such as
Age over 40 No children or children after 30 years of ageMother or sister with breast cancer History of breast biopsies or breast cancer Initiation of menses before 12 years of age
OverweightScreening to be every 2 yearsSlide7
Clinical Breast examination - Tips
Be sensitive to the woman by giving her opportunities to express any concerns before and during the examination.
Respect
the woman’s sense of
privacy.
If the woman is anxious, assure her that you will do your best to make the examination comfortable.Throughout the examination, approach the woman slowly and avoid any sudden or unexpected movements.Do not rush through the examination. Perform each step gently and ask her if she is having any discomfort during any part of the examination. Be aware of her facial expressions and body movements as indications that she is uncomfortable.Always take into consideration any cultural factors when deciding what clothing the woman should remove. Have a clean sheet or drape to cover the woman’s breast if needed.
These examinations should be performed in a clean, well-lit, private examination or procedure room that has a source of clean water. A female assistant should be available to accompany the woman when a male clinician is the examiner.Slide8Slide9
Getting ready
Tell the woman you are going to examine her breasts.
This is a good time to ask if she has noted any changes in her breasts and whether she does monthly breast self-examinations. Tell the woman that you will show her how to do a breast self-examination before she leaves.
Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth or allow them to air dry before beginning the examination.
If there are open sores or nipple discharge, put new examination or high-level disinfected surgical gloves on both hands.
Ask the woman to undress till the waist. With the woman undressed from the waist up, have her sit on the examining table with her arms at her sides.Examine both in sitting and lying down positionSlide10
Performing a CBE
Steps of examination - CBE involves two main parts:
Inspection
to identify physical signs of breast cancer.Palpation
which involves using the finger pads to physically examine all areas of breast tissue including lymph nodes (underarm area) to identify lumps4 positionsArms by the side of trunk. Raising arms over the head. Pressing on the hips. Leaning forward.Slide11
inspection
In the sitting position first visually inspect the breast, initially when woman is sitting up right with arms on her hips, and then with her arms raised over
head.
Note any change in symmetry of breast shape
, size, skin changes–skin dimpling or retraction or ulceration the level of both nipples, retraction of nipple(s), inverted nipple. Slide12Slide13
Look at the breasts for shape and
size.
Note
any difference in shape, size, nipple or skin puckering or
dimpling. Although some difference in size of the breasts is normal, irregularities or difference in size and shape may indicate masses. Swelling, increased warmth or tenderness in either breast may suggest infection, especially if the woman is breastfeeding.Slide14
Look at the nipples and note their size and shape and the direction in which they point (e.g., do her breasts hang evenly?). Also check for rashes or sores and any nipple discharge.
Have the woman first raise her arms over her head
and
then press her hands on her hips to contract her chest wall (pectoral)
muscles. In each position, inspect the size, shape and symmetry, nipple or skin puckering or dimpling of the breast and note any abnormalities. (These positions will also show skin puckering or dimpling if either is present.) Then have the woman lean forward to see if her breasts hang
evenly.Slide15
palpation
Have the woman lie down on the examining table.
Placing a pillow under her shoulder on the side being examined will spread the breast tissue and may help in examining the
breast.
Place a clean sheet or drape over the breast you are not examining.Place the woman’s left arm over her head. Look at the left breast to see if it looks similar to the right breast and whether there is puckering or dimpling.
