Screening for Breast cancer - PowerPoint Presentation

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.Slide8
Slide9

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. Slide12
Slide13

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. Slide22
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Slide24

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.Slide43
Slide44

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 appearanceSlide46
Slide47

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.