The News on Breast Cancer

1. The News on Breast Cancer January 2007 Presented By: Dail Jacob BScN, CON[C]

2. “Somewhere in your life, you will meet someone who is touched by breast cancer.”

3. What is Cancer? • Cancer is many diseases, the different types correlate with the origin of the cells involved. • The human body is made of millions of cells, grouped together to form specific tissues and organs. The blueprint for cell structure & function is DNA. Genes inside each cell order cells to grow, work, reproduce and die. • Cancer cells are cells which have lost their original ordered life cycle and characteristics. Something environmental or internally commands the cells to grow and function differently. • The abnormal growth of these cells eventually develop into a mass. • Cancer cells can “metastasize” or spread to other parts of the body. They do this by direct invasion or by traveling through the lymph or blood circulation. Two classifications of cancer exist: solid tumor and hematological cancer.

4. What is Breast Cancer? • Breast canceris the most common occurring cancer in Canadian women. • There are different types which can originate in different structures. The most common is ductal. [others – lobular, DCIS, invasive, Pagets, inflammatory]. • Most of the breast involves glandular tissue & fat. • The staging of the tumor once biopsied and the biochemical and morphological characteristics determine the stage of disease.

5. Canadian Statistics • In 2006, an estimated 22,200 women will be diagnosed with breast cancer and 5,300 will die of it. • An estimated 160 men will be diagnosed and 45 will die of it. • On average, 429 Canadian women will be diagnosed each week. • One in 9 women is expected to develop breast cancer during her lifetime. One in 27 will die of it. • Since 1993, incidence rates for breast cancer have stabilized and death rates have declined steadily. • The highest rates of breast cancer occur in the age bracket of age 50 – 69.

6. What Causes Breast Cancer? There is no single cause of breast cancer but some factors appear to increase the risk of developing it: • Age • Family history of breast cancer [especially in a mother, sister or daughter diagnosed before menopause or if BRCA 1 or BRCA 2 genes are present]. Heredity accounts for only 10% of all breast cancers • Family history of uterine, colorectal or ovarian cancers • Previous history of breast cancer, or biopsies which showed abnormal cells • Dense breast tissue

7. Hormone exposure – early menstruation, late menopause, no pregnancies or a late first pregnancy. It appears that the longer your body has been exposed to estrogen, the greater the risk. Use of Hormone replacement therapy [HRT] for more than 5 years has now also been linked to breast cancer. The choice to use HRT must be discussed with a doctor balancing the benefits with the risk. • Obesity – this is predominantly related to the fact that fat cells store estrogen. • Alcohol intake – alcohol intake of greater than 2 drinks daily, has been linked with breast cancer. • Environmental factors – use of insecticides, pesticides, preservatives and hormones in food stocks are suspected of causing chromosomal changes in the host or altering metabolic and hormonal activities in the body.

8. What Are Signs of Possible Breast Cancer • A thickening or a lump felt in the breast or underarm • A change in the size or shape of one breast that is different from the usual changes noted during your menstrual cycle • A change in color or texture of the skin or underlying tissue of the breast • Puckering or dimpling of the breast skin in one area as though something is pulling inside • Or occasionally a discharge or bleeding from the nipple. *The most common site of breast tumors in women is the upper outer quadrant of the breast. In men it is close to the nipple. *If these signs are noted, a person should see a physician for assessment as soon as possible! Many patient’s out of fear do not seek help.

9. Only women with a family history get breast cancer? T/F By omitting smoking, drinking, alcohol, caffeine, and a high fat diet makes your chances of getting breast cancer almost zero? T/F Only women in their 50’s get breast cancer? T/F If you have lumpy breasts, you are more likely to get breast cancer in the future? T/F An injury to the breast can cause breast cancer? T/F Stress has been associated with breast cancer? T/F 7. Breast cancer is associated with wearing an under wire bra and use of deodorant? T/F 8. Women who consume soy products, soya sauce and oysters have a reduced incidence of breast cancer? T/F 9. Microwave oven use is associated with increase cancer? T/F 10 Doing a self breast exam can prevent breast cancer? T/F 11 Doing a self breast exam in the shower is the best way to detect lumps? T/F 12 Small breasted women do not get breast cancer? T/F Most Common Beliefs/Myths About Breast Cancer

10. 4 Steps to Diagnosis • Self Breast Exam • Clinical Exam • Mammography • Biopsy if indicated