Use “Dial of clock method” for palpation, first use the finger pads of the middle three fingers to palpate the entire breast, in overlapping circular motions, one area at a time. Repeat both parts of the examination on both the left and rights breasts.Slide16
Woman in lying down position
Light
pressure for superficial breast tissue
Medium pressure for intermediate layer
Deep pressure for tissue close to chest wall
The finger pads of middle three fingers should be used to palpate the breast in circular motion
Palpation pressureSlide17
PALPATION
Pads of three middle fingers, hand bowed up
Slide between palpations without lifting fingers
Dime size circles
JAMA, Vol. 282, No 13, Oct. 1999Slide18
Spiral technique
Using the pads of your three middle
fingers,
palpate the breast using the spiral technique. Start at the top outermost edge of the
breast. Press the breast tissue firmly against the ribcage as you complete each spiral and gradually move your fingers toward the areola. Continue this until you have examined every part of the breast. Note any lumps or tenderness.Slide19
Check for nipple discharge
Using the thumb and index finger,
gently
squeeze the nipple of the
breast. Note any discharge: clear, cloudy or bloody. Any cloudy or bloody discharge expressed from the nipple should be noted in the woman’s record. Although it is normal to have some cloudy discharge from either or both breasts up to a year after giving birth or stopping breastfeeding, rarely it may be due to cancer, infection or a benign tumor or cyst. Repeat these steps for the right breast.Slide20
Axillary tail/ lymph nodes
To palpate the tail of the breast, have the woman sit up and raise her left arm to shoulder level. If needed, have her rest her hand on your shoulder. Press along the outside edge of the pectoral muscle while gradually moving your fingers up into the axilla to check for enlarged lymph nodes or
tenderness
.
It is essential to include the tail of the breast in the palpation because this is where most cancer occurs. Slide21
Dial of a clock method
Palpation
will be done in each segment until entire breast is covered.
Pads of finger (not tips of fingers)
of middle three fingers (index, middle and ring) with hand held in slightly bowed position will be used for palpation.
In the “dial of a clock” method the whole breast is palpated as if it was a dial of a clock, 12 O’ clock being the highest point at upper edge of breast just below the midclavicular point and 6 O’ clock being at the inframammary crease. The palpation is begun at 12 O’clock from periphery to the nipple by describing small circles of about 3 cm in diameter. Following circular movement of the “pad of fingers” 3 times with increasing pressure and without lifting the fingers, the next circle is felt towards the nipple , overlapping with the previous circle to about half in diameter. Once the areola and nipple area is reached, the next segment /sector is palpated at 1-O’clock. The procedure of palpation with “pad of 3 fingers” is repeated sequentially at 2 0’ clock, 3 0’, 4 0’, 5 0’, 6 0’, 7 0’, 8 0’, 9 0’, 10 0’ and 11 0’. If a lump is detected, its size should be measured using a Vernier caliper. The palpation of mammary ducts is done by gently rolling the ducts between the index finger and the thumb. Any thickening, tenderness or discharge is noted while palpating the mammary ducts. In case of retraction of the nipple an attempt is made to pull the nipple forward to see if the nipple could be brought forward or not and if any lump is present underneath the areola, whether the nipple and the ducts are tethered to the lump or not. The skin overlying the lump is gently pinched and moved with the fingers to see if the skin could be moved freely from /off the lump. If the skin is free from the lump but the movement of lump away from skin causes dimpling of skin, the skin is considered “tethered”. If no movement of skin is possible, it is considered “fixed”. The fixity of lump to underlying pectoralis major muscle is ascertained by requesting the lady to push her hand against the hip to contract the muscle and then moving the lump. Slide22Slide23Slide24
Note any discharge from the nipple(s),
colour
of the discharge, swelling/ lumps, consistency of the lumps, swelling in the armpit (axillary area), above the collar bone (
supraclavicluar
area) and root of the neck (infraclavicular area).Repeat this step for the right side.After completing the examination, have the woman dress herself. Explain any abnormal findings and what, if anything, needs to be done. If the examination is entirely normal, tell her everything is normal and healthy and when she should return for a repeat examination (i.e., annually or if she finds any changes on breast self-examination).
The optimal time for a CBE in a premenopausal woman is 5-10 days after the onset of menses, avoiding the week before the period is preferable. Postmenopausal women may have CBE performed at any time. On average, the time required to perform a CBE ranges is 6 to 8 minutesShow the woman how to perform breast self-examination.Record your findingsSlide25
Lymph node examination
Request the patient to sit on a bed or a stool. For axillary nodes palpation, pectoralis muscle is relaxed by examiner supporting patient’s forearm with his own forearm, while facing the patient. The medial or central, pectoral and lateral axillary nodes were palpated from in front while supraclavicular,
infraclavicular
and posterior axillary nodes were palpated in sitting position with examiner standing behind the patient.
