in f orma t ion Risk f a ct ors Progno st ic f a ct ors Diagno st ics and st aging syst em T rea t men t Follow up Pla n o f th e sem ID: 779051
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Slide1
Brea
st cancer
Slide2G
eneral informa
tion
Risk
factorsPrognostic factorsDiagnostics and staging systemTreatmentFollow up
Pla
n
o
f
th
e
sem
in
ar:
Slide3General
i
n
f
o
rma
ti
o
n
Slide4•
Most
masses we
can find in breast are benign (fibroadenomas)Can be detected by
screening
Around
200000 new cases of invasive breast ca /
year in EU (around 2000 in men).Crude incidence around 110
/100000 females; mortality 38.
4/100000Breast cancer
Slide5R
ISK
F
AC
T
O
R
S
Slide6W
hat are t
he
risk
factors ?SexThe most common cancer among womenWomen 100 times more oft
en
t
han men (men are at low risk)Age
Breast cancer incidence (look below) and death rates increase wi
th age<0,4% when 30-40 yr
3,7% when 60-70 yr
Slide7W
hat are t
he
risk
factors ?•Reproductive factors Long menstrual hist
o
ry:
early
menarche (before 12 yr), late menopause (aft
er 55 yr) Never having children(in contrary: breastfeeding
is a protective facto
Having first child after 30
yr
Race
W
hi
t
e
women
:
higher
incidence
of breast ca. than African women but… after 40 yr In contrary African women: higher incidence of breast ca. before 40 yr; also more likely to die because of breast ca. than White women (any age).
r)
Slide8W
hat are t
he
risk
factors ?•Breast cancer in relativesFirst-degree relative
(si
st
er, mother, daughter) with b.
c. increases the risk of developing b.c. Second-degree relatives
in case of their premenopausal diagnosis
Genetic changes
5-10%
o
f
b
.
c
are
conne
ct
ed
t
o genetic disorders: BRCA1 and BRCA2 (present in less than 1% - no screening tests recommended) around 70% lifetime risk (!) p53, CHEK2, Rb-1, C-Myc genetic disease: Li-Fraumeni or Cowden syndrome,
Slide9W
hat are t
he
risk
factors ?•Benign breast diseasesDuctal hyperplasia Atypical
du
ct
al hyperplasia (especially when with family history)
Previous irradiation Mantle radiation
for Hodgkin Lymphoma
Slide10W
hat are t
he
risk
factors ?•Previous history of breast cancerOther risk
fac
t
ors (dependent on life sty
le):Replacement hormone therapy (estrogen+ progesteron)Oral cont
raceptives Low physical activit
yBeing overweightn)
Slide11W
hat are t
he
risk
factors ?
Hig
h
ris
k :BRCA1/2 gene mutation or first-degree rela
tive with a BRCA1/2 A li
fetime risk of b.c. >
20%
(
based
mainly
on
a
f
amily
history )History of radiation therapy (between 10 ys and 30 yr)Some genetic disease (Li-Fraumeni syndrome)Increased risk :A lifetime risk of breast cancer 15 - 20%,Personal history of breast cancer,
ductal or lobular carcinoma in
si
t
u
,
a
t
ypical
du
ct
al
or
lobular
hyperplasia
Ext
remely
dense
brea
st
s
(shown
by
mammogram)
Slide12Que
stion
Y
ou
examined
a
3,5
cm mass in your 31-year old pa
tient’s left breast. A biopsy
(f
ine
needle
aspira
t
ion)
revealed
carcinoma
cell
s.
You know that the patient has a sister (33-year old) with a history of breast cancer. Which risk factor is the most likely to be responsible for this cancer?BRCA1 or 2 mutationPrior int
raductal papillomaEarly menarche
Die
t
rich
in
f
a
t
s
Slide13Que
stion
Y
ou
examined
a
3,5
cm mass in your 31-year old pa
tient’s left breast. A biopsy
(f
ine
needle
aspira
t
ion)
revealed
carcinoma
cell
s.
