management of breast cancer

8/13/2019 Management of Breast Cancer

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Management of BreastCancer

By

Hussein M. Khaled

Prof. Medical Oncology

Vice President

Post graduate Studies and Research

Cairo University


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BREAST CANCER

Worldwide incidence in females*

*Incidence per 100,000 population.

Parkin DM, et al. CA Cancer J Clin.1999;49:33-64.

67.4

36.0

28.6

71.7

21.2

25.0

31.5

25.5

86.3

EasternEurope

Japan

Australia/New Zealand

South CentralAsia

NorthernAfrica

SouthernAfrica

CentralAmerica

WesternEurope

NorthAmerica


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CANCER CONTROL

EARLYDETECTION

DIAGNOSISPRIMARY

PREVENTION

TREATMENT


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BREAST CANCERSigns and symptoms at presentation

Mass or pain

in the axilla

Palpable mass

Thickening

Pain

Nipple discharge

Nipple retraction

Edema or erythema

of the skin


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BREAST CANCER

Diagnosis path

Evaluationfor

biopsy

Cyst

aspiration

Biopsy

Excisional biopsy

Core-cutting needle biopsy

Fine-needle aspiration

Palpable

mass

Ductal

carcinoma

in si tu

Invasive

cancer

Lobular

carcinoma

in si tu

BenignInsufficientevaluation,rebiopsy

If persistent,

short-term

follow-up

with surgeon

Continued

appropriate

screening

Cyst Normal

Nonpalpable

mass

Treatment Path

Needle

localization


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Staging Classification of Breast Tumour


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Early Breast Cancer


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NSABP B-06:Effect of Lumpectomy v. Mastectomy on Survival

DISTANTDISEASE-FR

EESURVIVAL(%)

Cohort A Cohort B Cohort C

Total Mastectomy: 692/265 569/233 494/192

Lumpectomy: 699/302 634/282 520/236

No. of patients / No. of recurrences

YEAR

Lumpectomy + XRT: 714/278 628/253 515/204


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HT


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HER2 testing algorithm

Adapted from Bilous M, et al. Mod Pathol 2003;16:17382

Hanna W. Breast 2005;14(Suppl.1)S17 (Abstract 10)

+

FISH/CISH

Patient tumour

sample

IHC

2+ 3+1+0

+

FISH/CISH

+

Herceptin

therapy

Herceptin

therapy

Herceptin

therapy


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Locally Advanced Breast Cancer


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What elements drive therapy

decision making ?

Prognosis

Treatmentefficacy

Treatment

toxicity

Co morbidity


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ER +

ER -

ER +

ER -

T1a (0-5 mm) T1b (6-10 mm) T1c (11-20 mm)

NCI

NCCN*

St. Gallen

GUIDELINE RECOMMENDATIONFOR CHEMOTHERAPY FORSTAGE I BREAST CANCER

Not Recommended Optional Recommended

*) NCCN = National Comprehensive Cancer Network


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www/Adjuvant on line !


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The Breast Health Global Initiative (BHGI)Guideline Publication 2003

CONSENSUS

STATEMENTSEarly Detection PanelDiagnosis PanelTreatment Panel


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BHGI GLOBAL SUMMIT 2005:Guideline Stratification

Breast J 2006;12 Suppl 1:S117-120

Level of


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History

Physical examination

Clinical breast examination

Surgical biopsy

Fine-needle aspiration biopsy

Diagnostic breast ultrasound +/-

diagnostic mammography

Plain chest radiography

Liver ultrasound

Blood chemistry profile / complete

blood count (CBC)

Maximal

Stereotactic biopsy HER-2/neu status

CT scanning, PET scan, MIBI scan,

breast MRI

Sentinel node biopsy

IHC staining of sentinel nodes

for cytokeratin to detectmicrometastases

Enhanced

Diagnostic mammography

Bone scan

On-site cytopathologist

Preoperative needle localization

under mammographic or ultrasoundguidance

Basic

Interpretation of biopsies

Cytology and/or pathology

report describing tumor size,

lymph node status, histologic

type, tumor grade

Limited

Determination and reporting of

ER and PR status

Determination and reporting of

margin status

Core needle biopsy

Image guided sampling

(ultrasounographic +/-

mammographic)

Level of

resourcesClinical Pathology Imaging and lab tests

Diagnosis


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Controversial Issues :

FNAC or Frozen Sections

5 or 10 years of HT

T and AI

Type of CT

Herceptin and others

Pre or post op CT

Ov ablation

Cases who do not need systemic treatment


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Cancer Treatment

S

Chemo. Radio.