Please record the findings of a skin change, nipple change, nipple discharge, any lump and lymph node enlargement in axilla or neck on Case record form in a pictorial manner.Slide26
Interpretation & documentation
The results of CBE will be interpreted in the following ways:
Normal/negative:
No abnormality on visual inspection or palpation
Abnormal: Definite asymmetric finding on either visual inspection or palpation
. Presence of lump(s) in the breast, any swellings in the armpit, recent nipple retraction or distortion, skin dimpling or retraction ,ulceration, any nipple discharge Slide27
Warning signs
The changes that can be seen are:
Unusual increase in the size of one breast
One breast hangs unusually lower
Puckering of the skin
Dimpling or puckering of a nipple or areola
Swelling in upper arm
Change in the appearance of the nipple
Milky or bloody discharge from the nipple
The changes that can be found on feeling the breasts are:
Lump in the breast
Enlargement of lymph nodes in axilla or neckSlide28
Breast Self Examination
It is best to examine your breasts
7–10 days after the first day
of the menstrual period. (This is the time when the breasts are less likely to be swollen and tender).
You should examine your breasts every month, even after your menstrual period has stopped forever. If you are no longer menstruating, you should pick the same day each month (e.g., the first day of the month) to examine your breasts.
Breast self-examination can be done after bathing or before going to sleep. Examining your breasts as you bathe will allow your hands to move easily over your wet skin.Slide29
Breast self examination
First,
look
at your breasts.
Stand in front of a mirror with your arms at your sides and look for any changes in your breasts. Note any changes in their size, shape or skin color or if there is any puckering or dimpling.
Look at both breasts again, first with your arms raised above your head and then with your hands pressed on your hips to contract your chest muscles. Bend forward to see if both breasts hang evenly.Slide30
Breast self examination
Size, shape, color
Even ,no distortion
Swelling
Dimpling, puckering, bulging of skin,Nipple discharge, position
Red, sore, rashSlide31
Raise hands
Press nipples any dischargeSlide32
Then,
feel
your breasts.
You may examine your breasts while standing up or lying down. If you examine your breasts while lying down, it will help to place a folded towel or pillow under the shoulder of the breast you are examining.
Raise your left arm over your head. Use your right hand to press firmly on your left breast with the flat surface (fat pads) of your three middle fingers. Start at the top of the left breast and move your fingers around the entire breast in a large spiral or circular motion. Feel for any lumps or thickening. Continue to move around the breast in a spiral direction and inward toward the nipple until you reach the nipple.
Be sure to check the areas between the breast and the underarm and the breast and the collarbone.Raise your right arm over your head and repeat the examination for the right breast.Lie flat, arm below, with opposite hand and rotatory movements, feel for any irregularity in breast. Collarbone to abdomen, armpit to cleavage.Slide33
In shower, soap hands,
raise one arm,
feel with oppositeSlide34
What to look for
A
change in the
size or shape
of the breast.A puckering or dimpling of the breast skin.
A lump or thickening in or near the breast or underarm area. If the lump is smooth or rubbery and moves under the skin when you push it with your fingers, do not worry about it. But if it is hard, has an uneven shape and is painless, especially if the lump is in only one breast and does not move even when you push it, you should report it to your healthcare provider. If your breasts are usually lumpy, you should note how many lumps you feel and their locations. Next month, you should note if there are any changes in the size or shape (smooth or irregular). Using the same technique every month will help you know if any changes occur.Any nipple discharge that looks like blood or pus, especially if you are not breastfeeding, should be reported to your healthcare provider.