You know that the patient has a sister (33-year old) with a history of breast cancer. Which risk factor is the most likely to be responsible for this cancer?BRCA1 or 2 mutationPrior int
raductal papillomaEarly menarche
Die
t
rich
in
f
a
t
s
Slide14PR
OGNOST
I
C
F
AC
T
O
R
S
Slide15W
hat are t
he
progno
stic factors ?Size of the tumorLymph nodes i
n
v
o
lvement•Histological
type•Grading
Slide16W
hat are t
he
progno
stic factors ?Vessel invasionHER-2
rece
p
tor overexpression or amplifica
tion•(Estrogen and progesteron
e receptor expression)
Triple negative b.c- tumor wi
t
h
nega
t
ive
recep
t
ors
f
or
HER-2
,
ER and PR (10-15%)Predictive factors
Slide17W
hat are t
he
progno
stic factors ?HER-2 receptorHuman Epidermal growth factor Receptor 2 CD340, erbB2,
HER2
/
neu
Transmembrane oncoprotein Belongs to EGF receptors family
Orphan receptor Acts as a dimer
Slide18Que
stion
W
hich
o
f
t
he f
ollowing you would considered to be a
good prognostic factor for brea
st
cancer?
HER2
recep
t
or
overexpression
W
ell
di
f
f
erentiated tumor>4 lymph nodes involved in ca processVessel invasion
Slide19Que
stion
W
hich
o
f
t
he f
ollowing you would considered to be a
good prognostic factor for brea
st
cancer?
HER2
recep
t
or
overexpression
W
ell
di
f
f
erentiated tumor>4 lymph nodes involved in ca processVessel invasion
Slide20Hi
stology•
Usualy
‘benign’ tumors: Phyllodes tumor Intraductal papilloma
Slide21Hi
stology•
Carcinoma
in situ: Ductal DCISNo invasion of the basement membrane of the
brea
st
ducts Lobular LCISBenign-appearing proliferation
of terminal ductules, Often multifocal and bilateral
Cribriform DCIS with
central necrosis (x400).
Slide22Hi
stologyInfiltrating
ca:
Ductal (NOS)The most common breast cancer (around 75% )Scirrhous; Medullary; Mucinous
Page
t
disease is a subtype in which malignant du
ctal cells extend intraepithelially to the skin of
the nipple.
Mucinous carcinomaClusters of t
umor
cells
f
loa
t
in
a
pool
o
f
extracellular mucin
Slide23Hi
stologyInfiltrating
ca:
LobularAbout 10% of breast cancersArises from terminal ductules of the lobules
Oft
en
multicentricOften bilateral (20%)
Infiltrating lobular carcinoma. The tumor cells
infiltrate in typical linear
files
Slide24Hi
stology•
O
t
her rare tumorsSarcomaLymphomaHigh grade sarcoma
Slide25Que
stion
W
hich
o
f
the following connections
is false?
Phyllodes
tumor - usually behaves as benign
change
LC
IS
-
o
ft
en
mul
t
i
f
ocal
Infiltrating ductal ca. - the most common breast ca.Paget disease - a type of Infiltrating lobular ca.
Slide26Que
stion
W
hich
o
f
the following connections
is false?
Phyllodes
tumor - usually behaves as benign
change
LC
IS
-
o
ft
en
mul
t
i
f
ocal
Infiltrating ductal ca.- the most common breast ca.Paget disease - a type of Infiltrating lobular ca.
Slide27D
IA
GNOS
I
S
Slide28Ho
w do we
diagnose
breast cancer ?Physical examination: Women in their 20s and 30s - a clinical breast exam (CBE)
every
3 years performed by a health professional W
omen after 40 yr- CBE every 1 year performed by a
health professional Breast self-examination
(BSE) – every month! Don’t
f
orge
t
t
o
check
i
f
t
here
is nipple discharge !! Breast cancer occurs most often in the upper outer quadrant of the breast !Picture taken from www.mammoscan.com
Slide29Ho
w do we
diagnose
breast cancer ?Mammogram - an x-ray exam of the breast every two years
f
or
every woman > 50yr without symptomsBILAT
ERAL MAMMOGRAPHYUsually 2 x-ray pictures of each breast
USGMRI(in addition t
o, not instead of mammogram)
W
omen
a
t
high
risk
should
ge
t
an
MRI anda mammogram every year starting from 30 yrWomen at moderately increased risk should have additional MRI screening considered and should have a mammogram every year starting from 30 yr
Slide30Ho
w do we
diagnose
breast cancer ?What do we look for on mammograms? Calcifications Macrocalcifications
:
usually
related to non-cancerous conditions (also usually do
not require a biopsy). They are found in about 1/
2 of all women > 50 yr
, and in 1/10 women <
50
y
r
.