Types of cancer treatment

Application of cancer

treatmentCost of cancer treatment
http://images.search.yahoo.com/search/%20http:/images.search.yahoo.com/search/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dmoney%26ei%3DUTF-8%26fr%3Dyfp-t-501%26x%3Dwrt%26js%3D1%26ni%3D21&w=640&h=480&imgurl=www.matchstick.com%2Fmatt%2Fport%2Fww%2Fmoney.jpg&rurl=http%3A%2F%2Fwww.matchstick.com%2Fmatt%2Fport%2Fww&size=258.7kB&name=money.jpg&p=money&type=jpeg&no=7&tt=4,641,087&oid=018a458227ce7610&ei=UTF-8http://images.search.yahoo.com/search/%20http:/images.search.yahoo.com/search/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dmoney%26ei%3DUTF-8%26fr%3Dyfp-t-501%26x%3Dwrt%26js%3D1%26ni%3D21&w=255&h=204&imgurl=www.zdeinvestments.com%2Fimages%2Fmoney-stacked.jpg&rurl=http%3A%2F%2Fwww.nationalegamingforums.nl%2Fshow.php%2Fact%2FST%2Ff%2F267%2Ft%2F74034&size=10kB&name=money-stacked.jpg&p=money&type=jpeg&no=3&tt=4,641,087&oid=05696bc4399aea00&ei=UTF-8http://images.search.yahoo.com/search/%20http:/images.search.yahoo.com/search/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dmoney%26ei%3DUTF-8%26fr%3Dyfp-t-501%26x%3Dwrt%26js%3D1%26ni%3D21&w=350&h=281&imgurl=www.gosfi.net%2Fimages%2Fmoney.jpg&rurl=http%3A%2F%2Fblog.lide.cz%2Fkalioglou%2F2004%2F10%2F20%2F331&size=12.7kB&name=money.jpg&p=money&type=jpeg&no=11&tt=4,641,087&oid=0e25b0c9f55304be&ei=UTF-8


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Situation Analysis

Egypt


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EGYPT

Gharbia Populationbased registry


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Rate per 100 000 pop.

Incidence Rates of Common Sites of Cancer

Population Data: Females

37.8

8.1

4.1 3.7 3.7 3.4 3 2.3 2.4

49.6

10.7

6 5.2 5 5.33.5 3 3.6

0

10

20

30

40

50

60

Breast NHL Liver Colon-

Rectum

Ovary Bladder Brain&CNS Thyroid Lung

Crude Rate ASIR


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GLOBAL STATISTICS:

Age-Specific Rates / 100,000 Females (all ages)

Globocan 2002 (IARC)


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The National Cancer Institute

Cairo University

www.nci.cu.edu.eg

Cairo University National Cancer Institute
http://www.nci.cu.edu.eg/http://www.nci.cu.edu.eg/


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NCI Most Common Sites in Males and

females


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National Cancer Registry


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Cumm. %Proportion

7.7

20.3

35.1

52.7

68.9

79.3

90.5

95.5

100.0

7.7

12.6

14.8

17.6

16.2

10.4

11.2

5.0

4.5


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US SEEREgypt

1.3

7.1

25.2

61.7

117.5

192.1

253.1

1.4

9.8

28.9

63.6

96.7

171.5

181.2

20-24

25-29

30-34

35-39

40-44

45-49

50-54

Age-specific Incidence Rates of Breast cancer

in younger age groups: Egypt and US SEER


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Magnitude of Breast Cancer in Egypt: 2025

Population size: 51 million females

Crude incidence rate: 55.1./100,000 females Incidence: 14,00028,000 breast cancer cases Prevalence: 42,00084,000 breast cancer cases

Magnitude of Breast Cancer in Egypt: 2050

Population size: 64 million females Crude incidence rate: 68.8./100,000 females Incidence: 14,00044,000 breast cancer cases

Prevalence: 42,000132,000 breast cancer cases

Projection of Magnitude of Breast Cancer

in Egypt: 2025, 2050


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Breast cancer T stage 1984 - 2006, Port Said, Egypt

0

10

20

30

40

50

60

70

80

84-1985 86-1988 94-1999 2004 2005 2006

T1 T2 T3 T4

SOURCE: Prof. Dr. Ahmed Elzawawy


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Cancer Control in Egypt


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Inflammatory Breast Cancer (IBC)

Swollen

Erythema

Peau dOrange

Frequently

Mistaken for

Mastitis


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ClinicoPathological Correlationin Breast Cancer Cases

(2002)

Revision of the slides of 212 patients.

Only 16 patients had both clinical and pathological features

of IBC (8%) Age distribution

4 patients 35 yrs or less

8 patients 45 yrs or less8 patients More than 45 yrs

The youngest 25 yrs

The oldest 76 yrs


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More than 90% of IBC showed positive axillary nodes.

IBCsare characterized by:

High histologic grade tumors with high

Nuclear grade, necrosis and high PCNA and MIB-

1(Ki-67)labeling indices.

ER & PgRare frequently negative.

p53> 70% positivity.

HER-2/Neu> 60%.

Biologic profile Immunphenotypic signature


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Tumor emboli and LYVE-1 and RhoC expression in IBC tumors from

Egypt and the United States

Rh C S i d T E b li f E ti ti t


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RhoC Scoring and Tumor Emboli for Egyptian patients

with IBC and non-IBC

IBC (N=46)

No. (%)

Non-IBC (N=64)

No. (%) P-value

RhoC Score

1

2

3

4

1 (2)

5 (10)

20 (44)

20 (44)

24 (38)

29 (45)

7 (10)

4 (6)


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Cairo University National Cancer Institute

Thank you

management of breast cancer

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