11. Staging of Disease Stage 1: The tumor is no more than 2 centimeters (cm) across (T1)      • The lymph nodes in the armpit are not affected      • The cancer has not spread Stage 2 :Divided into 2 groups Stage 2A means: • The tumor is less than 2 cm, the lymph nodes under the arm contain cancer but are not stuck to each other and the cancer has not spread or • The tumor is less than 5 cm, there are no cancer cells in the lymph nodes in the armpit and the cancer has not spread or • Although no tumor is seen in the breast, the lymph nodes under the arm contain cancer but are not stuck together, and there is no sign of spread to other parts of the body • Stage 2B means: • The tumor is less than 5 cm and the lymph nodes under the arm contain cancer but are not stuck to each other, and the cancer has not spread or • The tumor is bigger than 5 cm across, there are no cancer cells in the lymph nodes in the armpit and the cancer has not spread

12. Stage 3: Stage 3 breast cancer is divided into 3 groupsStage 3A means • Although no tumor is seen in the breast, the lymph nodes under the arm contain cancer and are stuck together, but there is no sign of cancer spread or    • The tumor is 5 cm or less, the lymph nodes in the armpit contain cancer and are stuck to each other, but the cancer has not spread elsewhere or    • The tumor is more than 5 cm, the lymph nodes in the armpit contain cancer and may be stuck together, but there is no further spread • Stage 3B means • The tumor is fixed to the skin or chest wall, the lymph nodes may or may not contain cancer, but there is no further spread • Stage 3C means • The tumor can be any size and has spread to lymph nodes in the armpit and under the breast bone, or to nodes above or below the collarbone, but there is no further spread Stage 4: • The tumor can be any size      • The lymph nodes may or may not contain cancer cells    • The cancer has spread or metastasized to other parts of the body such as the lungs, liver or bones • If you only have cancer spread to the lymph nodes in your armpit, you do not have stage 4 breast cancer.  Stage 4 only applies to cancer spread to other body organs. • The most common sites of distal metastasis include bone, lung, liver & brain.

13. Treatments: Goals: • Cure • Control • Palliation • A metastatic work – up is often done before a surgical procedure is done. If the patient has distant metastasis, surgery may not be the first approach to management.

14. Treatment of Breast Cancer • Surgery • Chemotherapy • Radiotherapy • Hormonal Therapy

15. Surgery • Complete or radical mastectomies are rarely done now. Some indications for still performing this procedure include: multiple sites of tumor in the breast, inflammatory breast cancer or tumors which are large > 5 cm or involving the skin, pregnancy where radiotherapy is contraindicated, previous radiotherapy, local recurrence of disease, lupus or scleroderma, severe cardiac or lung disease. • The most common procedure is a partial mastectomy. • Sentinel Node biopsy. • Reconstruction • Axillary Node Dissection, risk of lymphedema.

16. Chemotherapy Indication: Systemic control of disease. • Recommend starting chemotherapy 4 – 6 weeks after surgery. • Choice of which chemotherapy is guided by practice guidelines based on the type of breast cancer, the stage of disease, the characteristics of the tumor seen by the pathologist and goals of treatment. • Can be given prior to surgery – neoadjuvant. This is indicated for a large breast tumor or with inflammatory breast cancer. • Many types of medications. Chemotherapy medications are usually given in combination to have a synergistic effect upon cancer cell destruction or prevention of cell duplication and growth. • Gene therapy. • Side effects of chemotherapy.

17. Radiotherapy: Indication: local control of disease. • External beam or brachytherapy. • Usually started 1 month after chemotherapy. • Indications for boost therapy – young patients with DCIS or patient’s identified to be at high risk for local recurrence. • Side effects of radiotherapy. Hormone therapy:

18. Breast Cancer Recurrence • In Canada, 1:4 women with breast cancer will eventually have a recurrence. • For a subgroup of patients who are HER2 positive, the risk of recurrence was reduced with the upfront use of the drug Herceptin. This news in 2004 changed the front line practice for this subgroup of patients. [Approx. 25% of all breast cancer patients are HER2 positive]. HER2 positive patients generally have a poorer prognosis therefore this outcome is great news. • 3 types of recurrence take place: • Local • Regional • Distant • Some of the prognostic indicators or indications that a patient may eventually reoccur include: # lymph node involvement; ER/PR status; Grade of the tumor; clear margins; tumor size; oncogene expressions in the cells.