Microcalci
f
ica
t
ion
s
:
t
iny
specks of calcium, alone or in clusters. If a suspicious look and pattern - a biopsy A mass: may be just cysts or non-cancerous solid tumors but also may be a cancer (usually masses should be biopsied if they are not cysts)
A mammogram cannot prove t
ha
t
an
abnormal
area
is
a
cancer
Hi
stopathological
assesmen
t
(a
needle
biopsy
or
an
open
surgical
biopsy)
is
needed
Mammogram
repo
rt
s
The
American
College
o
f
Radiology
has
developed
a
st
andard
syst
em
o
f
describing
mammograms
which
is
called
t
he
Brea
st
I
maging
Repo
rt
ing
and
Da
t
a
Syst
em
(
BI
-RAD
S
).
Pi
cture
t
aken
f
rom
ww
w
.
cance
r
.
org
Slide31Que
stion
The
be
st
evidence
for a
mortality benefit for mammography is in women
aged:30 to 39 years
40
t
o
49
years
50
t
o
69
years
70 to 89 years
Slide32Que
stion
The
be
st
evidence
for a
mortality benefit for mammography is in women
aged:30 to 39 years
40
t
o
49
years
50
t
o
69
years
70 to 89 years
Slide33W
hat else should
we
do (after receiving a histopathological report) before treatment?Blood tests
(
f
ull blood count) and routine chemistry(+
alkaline fosfatase)•Chest X-Ray, CT•
abdominlal USG, CTBone scan
•*Ca 15.3
Slide34S
T
A
GI
N
G
Slide3536
TNM staging
TX
means that the tumour size cannot be assessedTis means DCIST1 – The tumour
is
2 centimetres (cm) across or less
Slide3637
TNM T
T1
is further divided into 4 groups-T1mi – the tumour is 0.1cm across or less-T1a – t
he
t
umour is more than 0.1 cm but not more than
0.5 cm-T1b – the tumour is more than 0.5 cm
but not more than 1 cm-T1c
– the tumour is more than 1
cm
bu
t
no
t
more
t
han
2
cm
Slide3738
T2 –
T
he
tumour is more than 2 centimetres, but no more than 5 centimetres
across
Slide3839
T3
–
T
he tumour is bigger than 5 centimetres across
Slide3940
TNM T
T
4
is divided into 4 groupsT4a – The tumour has spread into the chest wall
T4
b
– The tumour has spread into the skin
and the breast may be swollenT4c – The tumour
has spread to both the skin
and the chest wallT4d –
I
n
f
lamma
t
ory
carcinoma
–
t
his
is
a cancer in which the overlying skin is red, swollen and painful to the touch
Slide4041
T4
Slide4142
N staging
NX
means that the lymph nodes cannot be assessed (for example, if they were previously removed)
N0
–
No cancer cells found in any nearby nodesIsolate
d tumour cells (ITCs) are small clusters of
cancer cells less than0.2 mm acro
ss, or a single tumour cell,
or
a
clu
st
er
o
f
f
ewer
t
han
200 cells in one area of a lymph node. Lymph nodes containing only isolated tumour cells are not counted as positive lymph nodesN1 – Cancer cells are in the lymph nodes in the armpit but the nodes are not stuck to
surrounding tissuespN1mi –
O
ne
or
more
lymph
nodes
con
t
ain
areas
o
f
cancer
cells
called
microme
t
a
st
ases
t
ha
t
are
larger
t
han
0
.
2mm
or
con
t
ain
more
t
han
200
cancer
cells
bu
t
are
less
t
han
2mm
Slide4243
N staging
N2
is divided into 2 groupsN2a – there are cancer cells in the lymph nodes in the armpit, which are
st
uck
to each other and to other structuresN2b
– there are cancer cells in the internal mammary nodes( behind breast
bone) which have either been seen on a
scan or felt by the doctor.
There
is
no
evidence
o
f
cancer
in
lymph
nodes in the armpit
Slide4344
N staging
N3
is divided into 3 groupsN3a – there are cancer cells in lymph nodes below the collarbone N3b – there
are
cancer cells in lymph nodes in the armpit and behind the
breast boneN3c – there are cancer cells in lymph nodes above the
collarbone
Slide4445
The M
sta
g
es (metastases)M0 means that there is no sign of cancer spreadcMo(i+) means there is
no
sign of the cancer on physical examination, scans
or X-rays but cancer cells are present in blood, bone marro
w, or lymph nodes far away f
rom the breast cancer – the
cells
are
f
ound
by
labora
t
ory
t
e
st
sM1 – means the cancer has spread to another part of the body
Slide45Brain
Me
ta
sta
tic
disease
Liver
Bones
Lungs
Brea
st
….
