Breast Cancer 101

1. Breast Cancer 101 Barbara Lee Bass, MD, FACS Professor of Surgery Associate Chair for Academic Affairs and Research University of Maryland School of Medicine

2. What is Breast Cancer? • Abnormal cells develop from normal cells in the breast to form tumors • Tumor cells have genetic defects that allow the cells to grow too rapidly and to invade normal tissues • 90% of women with breast cancer have tumors due to spontaneous new mutations arising in their breast tissue as they age

3. What is Breast Cancer? • The cause of these mutations is not known • 10% of women with breast cancer have an inherited risk for cancer due to genes passed on from their parents

4. Breast cancer: Steps in the development of a tumor • Cancers develop due to a series of molecular changes in the the cells of the breast • These cellular changes lead to pre-malignant tissues in the breast that can be identified in a biopsy • Cancers develop from a microscopic group of cells that grow into larger tumors over time

5. Stages of breast cancer? • The rate at which a cancer will grow is not predictable - some tumors grow slowly, others rapidly • The earlier a tumor is identified, the better the chance for cure • 95% of women with cancers less than 1/2 inch in size are cured

6. Breast Cancer: Statistics • Breast cancer is the most common cancer in American women • 185,000 new cases this year • 41,000 American women will die of breast cancer - second only to lung cancer as a cause of cancer death among women • Lifetime risk for the average woman; approximately one in nine will develop breast cancer

7. What is my risk for developing breast cancer? • Age greater than 50 years • History of breast cancer in a close relative (mother/sister/daughter) • 90% of women with breast cancer have no relatives with the disease

8. Risks • Finding of premalignant changes in your breast tissue • Never having children • Having your first child after age 30 • Obesity - Alcohol - Estrogen therapy

9. What is my best defense against breast cancer? EARLY DETECTION • Be aware of your personal risk for breast cancer • Have a screening mammogram every year once you are 40 years old • Have an annual breast exam every year after age 40

10. Early Detection • Practice monthly breast self exam • See your doctor promptly if you note a new breast lump or thickening • Enjoy a healthy life: control your weight, minimize alcohol, don’t smoke, exercise

11. Why are mammograms important? • Mammograms are sensitive xrays of the breast • Small, safe dose of radiation is used • Minor discomfort due to pressure on the breast is noted by some women EARLY DETECTION LEADS TO CURE

12. Why are mammograms important? • Mammograms can detect changes in breast tissue that may be associated with cancers and premalignant changes • Mammograms are the best means to find early curable cancers - cancers too small to be detected by touch • 85% of cancers will show up on a mammogram - 15% will not

13. What if I have an abnormal mammogram? • See your doctor for a breast examination • Special mammogram will be done to confirm if the finding is real • Additional imaging tests - ultrasound - for better definition • Close follow-up imaging may be recommended at 6 months or:

14. What if I have an abnormal mammogram? • Biopsy may be recommended • Needle biopsy - Ultrasound directed • Needle biopsy - mammogram directed • Surgical biopsy • The tissue diagnosis is the most important information in planning treatment • Most mammogram abnormalities are not cancer; most are due to benign changes

15. What if I feel a lump in my breast? • Go to you health care provider promptly for a physical examination; don’t wait for your annual examination • She may refer you for breast imaging - even if you had a mammogram less than one year previously • He may refer you to a Breast Center - or specialist in breast care - a surgeon or medical oncologist EARLY DETECTION LEADS TO CURE

16. What if I feel a lump in my breast? • A biopsy may be recommended, depending on the features of the lump • Many lumps in the breast are NOT cancer; benign fibrocystic disease and benign tumors are common

17. How is the diagnosis of breast cancer made? • A suspicious sign on a mammogram or a lump in the breast will indicate the need for a tissue biopsy • A biopsy of the abnormal tissue is required to make the diagnosis of breast cancer • A careful physical examination will give signs about the stage of the cancer • size of tumor in breast • lymph node enlargement under arm • status of the opposite breast

18. How is the diagnosis of breast cancer made? • Features of the tumor: • type of breast cancer - ductal, lobular, etc • grade of the tumor • hormone receptor status • indicators of biologic growth rate potential • c-erb

19. How is breast cancer treated? 1. SURGERY: to remove all the tumor Breast preserving surgery - most patients Removal of the full breast - mastectomy - may be required for some patients 2. DETERMINE THE STAGE OF THE TUMOR: Remove some of the lymph nodes under the arm to look for tumor metastases

20. How is breast cancer treated? 3. ADJUVANT THERAPY: Medical therapy to decrease the chance of tumor recurrence - to improve the chances for cure Chemotherapy - many different therapies Hormonal therapy - tamoxifen, aromatase inhibitors 4. RADIATION THERAPY - to prevent tumor recurrence in the remaining breast tissue; required for breast preserving therapy

21. Can breast cancer be prevented? • NSABP P1 Trial: showed that women with an increased risk for breast cancer can have that risk decreased by 40 - 50% by taking the anti-estrogen medication tamoxifen • Tamoxifen benefited women with: • the breast cancer gene • age greater than 55 years • premalignant changes in previous biopsies • Side effects • very small increase in risk of cancer of the uterus • blood clots

22. Can breast cancer be prevented? • Who should be offered chemoprevention? • How long should we give this medication? • Are the long term effects satisfactory?

23. STAR Chemoprevention Trial(Study of Tamoxifen against Raloxifene) • National clinical study that will enroll 22,000 women to test the effectiveness of 2 different anti-estrogens for the prevention of breast cancer

24. STAR Chemoprevention Trial(Study of Tamoxifen against Raloxifene) • Tamoxifen vs. Raloxifene • both are approved medications that selectively block estrogen receptors • estrogen receptors are present on many tissues - breast, bone, uterus, blood vessels, and many others • Tamoxifen - breast cancer medication • Raloxifene - anti-osteoporosis medication • Compare the 2 groups of women for development of breast cancer, possible side effects or other benefits

25. STAR Chemoprevention Trial(The Study of Tamoxifen against Raloxifene) • Eligibility for participation is based on a 5 year predicted risk for developing breast cancer. The following factors contribute to this calculated risk: • Age: post-menopausal women over the age of 35 • positive family history of breast cancer • history of benign breast biopsies • history of lobular carcinoma is situ on previous breast biopsy

26. STAR Chemoprevention Trial(The Study of Tamoxifen against Raloxifene) • The Breast Evaluation Program of the Greenebaum Cancer Center is a participating site for this trial. If you would like to be considered for participation please call 410-328-7855 for an appointment.