There may be some discharge from one or both breasts for up to a year after having a baby or stopping breastfeedingSlide35
Clinical algorithm
Negative
Positive
Evaluation by surgeons
Mammography
UltrasonographyFNAC
Core biopsyCBE
Normal
Reentry into primary screening
Suspicious of malignancy
Refer to Medical College/ Regional Cancer Centre for staging/treatmentSlide36
Next step in this caseSlide37
Fine needle aspiration (FNA)Slide38
Core biopsySlide39
Size of breast lumpsSlide40
Management of Breast CancerSlide41
Risk factors for Breast cancer
Female
Aging
First degree
relative had breast cancer / ovarian cancer.
Menstrual history: early onset, late menopauseChild birth >30yrsLong term HRT, 30% increased risk.
Oral Contraceptives, risk slight, risk returns to normal once the use of OC’s has been discontinued.Prior radiation exposure to breast at young age.Breast diseaseAtpyical
HyperplasiaIntraductal carcinoma in situIntralobular carcinoma in situObesity, high BMIDiet rich in Fats, Alcohol
Genetic risk factorBRCA-1BRCA-2P53 Her-2/neu Slide42
Breast cancer Risk Assessment
Modified Gail model, 7 factors to calculate risk:
Age>35 years
First degree relative with breast cancer
Prior breast biopsies – atypical ductal hyperplasiaAge at menarcheAge at first child birth
Ethinicity Risk of developing breast cancer is indicated by composite score of relative risk for each factor.Slide43Slide44
Factors that influence survival
Age at diagnosis
Tumor size
Stage at diagnosis
Biologic characteristics of tumor:Hormone receptor status (less significant)HER 2Slide45
mammography
Look for:
Masses
Microcalcifications
: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer
.spiculated appearanceSlide46Slide47
The Stages of Breast Cancer
Breast Cancer is diagnosed according to stages (stages 0 through IV) under the
TNM
classification.
Factors used in staging of Breast Cancer: Tumor SizeSize of primary tumor
Nodal statusIndicates presence or absence of cancer cells in lymph nodes MetastasisIndicates if cancer cells have spread from the affected breast to other areas of the body (i.e. skin, liver, lungs, bone)
Source:
National Cancer InstituteSlide48
Staging
Breast Cancer
Stage 0
Ductal carcinoma in situ (DCIS) is very early breast cancer that has not spread beyond the duct.
Stage I
Tumor is < 2 cm and has not spread outside the breast.Stage IIANo tumor is found in the breast, but cancer is found in the axillary lymph nodes, or tumor is
≤ 2 cm and has spread to the axillary lymph nodes, or tumor is 2-5 cm but has not spread to the axillary lymph nodes.Stage IIBTumor is 2-5 cm and has spread to the axillary lymph nodes or is > 5 cm but still confined to the breast.
Source:
National Cancer InstituteSlide49
Advanced Breast Cancer
Stage IIIA
The tumor in the breast is smaller than 5 centimeters and the cancer has spread to underarm lymph nodes that are attached to each other or to other structures, OR the tumor is more than 5 centimeters across and the cancer has spread to the underarm lymph nodes.
Stage IIIB
Tumor has spread to tissue near the breast (i.e. the skin or chest wall) and may have spread to lymph nodes within the breast area or under the arm.
Stage IIICTumor has spread to the lymph nodes beneath the collarbone and
near the neck, and may have spread to the lymph nodes within the breast area or under the arm and to the tissues near the breast.Stage IVTumor has spread to other organs of the body (i.e. lungs, liver, or brain).
Source:
National Cancer InstituteSlide50
Breast cancer treatment
Surveillance LCIS, DCIS
Physical exam, mammography, MRI
Surgery DCIS:
Lumpectomy if DCIS in 1 area, Mastectomy if DCIS in 2 area or large or multifocal
Radiotherapy DCISUsually accompanies lumpectomyHormonal therapy DCIS
In selected ER+ve, for 5yrs lowers cancer risk.TNM stage 0Slide51
Breast cancer treatment
Breast conservative Surgery
Lumpectomy
Quadrantectomy
Radiotherapy Axillary dissectionAffected breast chest wallAdjuvant chemotherapyCombination chemotherapy 3-6
mthsAdjuvant Hormonal therapy Premenopausal: tamoxifen in ER+ve, Postmenopausal: Tamoxifen & aromatase inhibitor.TNM stage 1 & 2Slide52
Breast cancer treatment
Surgery
Lumpectomy
Mastectomy
Radiotherapy Chest wall, regional lymph nodesAdjuvant chemotherapyCombination chemotherapy 4-6
mthsAdjuvant Hormonal therapy If ER+ve or PR+ve, TNM stage 3Slide53
Breast cancer treatment
Surgery
Select cases to relieve symptoms
Radiotherapy
Select cases to relieve symptoms and control local disease.