Skin
O
vary
Slide46TNM-stag
ing
0
Tis
N0 M0IT1 N0 M098% 5-yr
survival
II
ABT0/1 N1
M0 or T2 N0 M0T2 N1 M0 or T3 N0
M088% 5-yr survival
76% 5-yr survivalIII
A
B
T0/1/2
N2
M0
or
T3
N1/2
M0
T4 Any N M0 or any T N3 M0A 56% 5-yr survival B 49% 5-yr survivalIVAny T Any N M116% 5-yr survival
Slide47T
reatme
n
t
Slide48T
reatment
- -
- - -Surgery Chemotherapy Radiotherapy Hormone therapy Targeted therapy
Slide49Surgery
-Tumorectomy
-
Breast Conserving Therapy- Total mastectomy- Modified mastectomy- Reconstruction- Palliative operationsPathologic diagnosis with
core
needle biopsy (CNB) should be obtained before any
surgical procedureSuspicious lymph nodes should also be biopsied (fine needle aspiration)
BC
T
:
removing
o
f
t
umo
r
,
sen
t
inel
lyph node followed by RTH Radical treatment!
Slide50BCT
Uni
focal
disease
Primary
t
umor
size less
than 5cm
Proper
ra
t
io
o
f
t
umo
r-
t
o-brea
st
sizeRetroareolar localization is a contraindicationPrior therapeutic chest irradiation is a contraindicationPositive lumpectomy margins after resection is a contraindicationDiffuse, malignant-
appearing
microcalci
fica-
t
ions
o
n
the
preopera
t
ive
mammogram
is
a
con
t
raindica
t
ion
Slide51BCT
Comp
l
ic
a
t
ions
Ar
m
edema
Rib fractures
Radiation pneumon
it
i
s
Brachia
l
plexus
lesion
Sec
on
d
no
n
breast malignancyPoor cosmetic outcome
Slide52Sen
tinel lymph node
biopsy
A
sentinel nodeTheoretically, first lymph node collecting cancer cells that meta
st
a
si
ze from the tumorProcedureAn injection
with a radionuclide near the tumor -Scinctigraphic imaging
Just before the biopsy: inje
ction of a blue dye During
t
he
biop
sy:
visual
de
t
e
ct
ion
+
radionuclide
detection of a sentinel node
Slide53Palpable
axillary
nodes
After
neoadjuvant
systemic
treatment
Pregnancy
or
la
ct
a
t
ion
Brea
st
recon
struction
or
implan
tation of a prothesis
Prior
axillary
surgery
Mul
ticentric
tumors
T>
T
3
Sen
t
inel
node
biopsy
should
no
t
be
carried
ou
t
Slide54Surgery
Poor cosme
tic
ou
tcome (poor incision placement, incisioformation)n size, and hematoma
Slide55Surgery
Metachronous
bilateral
breast cancers treated with radical mastectomy (left) and modified radical mastectomy
(righ
t).
Reconstruction of the breast
Slide56S
ystemic
tr
e
atment57
Slide5758
St. Gallen consensus
Slide5859
Ki-67
- is
a protein that in humans is encoded by the MKI67 gene (antigen identified by monoclonal
an
t
ibody Ki-67).- is a cellular marker for
proliferation.[5] It is strictly associated with
cell proliferation. During interphase,
the Ki-67 antigen can be exclusively
de
t
e
ct
ed
wi
t
hin
t
he
cell
nucleus, whereas in mitosis most of the protein is relocated to the surface of the chromosomes. Ki-67 protein is present during all active phases of the cell cycle (G1, S, G2, and mitosis), but is absen
t from resting cells (
G
0
).
Slide5960
St. Gallen consensus
( Ki67 20%
- new borderline)
Slide6061
St.
