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Updates in Breast Cancer

Updates in Breast Cancer. Lynn M. Tucker, MD Lexington Surgical Associates Lexington Medical Center. BREAST CANCER. 1 in 8 women over lifespan Estimated 290,170 cases this year 226,870 invasive 63,300 in situ (pre-invasive) 39,510 deaths this year

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Updates in Breast Cancer

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  1. Updates in Breast Cancer Lynn M. Tucker, MD Lexington Surgical Associates Lexington Medical Center

  2. BREAST CANCER • 1 in 8 women over lifespan • Estimated 290,170 cases this year • 226,870 invasive • 63,300 in situ (pre-invasive) • 39,510 deaths this year • 3.4% annual decline in death rate since1995 • Largest decrease in women < 50

  3. BREAST CANCER • South Carolina Estimates (2012) • 3,570 new cases • 660 deaths

  4. BREAST CANCER • SEER Data • Diagnosis rate • 63% increase 1950 -1998 • 3.5% annual decrease since 2001 • Death rate has fallen • 40% (1954) vs. 13% (1998) • Mostly due to better treatment and early detection

  5. BREAST CANCER • Age • Risk with age • Average age @ diagnosis 62 • 80% cases > 50 years of age

  6. BREAST CANCER

  7. BREAST CANCER • Family History • First degree relatives (mother/sister) • Premenopausal breast cancer • Ovarian cancer • BRCA-1 & BRCA-2 • Up to 65% lifetime risk • Only 5-10% of the total cases

  8. BREAST CANCER • Previous Breast Biopsies • Atypical Ductal Hyperplasia • 10 % develop breast cancer within 10 years • Lobular Carcinoma in Situ • 1% per year risk of developing breast cancer

  9. BREAST CANCER • Additional Risk Factors • Early onset of puberty (menarche) • No children • First child after 30 years of age • Late menopause (> 55 years)

  10. BREAST CANCER • Additional Risk Factors • Prior chest wall radiation between 10 & 30 years of age • High density breast • race • caucasian : highest risk of developing • African-American : highest death rate • Alcohol (>1-2 drink per day) • HRT (estrogen / progesterone) • post-menopausal obesity

  11. BREAST CANCER

  12. BREAST CANCER • Risk Assessment • Gail Model • Genetic Testing (BRCA-1, BRCA-2)

  13. BREAST CANCER • Gail Model • Age, race, menarche, first child, first degree relatives, previous biopsies, ADH • Relative Risk 1.76 candidates for : • Tamoxifen or Evista for 5 years • Annual MRI along with MMG

  14. BREAST CANCER • Positive Genetic Testing (BRCA1/BRCA2) • Consider Tamoxifen versus prophylactic mastectomies +/- oophorectomies (before 50 yrs) • Early surveillance with triple screen (MRI, MMG, U/S)

  15. BREAST CANCER • Methods of Detection • Physical exam • Hard and/or asymmetric lump • Skin or nipple indentation • Erythema &/or edema without infection • Rash on nipple (Paget’s)

  16. BREAST CANCER • Methods of Detection • Breast Exams • No improvement in survival • Earlier detection allows more treatment options • 10-15% of MMG will miss a cancer • Breast Aware

  17. BREAST CANCER • Methods of Detection • Screening Mammography • Irregular nodule • Microcalcifications • Asymmetry

  18. BREAST CANCER • Screening Mammogram • Canadian Study (2002) • Age 40-49 , no difference in death rate • More cancers were identified • Swedish Study (2001) • 63% reduction in mortality (ages 40 - 69)

  19. BREAST CANCER • Methods of Detection • Ultrasound • Adjunct to mammography • Distinguishes cyst from solid tumors • Irregular margins and shadowing suggest cancer • Poor screening tool

  20. BREAST CANCER • Methods of Detection • MRI • Adjunct to mammography • More accurate in dense breast • Determines extent of cancer • Screening in high-risk patients • 10% false-positive rate

  21. BREAST CANCER • Breast Health Program • Self breast exams • No longer recommended • Breast Aware • Physician breast exam • Every 3 years beginning @ age 18 • Annually beginning @ age 40 • Annual screening mammogram • Beginning @ age 40 • Earlier if family history (10 years earlier than youngest diagnosed)

  22. BREAST CANCER • Biopsy Techniques • Stereotactic Biopsy • Ultrasound Guided Biopsy • Needle Localization Biopsy • Open Biopsy

  23. BREAST CANCER • Different Types (In-situ) • DCIS (pre-malignant) • LCIS (lobular neoplasm)

  24. BREAST CANCER • DCIS • Lumpectomy (invasive recurrence 2%) • Radiation • Tamoxifen • Mastectomy (invasive recurrence <1%)

  25. BREAST CANCER • Lobular Neoplasm (LCIS) • Observation • Tamoxifen • 56% risk reduction • Bilateral Prophylactic Mastectomies • 80-90% risk reduction

  26. BREAST CANCER • Different Types (Invasive) • Invasive Ductal (80%) • Invasive Lobular (10%) • Tubular, Medullary, Colloid, Inflammatory, Paget’s (10%)

  27. BREAST CANCER • Tumor Biology • ER +/ PR+ • ER+/ PR- • Her-2-neu + • Triple negative

  28. Breast Cancer • Local-Regional Treatment Options • Lumpectomy, sentinel node biopsy, radiation • Mastectomy, sentinel node biopsy, +/-reconstruction

  29. Breast Cancer • Breast Conservation • Survival / Recurrence Equivalent • Larger tumors may need pre-op tx. • Chemo vs. hormonal therapy

  30. Breast Cancer • Mastectomy • Tumors unresponsive to pre-op TX • Diffuse malignant calcifications • Local recurrence after lumpectomy

  31. BREAST CANCER • Reconstruction • Tissue expanders / Implants • Transverse rectus abdominis myocutaneous (TRAM) flap • Latissimus dorsi myocutaneous flap

  32. BREAST CANCER • Systemic Therapy (Targeted Therapy) • Hormonal • Tamoxifen 5 yrs then +/- Femara • Aromatase inhibitors (postmenopausal) • Pre-op Hormonal Therapy for large ER/PR + tumors

  33. BREAST CANCER • Systemic Therapy (Targeted Therapy) • Chemotherapy • CMF • TAC • Herceptin & Tykerb • Perjeta (metastatic)

  34. BREAST CANCER • Radiation • Mastectomy • Large tumors >5cm • Close margins • Positive LN / lymphovascular invasion • Lumpectomy • Always except > 70 with low grade tumors + AI

  35. BREAST CANCER Prognosis – 5 Year Survival DCIS >99% Localized 99% Regional 84% Metastatic 23%

  36. BREAST CANCER • Breast Conservation for multicentric dz • SLN Axillary Staging only • Targeted Treatment • Vaccine

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