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BREAST CANCER

BREAST CANCER Curtis Tucker M.D. Epidemiology 32% of all female cancers 15% of cancer deaths 217,000 new cases per year 40,500 deaths per year Risk Factors FEMALE Increasing age – very uncommon below the age of 40, but risk increases to 1 in 8 for women living into their 80’s

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BREAST CANCER

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  1. BREAST CANCER Curtis Tucker M.D.

  2. Epidemiology • 32% of all female cancers • 15% of cancer deaths • 217,000 new cases per year • 40,500 deaths per year

  3. Risk Factors • FEMALE • Increasing age – very uncommon below the age of 40, but risk increases to 1 in 8 for women living into their 80’s • Family history – relative risk is 1.7 if women have a first degree relative with breast cancer • Proliferative breast disease- ductal hyperplasia, sclerosing adenosis, lobular hyperplasia, LCIS • Personal history of breast cancer (also colon, ovarian, endometrial) • Reproductive factors • Radiation exposure, especially at early age • ?? HRT • Alcohol, high fat diet, obesity

  4. Genetic Risk Factors • Hereditary forms of breast cancer account for only 5% of breast cancer cases • BRCA1 mutation – inherited AD fashion with a lifetime risk of breast cancer of ~55% - 85% and ovarian cancer risk of ~15 – 45% • BRCA2 mutation – 6% lifetime risk of breast cancer

  5. Screening • Breast self-exams – beginning in their 20’s • Clinical breast exam – beginning at age 20 q 3 yrs and annually after age 40 (15% of breast cancers detected only clinically) • Mammography – annually beginning at age 40 or 5-10 yrs prior to any first degree relatives dx age (85% of tumors mammographically detectable) 50% of lesions dtected by mammo only • Screening US for dense breasts • ?? Breast MRI

  6. Signs and Symptoms • Mammo findings – microcalcifications, asymmetry, mass, architectural distortion most DCIS found on mammo only • Breast lump – 65% of cases • Eczematoid changes in the nipple (Paget’s dz) • Nipple retraction/discharge • Skin changes/ulceration

  7. Pathology • Ductal Carcinoma In Situ (DCIS) - 25% of cases • Infiltrating Ductal Carcinoma – 65% of cases • Infiltrating Lobular Carcinoma – 5-10% of cases • Rare types – medullary, tubular, lymphoma, sarcoma

  8. TNM Staging • Tx – tumor cannot be assessed • T0 – no evidence of primary tumor • Tis – DCIS • T1 - tumor less than/equal to 2 cm • T2 - tumor > 2 cm but not > 5 cm • T3 – tumor > 5 cm • T4 – involvement of skin or chest wall or inflammatory carcinoma

  9. TNM Staging • Nx – lymph nodes (LN) cannot be assessed • N0 – No regional LN • N1 – movable axillary LN • N2 – fixed/matted axillary LN or internal mammary LN only • N3 – both axillary and internal mammary LN, or infraclavicular LN or supraclavicular LN

  10. TNM Staging • Mx – metastasis cannot be assessed • M0 – no distant mets • M1 – distant mets

  11. TNM Staging • Stage 0 – DCIS • Stage I – T1 N0 M0 • Stage II – T1 N1 M0 T2 N0-1 M0 T3 N0 M0 • Stage III – T3 N1 M0 any N2-3 M0 any T4 M0 • Stage IV – any M1

  12. Prognostic Factors • TNM staging • Lymph node status – prognosis directly correlates with number of positive LN • Node negative - 20% recurrence at 5 yr • LN+ > 10 nodes – 75% recurrence rate at 5 years • Hormone receptor status – ER/PR positive is more favorable • Her2/neu positive is more unfavorable

  13. Breast Cancer Survival Ratesat 8 years • Stage 0 – 98% • Stage I – 90% • Stage II – 70% • Stage III – 40% • Stage IV – 10%

  14. TreatmentLCIS • Not breast cancer • Marker for increased risk of breast cancer • Lifetime risk of developing breast cancer 25 to 30% • Do not need excisional bx or clear margins • Treatment options – close observation, tamoxifen, bilateral prophylactic mastectomies

  15. Treatment DCIS • Pre-invasive cancer • Risk of LN involvement/distant mets is 1% • Do not need met w/u or LN dissection • Options for tx – breast conserving therapy vs simple mastectomy • Need clear margins for breast conservation

  16. BCT for DCIS • DFS rate at 5 years – 99% • Review of NSABP-06 showed no difference in survival for BCT vs mastectomy • NSABP-17 prospective randomized trial lumpectomy vs lumpectomy and radiation at 8 yrs local recurrence reduced from 27% to 12% with radiation, no difference in survival (no boost) • European trial prospective trial same results • All subgroups showed decrease in local recurrence rate • Addition of tamoxifen further reduced risk (6 year FU 13% recurrence vs 8%)both ipsilateral and contralateral • Do patients need radiation? Yes.

  17. Invasive Breast CancerEarly Stage • Treatment options include BCT vs. modified radical mastectomy

  18. BCT vs Mastectomy • Multiple US and international prospective randomized trials all show equivalency of BCT with radiation to mastectomy (over 4000 patients total) • Largest US trial NSABP-06, 1800 women randomized, 20 year follow up no difference in either local/regional recurrences – 15% mastectomy vs 9% BCT, or in disease-free survival 36% mastectomy vs 35% BCT

  19. BCT vs Mastectomy • This study included an arm with lumpectomy alone and although DFS was not significantly effected (P 0.07) local recurrence rate was 40% • Ability to have is BCT is not affected by LN status and in fact in women with positive LN after mastectomy appear to have a survival benefit with the addition of radiation to the chest wall • Current radiation techniques yield a failure rate in the breast of ~ 4% at 5 years

  20. Breast Conserving TreatmentCriteria • Typically less than 5 cm lesion • No multicentric dz/calcifications • Must have negative margins (>1mm) this includes DCIS • No Scleraderma/autoimmune dz • Breast/tumor proportion – cosmetic outcome

  21. Early Stage Breast CancerAdjuvant Treatment • Chemotherapy • Hormonal therapy – tamoxifen, arimidex, femara, aromasin, raloxifene • Herceptin monoclonal antibody to her2/neu receptor

  22. Advanced Stage Work Up • CBC, CMP • CT chest and upper Abd • Bone scan • Consider PET scan

  23. Advanced StageTreatment • Typically includes surgery, chemotherapy, radiation, and if possible hormonal therapy

  24. Inflammatory Breast Carcinoma • Can present with a cellulitis type picture and usually arises very quickly • Does not typically have a dominant mass • Poor prognosis and must be treated very aggressively • Treated with chemotherapy followed by mastectomy then radiation and more chemotherapy

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