BREAST CANCER: EARLY

DIAGNOSIS BETTER

PROGNOSISDR. A. AKHATOR FWACS, FICS

SENIOR LECTURER DELSU CONSULTANT SURGEON DELSUTH

PRE-TEST1. Breast cancer is the most common

cancer in women in Nigeria 2. Breast cancer is the most common

cause of cancer related deaths3. Breast cancer commonly present as

painful breast lump4. Prognosis of breast cancer is related

to the size of the breast tumor5. Trastuzumab (HerceptinR) is treatment

for ER/PR positive tumor

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 management

OCTOBER IS BREAST CANCER AWARENESS MONTH

BREAST

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 disease

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 COUNTRIES

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 women

FACTORS THAT INCREASE RISK

Family History

•Lifestyle

•Personal History

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.

FAMILY HISTORY SHARED GENETIC MAKEUP SHARED LIFESTYLE SIMILAR ENVIRONMENTAL EXPOSURE 5-10% CAUSED BY INHERITED GENETICS

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 Therapy

LIFESTYLE

Several studies found a lower incidence of breast cancer among women who exercise regularly

Higher proportion of breast cancer among obese women.

Smoking

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 risk

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 RISK

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 TRUE

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 disease

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, M1

Total Cancers Per Cent

In Situ Carcinoma * 15–30Ductal carcinoma in situ, DCIS 80

Lobular carcinoma in situ, LCIS 20

Invasive Carcinoma 70–85No 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)

EARLY DIAGNOSIS ….. Early diagnosis leads to better prognosis The size of the tumor and extend of

spread determines the prognosisEarly stageBetter possibility for cureLess morbidityLess toxic treatment

PROGNOSIS1. Overall survival/Disease free interval2. Quality of life

a. Adverse effect/toxicity of treatmentb. Body habitusc. Psychological

PROGNOSTIC FACTORS Age Tumor size Axillary LN status Histological grade Receptor status – ER, PR HER2-neu(C-erb B2)

OVERALL SURVIVAL CURE RATES FOR BREAST CANCER 5 year cure rates of >90% obtainable

for early tumours, < 30% for late tumours

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%

QUALITY OF LIFE Scars of treatment/no breast Younger survivors face

Emotional stressesTrouble with social functioningChemotherapy induced early menopauseSexual difficulties

DIAGNOSIS ASYMPTOMATIC PATIENT SCREENING

BSECBEMammographyMRI

SYMPTOMATIC PATIENTClinical evaluationDiagnostic investigations

BREAST SELF EXAM

ADVANTAGES OF BSE1. It is simple and easy to perform.2. It is convenient and requires little

time.3. It is private.4. It involves no medical cost5. It is safe and non-invasive.6. It requires no specific equipment.

METHODS OF TRAINING Pamphlets and leaflets. Instructional videos. Demonstrations and personal

instructions.

BREAST-SELF-EXAMINATION Breast self examination – monthly Understand the breast and look for

changes1. Development of a lump.2. Swelling.3. Skin irritation or dimpling.4. Nipple pain or retraction.5. Redness or scaliness of the nipple or

breast skin.6. Discharge - other than milk. Standing and lying

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.

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% survival

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 older

EARLY DIAGNOSIS TRIPLE ASSESSMENT1. CLINICAL EVALUATION2. IMAGING3. HISTOCYTOLOGY

CLINICAL EVALUATION History

Progression of symptomsRisk factors for breast cancerTreatment to date

Physical examinationLocal systemic

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 spread

LUMP IN THE BREAST

LUMP IN THE AXILLA

RETRACTED NIPPLE

RETRACTED NIPPLE

INFLAMMATORY BREAST CANCER

BLOODY NIPPLE DISCHARGE

BREAST ULCER

BREAST ULCER

BREAST CANCER IN A MAN

IMAGING Breast scan Mammogram

Digital mammogramComputer aided diagnosis (CAD)

MRI OTHERS

ThermographyScintimammographyTomosynthesis (3D Mammography)

HISTOCYTOLOGY TYPES OF BIOPSY TECHNIQUE FNAC Core Needle

Vacuum assisted Open biopsy

Incisionalexcisional

TREATMENT SURGERY1. Mastectomy + reconstruction2. BCS HORMONAL THERAPY CHEMOTHERAPY TARGETED THERAPY RADIOTHERAPY

MASTECTOMY - INDICATIONS Large tumors Centrally located tumors Large tumors cf size of breast Multicentric tumor – mammogram Previous radiotherapy Patient’s preference

MASTECTOMY Simple mastectomy + SLND Skin-sparing mastectomy

Nipple-sparing mastectomy Modified Radical mastectomy Breast reconstruction/breast form

Radiotherapy after mastectomy1. Large tumors 5cm or larger2. Deep seated tumors3. 4 or more positive lymph nodes

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 QUART

CONTRAINDICATION TO BCT1. Very small breast2. Very large breast3. Advanced/high grade disease4. Lactating breast/pregnancy5. Multicentric disease6. Contralateral disease7. Previous RT8. Central tumors9. Multiple tumors10. Risk for 2nd tumor

BCS WITHOUT RADIOTHERAPY BCS is considered without radiotherapy

if all of the following are present1. Patients aged 70 years or older2. Tumor is <2cm and has been

completely excised3. Tumor is hormone receptor positive

and patient is placed on hormone therapy

4. No positive axillary lymph node

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, bladder

HORMONAL Tamoxifen; Raloxifene; Toremifene Fulvestrant – eliminates receptor Aromatase inhibitiors

Letrozole Anastrozole exemestane

Ovarian ablation Oophorectomy LHRH analogs – goserelin, leuprolide

Megastrol acetate androgens

TARGETED THERAPY HER2/Neu monoclonal antibodies

Trastuzumab (HerceptinR)Lapatinib (TyrkebR)

Angiogenesis inhibitorsBevacizumab (AvastinR)

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 menopausal

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 metastasis

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?

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 PROGRAM

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

complaints

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 earlierBSECBEMammogram

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.

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 prospects

THANK YOU AND GOD BLESS

POST TEST1. Breast cancer patients present

commonly to breast clinic with early disease in Warri

2. The prognosis of breast cancer is related to the grade of the tumor

3. Hormone receptor assay is essential in the management of breast cancer.

4. BSE is the most widely recommended method for screening breast cancer

5. Breast conservative surgery is the best treatment for stage III disease.