ChemotherapyPrimary treatment, single agent or Combination chemotherapy.Hormonal therapy
If ER+ve or PR+ve, Monoclonal antibodyHER 2 +veTNM stage 4Slide54
Local therapy: surgery
Local therapy provides adequate control of
locoregional
disease, includes surgery and radiotherapy.
Surgery:Mastectomy: Modified radical with sentinel LN evaluation
Radical /total mastectomy with sentinel LN evaluation May include breast reconstructionBreast conservation surgery: Wide local excision Quadrantectomy Lumpectomy , includes axillary dissection if disease invasive.Slide55
Complications of surgery
Lymphedema
10-305 women who undergo axillary dissection
3% if sentinel node biopsy only
NumbnessReduced shoulder mobilityPsychosocial problems of mastectomyPhantom breast sensationSlide56
Local therapy: radiotherapy
Adjuvant radiotherapy in ESBC
Reduces risk of recurrence
May improve survival
Radiotherapy in MBCRelieves symptoms such as pain, in pts with bone, brain metastasis while not effecting a cure.Slide57
Rt: methods of delivery
External beam irradiation, to entire breast.
Partial breast irradiation, including brachytherapy
Radioactive seeds/pellets placed internally near site of tumor for local effects.
Can deliver high dose rate radiation, allowing shorter treatment regimes compared to traditional RT5yr survival rates comparable to whole breast RT.Slide58
Systemic therapy for breast cancer
Hormona
l
therapy
ChemotherapyTargeted therapyClinical trails provide support for optimal implementation for above therapies in pts with breast cancer.Slide59
Evolution of systemic adjuvant therapy for esbc
Mastectomy alone
Adjuvant CMF
Adjuvant CAF, CEF
Adjuvant AC, EC, FEC
Adjuvant AC + TDose dense AC+T TAC
Addition of Tamoxifen/ Aromatase inhibitor
Progressive improvement in disease free and overall survivalSlide60
Evolution of systemic adjuvant therapy for esbcSlide61
Preferred CT: MBC
Single agent options:
Anthracycline – doxorubicin,
epirubicin
taxane: - paclitaxel, docetaxelCapecitabine
Others – vinoretbine, irinotecanCombination optionsCAF/FAC -docetaxel, capecitabineAT – paclitaxel, gemcitabineFECCMFAC, EC – paclitaxel, carboplatin, trastuzumab.
Single drug/combination controversial topicCombinations preferred in MBCNewer combinations improve outcome & manageable safety profileSequential therapy may be appropriate for pts with indolent disease or nonvisceral MBC>Slide62
Summary: adjuvant CT in ESBC
Adjuvant CT improves survival
inESBC
Improved survival outcomes demonstrated with CMF
Regimes with anthracycline or a taxane improve outcomeDose dense approach has demonstrated benefit in disease free and overall survival.Slide63
Targeted therapy options in BC
HER2 inhibitor family
Antibodies
Trastuzumab
Small moleculesGefitinibErlotinib
LapafarnibAngiogenesis inhibitorAntibodiesBevacizumabSlide64
conclusions
Although breast cancer incidence has increased, mortality rates due to breast cancer are reducing.
Advances in conventional therapy include less radical surgery and reduced radiation field.
Cytotoxic CT advances include improved types, doses, scheduling.
Improvements in hormonal therapy.Newer target therapyTreatment regimes
: individualized.