BREAST CANCER Oncology

1. BREAST CANCER Oncology John Dewar

2. Breast Cancer • Commonest cancer in women • 2nd commonest cause of death from cancer in women • Survival improving – 5 yr. survival improved from 56% 1970 to 79% in 1999 (year of diagnosis) • Increasing incidence – ageing population

3. Presentation • Screening – age 50-64(70), small, impalpable • Symptomatic – lump in breast 8% with distant metastases 8% locally advanced/inoperable 84% operable

4. TREATMENT • Surgery • Radiotherapy • Systemic therapy hormonal therapy cytotoxic chemotherapy immunotherapy

5. RADIOTHERAPY • Postoperatively to breast/chest wall nodal areas: axilla, supraclavicular fossa, internal mammary nodes • Primary radical for locally advanced • Palliatively to painful bony mets, skin deposits, brain mets etc.

6. POSTOPERATIVE RADIOTHERAPY • Reduces the risk of local recurrence by about two thirds: 60% to 20% 30% to 10% 3% to 1%

7. POSTOPERATIVE RADIOTHERAPY • All patients being treated conservatively (wide local excision/lumpectomy) • Mastectomy patients selectively – large tumour, extensive nodal involvement, involved margins etc.

8. Postoperative Radiotherapy – acute side effects • Skin erythema to moist desquamation • Tiredness • Dysphagia if irradiating supraclavicular fossa • No alopecia

9. Postoperative Radiotherapy – late effects • Local fibrosis and telangectasia • Lung fibrosis (rarely symptomatic) • Cardiac damage (ischaemic heart disease) – rarer now treatment better planned

10. Postoperative Radiotherapy – late effects • Survival • Overall 5% improvement in breast cancer survival (at 15 yrs.) for 20% improvement in local control (4% improvement in overall survival) • Localised local recurrence can act as nidus for distant metastases

11. SYSTEMIC THERAPY – adjuvant • Most operable, why not curable? • Occult distant metastases at presentation • Systemic therapy after surgery reduces the risk of recurrence and death – adjuvant therapy

12. SYSTEMIC THERAPY – adjuvant • Hormone therapy: ovarian ablation, tamoxifen, aromatase inhibitors (ER/Pg +ve patients only) • Cytotoxic chemotherapy: CMF, doxirubicin/epirubicin, taxanes • Trastuzumab [Herceptin] • All decrease odds of death by about 17%, absolute benefit of about 6% at 10 years.

13. Hormone therapy: Infertility Menopausal symptoms Weight gain Endometrial cancer Deep venous thrombosis Chemotherapy Nausea & vomiting Infertility Alopecia Neutropenia (sepsis) Mouth ulcers Lassitude SYSTEMIC THERAPY – adjuvant: side effects

14. METASTATIC DISEASE • Incurable but treatable • Optimise quality of life and survival • Median survival with mets: 2 years (20% at 5 yrs.) • Varies from acute aggressive disease to chronic disease (like diabetes, renal failure etc.)

15. METASTATIC DISEASE • Assess extent of disease Stage: local recurrence, lung, liver, bone • Hormone receptor status • HER2 receptor status

16. METASTATIC DISEASELocal problems • Palliative radiotherapy: bony mets, brain mets etc. • Drainage of pleural or peritoneal effusions • Pining of pathological fractures

17. METASTATIC DISEASE Systemic therapy • Hormone therapy if ER/Pg +ve • Chemotherapy • Bisphosphonates for bony mets • Trastuzumab if HER2 +ve

18. METASTATIC DISEASE Systemic therapy • ER +ve: Hormonal agents: ovarian ablation, aromatase inhibitors, tamoxifen, progestagens in sequence unless liver mets or lymphangitis carcinomatosa when usually chemotherapy

19. METASTATIC DISEASE • Chemotherapy: CMF, anthracyclines, taxanes, capcitabine etc. etc. • Use in sequence so long as respond and patient fit

20. BREAST CANCER • Need multidisciplinary management: nurses, surgeons, radiologists, pathologists, oncologists, GP. etc. etc. • Different patients have different needs • Most will need considerable support • Major impact on the patients but also their families