BREAST CANCER: EARLY DIAGNOSIS BETTER PROGNOSIS - PowerPoint Presentation

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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

BREASTSlide6
Slide7

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 BREASTSlide39
Slide40

LUMP IN THE AXILLASlide41
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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 PROGRAMSlide64
Slide65
Slide66
Slide67
Slide68

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.