Gallen
2013
Slide61No
•
Rare
phenotypes with N0 and no other signs of increased metastatic potentialIn T1a N0
•
Y
es
Triple negative tumor
Patients receiving anti- HER2 treatmentAdjuvant Chemot
herapy in ER-negative disease:
Slide62Rela
tive indications:
High
grading (3)Lower hormone receptors level> 4 lymph nodes involvedExtensive peritumoral vascular invasion
p
T>
5cm (T3)Patient’s preference
Adjuvant Chemotherapy in ER-positive, HER2-negative disease:
Slide6364
neoadjuvant
t
r
eatment» with locally advanced tumors cT3; N2+
Slide64Que
stion
W
hich
f
a
ct
or
is
a relative indication for adjuvant
chemotherapy for patients wi
t
h
ER-posi
t
ive
and
HER2-nega
t
ive
brea
st
cancer?Low grading (1)> 2 lymph nodes involvedLower hormone receptors level
Slide65Que
stion
W
hich
f
a
ct
or
is
a relative indication for adjuvant
chemotherapy for patients wi
t
h
ER-posi
t
ive
and
HER2-nega
t
ive
brea
st
cancer?Low grading (1)> 2 lymph nodes involvedLower hormone receptors level
Slide66ADJU
VANT SYSTEMIC
Chemotherapy
USED IN THE TREATMENT OF EARLY BREAST CANCER4x AC (doxorubicine + cyclophopsphamide) – given every 3 weeks4x AC (ddAC for young patients) followed by 12x paclitaxel
weekly
4x AC (
ddAC
for young patients) followed by 4x docetaxel every tree weeksIf HER2 positive : add trastuzumab to taxaneIf triple negative and residua
disease after neoadiuvant taxane, alkylator andantracycline : adiuvant capecitabine
Slide67H
ormon t
herap
i
esSelective estrogen receptor modulators(SERM)tamoxifen, toremifeneLuteinizing hormone-releasing hormone analogue(
GnRHA
–
gonadotropin-releasing hormone analogue)goserelin, luprorelin, triptorelin, buserelin
Third-generation aromatase inhibitors(AI)anastrozole, letrozoleexemesth
aneProgestinsmedroxyprogesterone acetate, megestrol
acetateEstrogen receptor down-regulator
fulvestrant
Slide68Adju
vant endocrine therapy:
•
Applied
in all pts whose tumors show evidence of endocrine responsiveness (the presence of ANY
de
t
e
ctable estrogen receptor)
Slide69Que
stion
Adjuvan
t
endocrine
t
herapy
should
be given to the patients
:whose tumors show t
he
presence
o
f
any
de
t
e
ct
able
e
strogen receptorwhose tumors show presence the estrogen receptors in at least > 9% of tumor cells
Slide70Que
stion
Adjuvan
t
endocrine
t
herapy
should
be given to the patients
:whose tumors show t
he
presence
o
f
any
de
t
e
ct
able
e
strogen receptorwhose tumors show presence the estrogen receptors in at least > 9% of tumor cells
Slide71Que
stion
A
woman
wi
t
h
a 6-cm breast
cancer (cT3) and clinically palpable immobile ipsilateral axillary
nodes (cN2) would best be served bysurgery
neoadjuvan
t
chemo
t
herapy
adjuvan
t
chemo
t
herapy
radia
t
ion
therapy
Slide72Que
stion
A
woman
wi
t
h
a 6-cm breast
cancer (cT3) and clinically palpable immobile ipsilateral axillary
nodes (cN2) would best be served bysurgery
neoadjuvan
t
chemo
t
herapy
adjuvan
t
chemo
t
herapy
radia
t
ion
therapy
Slide73Adju
vant endocrine therapy (ER+):
Po
st
menopausal patients 1.Tamoxifen2. Aromatase inhibitorsPremenopausal patients1. Tamoxif
en
+
/-
ovarian function suppression GnRHA2. Aromatase inhibitors +
ovarian supressionContraindicated: aromatase inhibitors without ovarian
supression
Slide7475
TAMO
XIFEN
Slide7576
Tamo
xif
en
side effects therapy»»»endometrial cancers thromboemboliaeBUT improves
bone
mass
Slide7677
AI
Ar
om
atase Inhibitors
Slide7778
Tamo
xif
en
vs IA
Slide78Que
stion
W
ha
t
kind
o
f t
he adjuvant endocrine therapy is the
best option for your premenopausal pa
t
ien
t
s
wi
t
h
brea
st
cancer
(ER
+):
Tamoxifen + GnRHAromatase inhibitor aloneC Initial treatment with aromatase inhibitor and then Tamoxifen
Slide79Que
stion
W
ha
t
kind
o
f t
he adjuvant endocrine therapy is the
best option for your premenopausal men
st
rua
t
ing
pa
t
ien
t
s
wi
t
h
brea
st cancer (ER+):Tamoxifen+ GnRHAromatase inhibitor aloneC Initial treatment with aromatase inhibitor and then Tamoxifen
Slide80T
argeted Therapy
T
rastuzumab- Humanized monoclonal antibody against HER2 receptor- Reduces cancer cells proliferation
-
Suppresses
angiogenesis- Side effects: cardiotoxity
(especially when given with antracyclines!); also weakness, nausea, vomi
ting- rareBevacizumab (anti VEGF)
Slide8183
Slide82An
ti-HER2 therapy in
adjuvant/neoadiuvant:
•
•••1 year duration of trastuzumab therapy Anti-HER2 + chemot
herapy
An
ti-HER2
+ endocrine therapyNo need if HER2+ i
f T<1cm and N0Future :double blockade with pertuzumab
Slide83Que
stion
A
55-year-old
woman
no
t
ed a mass in her left brea
st 2 months ago. On examina
t
ion
:
2
t
o
3
cm
mass
in
the upper outer quadrant, no palpable lymph nodes. BCT is performed. Cancer cells are negative for ER and PR, but positive for HER2. Which of the following additional treatment options is most likely to be ef
fective in this case?