19. Support Services for Cancer Patients • Look Good/Feel Better • Support Groups • Educational Sessions • Psychosocial support – psychologist, pastoral care, social worker & the nursing team • Rehab – Nutrition & Exercise Programs • Lymphedema Management • Music Therapy, Art Therapy , Massage Therapy • Resource Room with library, wigs & prosthesis information • Volunteers

20. The Future • Overall survivorship of patient’s with breast cancer has increased. We look at it as a chronic illness, though some patients will die of this disease. • Many options of treatment; and the research is focusing on more targeted therapies with fewer side effects. • We have excellent medication and support services to help patients, and reduce the side effects of treatment • A national Cancer Control Strategy has been established. Many provinces also have set up comprehensive programs to oversee the approach to diagnosis, management and outcomes. • Canadians are becoming more health conscience and aware of environmental risks and concerns. • Development of programs to achieve healing and wholeness after the cancer experience

21. Testimonial of Personal Experience with Audrey Phillips

22. Gastric Cancer

23. Gastrointestinal Cancers • Esophageal – 1,200 – 1,400 new cases • Gastric – 2,800 – 3,200 new cases • Colorectal – 17,000 new cases. 3rd most common in incidence & death.

24. Stomach [Gastric] Cancer • Stomach cancer starts in the cells of the stomach. The stomach is a muscular sac and is lined with glandular cells that produce acid and special proteins called enzymes which help to digest food. • The most common type of gastric cancer is adenocarcinoma [85%], which starts in the glandular cells in the lining of the stomach. • There are 2 less common types: • Gastric lymphoma [involves the lymph system] • Leiomyosarcoma [ involves the muscle] • Worldwide – accounts for 3% of all cancers. Areas where there is a higher incidence include Japan, South America, Eastern Europe & the Middle East. • In Canada the areas of highest incidence include the Maritimes, Quebec and Manitoba.

25. Etiology of Gastric Cancer • No single cause • Factors associated with increased risk include: • Age > 50 [ age 50 – 59 highest incidence] • Gender – 2X greater in men • Diet – higher incidence with salted or cured, pickled or BBQ foods. There is a higher incidence with low intake of fruits & vegetables [low in Vit. A or C]. • Smoking / ETOH • Workplace exposure to asbestos, nickel, coal dust, gold mining, silica, chromium, oil mist or diesel emissions; and rubber & timber processing materials. • Lower production of stomach acid than normal • Helicobacter pylori bacteria • H/O pernicious anemia [Vit B12 deficiency] • H/O GERD –gastro esophageal reflux disease • Contaminated water source , lack of refrigeration • Genetic – small group [Type A blood, nonpolyposis colon ca, Li Fraumeni syndrome].

26. Signs & Symptoms of Gastric Cancer • Unfortunately, tumors in the stomach can grow for a long time before someone is aware of a problem. The symptom are often vague at first and resemble other gastric ailments such as ulcer disease. • Indigestion / heartburn • Bloating / fullness after meals • Loss of appetite • Nausea • Abdominal discomfort, especially after eating • Pain in upper back or upper chest • Vomiting blood / Blood in stool • Difficulty swallowing • Change of bowel habit • In the advance stages: anemia, weight loss, Nausea & vomiting, pain, jaundice & malnutrition.

27. Diagnosis of Gastric Cancer • There is no routine screening for this disease. • Report symptoms to family physician, clinical exam • Blood work • Gastroscopy & biopsy. • UGI Series Stool test for occult blood • Metastatic work-up, as stage of disease will help determine the approach to treatment.[ CT scan, ultrasound, MRI, PET scan].

28. Treatment of Gastric Cancer • The best scenario for cure is if the patient is able to have surgical removal of the gastric tumor. Generally this involves a partial or total gastrectomy and resection of the nodes and adjacent tissues involved. In North America, only 10 – 20% of patients are diagnosed in the early stages. • Approximately 80% of patients have metastasis at the time of confirmed diagnosis. • Other treatments include: • Chemotherapy • Radiotherapy – external beam or by brachytherapy • Chemoradiation combined either before surgery or after • Endoscopic laser surgery and insertion of stents to treat obstructions. • Biologic therapies available in clinical trials [involves a treatment that uses the patient’s immune system to fight cancer These substances made in the body or in a lab, are used to boost, direct or restore the body’s natural defenses].

29. Patient Care Concerns • Post operative complications: • Anastomotic leak • Dumping syndrome • Nutritional challenges • Symptom control related to disease & treatment option: • Pain control • Nausea & possible vomiting • Mucositis or esophagitis • Fatigue & weakness • Myelosuppression, particularly anemia • Performance status – ability to maintain functional status • Recurrence of disease

30. Questions ?

31. Resource Sites • Canadian Cancer Society www.cancer.ca/ccs • National Cancer Institute of Canada www.ncic.cancer.ca • National Cancer Institute/ US National Institute of Health www.cancer.gov • ASCO American Society of Clinical Oncology http://www.asco.org • National Surgical Adjuvant Breast & Bowel Project http://www.nsabp • ASCO People Living With Cancer http://www.plwc.org • Cancer Care Ontario http://www.cancercare.on.ca • B.C. Cancer Agency www.bccancer.bc.ca