Understanding Breast Cancer: Updates from Dr. Noha Al-Saleh

1. Updates on Breast Cancer Dr. Noha Al-Saleh,FRCSC Surgical Oncologist Kuwait cancer control center and AlSeef Hospital

2. Points to cover: • Statistics of breast cancer in Kuwait • What is breast cancer? • Who is @ risk for breast cancer? • Signs of breast cancer • Early detection plan • Treatment of breast ca • Summary of the facts

3. Statistics of breast cancer • Breast cancer is the most common cancer among women. • It is the 2nd leading cause of cancer deaths in women today (after lung cancer). • Deaths declined likely from earlier detection and advances in treatment. • Life time risk for breast ca is 1 in 8 women. • About 1 in 35 women die from breast cancer in U.S

4. Statistics in Kuwait

5. Statistics in kuwait • Amongst Kuwaiti women, rate of breast cancer was noted to increase dramatically for the past few years. • Between year 1980-1989 the recorded number of cases was 314. • This increased to 1555 cases between years 2000-2009( 5 fold increase).

6. Statistics in Kuwait • The age- standardized incidence rate of new breast cancer cases was 29.7 per 100,000 females in 1980-1989. • It increased by more than one and half fold in the following years and reached 49.4 cases per 100,000 females in 2000-2009.

8. Recent statistics in Kuwait2012 cancer registry • Estimated age-standardized incidence rate for Kuwait was 46.7 per 100,000 population. • It is higher than that estimated for the world 43.3 per 100,000 population.

10. What is breast cancer?

11. Breast anatomy:The breast is composed of ducts and lobules A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage

12. Cancer occurs when breast cells that line up the ducts become malignant (cancerous) • Malignant cells are made up of abnormal cells that grow out of control and invade normal breast tissue. • Can spread outside the breasts to other parts of the body

13. Risk factors for breast cancer

14. Factors you CANchange: • Don’t drink alcohol • Being overweight or gaining wt • Taking birth control pills >5yrs • Having had your first child after age 30 (breastfeeding is protective) • Having no children

15. Using some form of hormone replacement therapy (HRT) for menopausal symptoms • Being exposed to large amounts of radiation.

16. Factors you CAN NOT change: • Being a female • Getting older • Having already had breast cancer • Having certain mutated breast cancer genes (BRCA1&2)- family history (mother, sister)

17. Having your first period before age 12 • Having started menopause after age 55 • Having a breast biopsy that showed atypical hyperplasia or carcinoma in situ.

18. Classification of breast cancer Divided into two major groups: (1) In situ cancers  refer to breast tumors where the tumor cells remain confined within the ducts of the breast and show no evidence of invasion into surrounding breast tissue (2) Invasive or infiltrating cancers  invade into breast tissue

19. Incidence of breast cancer

20. Warning signs of breast cancer

21. A lump or thickening in the breast or underarm area. • Change in size or shape of the breast. • Nipple discharge or tenderness or nipple pulled back (inversion) into the breast.

23. Locally advanced breast ca

25. What can you do? (1) Breast self-examination

26. When to do BSE? • Check your breasts on a regular basis, for example, once a month • Check 5 to 10 days after your period starts so your breasts will be less tender. • Irregular Periods? Pregnant? No longer have a period? Pick the same day of the month.

27. Clinical breast examination • Clinical breast examination (CBE) seeks to detect breast abnormalitiesor evaluate patient reports of symptoms to find palpable breastcancers at an earlier stage of progression. • earlier detection of palpable tumors identifiedby CBE can lead to earlier therapy.

28. CBE is regarded as an adjunct to mammography • Neither CBE nor mammography is a substitute for the other asan independent examination for detecting breast abnormalities.When a suspicious mass is found on CBE, it must be evaluatedand explained even if mammography examination does not showan abnormality.

29. Breast screening guidelines • If you are under age 20- be familiar with your breasts • If between 20-39 have regular BSE every month and every1-3yearly physical examination • If between 40-49 you should have annual physical examination, mammogram every 1-2 yrs and monthly BSE

30. Above 50 yrs of age, you should have annual physical examination, annual mammogram and monthly BSE

31. Diagnosis of breast cancer

32. Mammogram • Mammogram is the best screening tool widely available to detect breast cancer early • It is a low dose x-ray picture of the breast, safe • Has the ability to detect breast cancers before they can be felt

33. Mammography has a sensitivity of about 85% to 90% in women older than 50 years of age • for women between the ages of 40 and 50, sensitivity is about 75% and is lower in women younger than age 40. • mammography will miss 1 in every 4 breast cancers in women between the ages of 40 and 50. • Clinical breast examination is required to address these gaps in screening sensitivity.

36. Microcalcifications on mammogram

37. Masses not felt clinically

39. Core biopsy • Main tool for establishing a proper diagnosis and so quick treatment thereafter. • DOES NOT SPREAD CANCER OUT

40. Pre-op wire localization/ biopsy

41. MRI Breast

42. Treatments of breast cancer

43. Treatment of invasive breast cancer Preop evaluation: Evaluation of extent locally in the breast and regional nodes and distant sites (lung, liver, bone) Bilateral mammogram rule out other masses Core biopsy u/s to evaluate axillary lymph nodes +/- FNAC of suspicious nodes.

44. Pre operative care • Main issue is the psychological element involved with mastectomy. • Patient should be aware about what it means and if necessary talk to patients who had this procedure done. • Show patients pictures in order not to be shocked after the procedure.

45. Two parts of the operation(breast options of treatment) • Depends on size of tumor and patient preference. • Mastectomy vs breast conserving surgery • Neoadjuvent chemotherapy to downsize the tumor followed by conserving surgery • Option of reconstruction immediate or delayed.

47. Axillary staging • Evidence of positive axillary lymph nodes by fine needle aspiration cytology pre-op ALND • Otherwise all should have SLNB

48. Sentinel lymph node biopsy • Sentinel node is the first node draining a particular portion of the body. It is the node at highest risk for harboring occult metastatic disease. • Lymphatic mapping performed by injecting a blue dye (1% isosulfan blue, or technetium-labelled sulfer colloid (a radioactive tracer material) or both, adjacent to tumor.

49. The tracer material progresses through lymphatic channels to sentinel node which may then be excised and tested for evidence of metastatic disease using frozen section. • If the sentinel node has mets, a complete axillary dissection is performed. • If no mets, the patient may be spared axillary dissection. • Morbidity is less than ALND from this procedure • False –ve rate is ~3-5%

50. Gamma probe for detection of SLNB