Pa
t
ey
’
s
opera
t
ion
T
amoxi
f
en
or
ana
st
rozol
Ce
f
alosporins
T
ra
st
uzumab
Slide84Que
stion
A
55-year-old
woman
no
t
ed a mass in her left brea
st 2 months ago. On examina
t
ion
:
2
t
o
3
cm
mass
in
the upper outer quadrant, no palpable lymph nodes. BCT is performed. Cancer cells are negative for ER and PR, but positive for HER2. Which of the following additional treatment options is most likely to be ef
fective in this case?
Pa
t
ey
’
s
opera
t
ion
T
amoxi
f
en
or
ana
st
rozol
Ce
f
alosporins
T
ra
st
uzumab
Slide85Que
stion
W
ha
t
is
t
he recommended
duration for the therapy wi
th Transtuzumab (Herceptin) in pa
t
ien
t
s
wi
t
h
brea
st
cancer
HER2+?
6
months1 year C 5 years
Slide86Que
stion
W
ha
t
is
t
he recommended
duration for the therapy wi
th Transtuzumab in patient
s
wi
t
h
brea
st
cancer
HER2+?
6
mon
t
hs1 year C 5 years
Slide87FOLLOW
UP
Slide88Rec
ommended
breas
t
cancer surveillanceMODE OF SURVEILLANCESUMMARY OF RECOMENDATIONHistory
/
physical
examinationEvery 3 to 6 months for the
first 3 years after primary therapy; every 6 to 12 months
for years 4 and 5; then
annualyReferral for genetic counseling
Criteria
inculde:
(1)
Ashkenazi
Jewish
heritage,
(2)
History
of ovarian cancer at any age in the patient or any first- or second-degree relatives, (3) Any first-degree relative with a history of breast cancer diagnosed before the age 50 years, (4) Two or more first- or second-degree relatives
diagnosed with breast cancer at
any
age,
(5)
Patient
or
r
elative
with
diagnosis
of
bilateral
b
r
east
cancer’
(6)
History
of
b
r
east
cancer
in
a
male
r
elative
B
r
east
self-
examination
All
women
should
be
counseled
to
perform
monthly
b
r
east
self-examinatin
Mammography
First
post-t
r
eatment
mammogram
1
year
after
the
initial
mammogram
that
leads
to
diagnosis
but
no
earlier
than
6
months
after
definitive
radiation
therap
y
.
Pelvic
examination
Slide89Rec
ommended
breas
t
cancer surveillanceMODE OF SURVEILLANCESUMMARY OF RECOMENDATIONHistory
/
physical
examinationEvery 3 to 6 months for the
first 3 years after primary therapy; every 6 to 12 months
for years 4 and 5; then annualy
Referral for genetic counseling
Criteria
inculde:
(1)
Ashkenazi
Jewish
heritage,
(2)
History
of ovarian cancer at any age in the patient or any first- or second-degree relatives, (3) Any first-degree relative with a history of breast cancer diagnosed before the age 50 years, (4) Two or more first- or second-degree relatives diagnosed
with breast cancer at any
age,
(5)
Patient
or
r
elative
with
diagnosis
of
bilateral
b
r
east
cancer’
(6)
History
of
b
r
east
cancer
in
a
male
r
elative
B
r
east
self-
examination
All
women
should
be
counseled
to
perform
monthly
b
r
east
self-examinatin
Mammography
First
post-t
r
eatment
mammogram
1
year
after
the
initial
mammogram
that
leads
to
diagnosis
but
no
earlier
than
6
months
after
definitive
radiation
therap
y
.
Pelvic
examination
Regular
gynecologic
follow-up
is
r
ecommended
for
all
women.
Patients
who
r
eceive
T
AM
should
be
advised
to
r
eport
any
vaginal
bleeding
to
their
physicans.