Abnormal screening mammogram (>25% of cases) Breast lump or thickening Axillary tumour / lump Presentation Breast skin changes

Nipple change - inv ersion, discharge Persistant breast tenderness / pain Sy mptoms of metastatic disease: bone pain, pathological f racture, spinal cord compression Lump Pain Indication f or Ref eral Nipple Discharge Nipple Retraction / inv ersion Axillary lump + Strong f amily history History & Examination Diagnosis Three Areas Triple Assessment Mammography +/- Ultrasound Fine Needle Aspiration Cy tology Score each area 1 to 5: 1 = normal, 2 = benign, 3 = aty pical, 4 = suspicous of cancer, 5 = cancer If disconcordant score perf orm biopsy f or gold standard diagnosis Better Tolerated Allows "hot reporting" v ery usef ul in one stop breast clinics Fine Needle Aspiration Poorer sensitiv ity 80%, and specif icity 60% Cannot dif f erentiate between insitu or inv asiv e cancer False positiv e rate 1/1000 Lower rate of inadequate sampling compared with FNA Core Biopsy Improv ed sensitiv ity and specif icity (95%) Allows staging and identif ication of receptor status Longer processing and reporting time, needs rev isit by patient Many women hav e occult micro metastases at diagnosis - if untreated these can cause metastatic diagnosis disease Reduce risk of local recurrence f ollowing lumpectomy (<10% @ 10 y ears) Breast irradiation Radiotherapy Care to minimise radiation to heart ad lungs Post mastectomy radiotherapy to chest wall increases surv iv al in patients with at least two of : >4cm, grade 3, ly mph node positiv e, v ascular inv asion Axillary irradiationAxillary irradiation Most Coomon Female Cancer in UK Increased Estrogen Exposure (HRT/Birth /control /pills) Age (Incidens doubles ev ery 10 y ears until Menopause) Early menarche / Late Menopause Risk Factors No Children / older age at 1st pregnancy Genetics Predisposition Diet (Obesity & Alcohol Consumption Alcohol consumption Increasing age at f irst f ull term pregnancy > 30 y ear Hormone replacement therapy Oral contraceptiv e pill usage Obesity Increasing age f rom 40 y ears old Early menarche ( < 12 y ear old) (RR 1.02) Late menopause ( > 55 y ear old) (OR 2.4) Nulliparity Benign breast disease with prolif eration without aty pia Dense breast Immunotherapy Personal history of inv asiv e breast cancer Lobular Carcinoma In Situ (LCIS) and Ductal Carcinoma In Situ (DCIS) Benign breast disease with aty pical hy perplasia High Risk (Relatif Risk > 2.0) Ionising radiation f rom treatment of breast cancer, Hodgkin s disease, etc. Carrier of BRCA1 and 2 genetic mutation Signif icant f amily history i.e. f irst degree f amily with breast cancer Ductal carcinoma in situ (DCIS) remains in the conf ines of the ductal basement membrane 45% occur in the upper outer quadrant, 25% are retro areolar 85% of breast cancers arise in the ducts of the breasts Ly mphatic regional nodes (commonly the axillary , less commonly internal mammary ) Sy stemic spread: bone, lung, pleura, liv er, skin, CNS Spread Pathology Pathophy siology Preop Assessment FBC - anaemia U&Es - real f unction f or drugs, risk of cardiac f ailure Clotting - liv er f unction Gxm - in case of blood loss ECG - heart f it f or surgery CXR - check f or lung mets LMWH - prophy laxis against DVT 70% of patients cured by surgery alone If clear margin: lumpectomy f ollowed by radiotherapy (f or good cosmetic results needs to be <10% of breast) Mastectomy Low recurrence rate f or both - less than 10% af ter 10 y ears Pref erred management f or majority of T1 & 2 breast cancers is lumpectomy f ollowed by radiotherapy Breast surgery Surgical treatment of breast and axilla Breast conserv ation may not alway s be appropriate Multif ocal disease Large tumour (> 3cm / 10%) in small breast Where breast irradiation is contraindicated: pregnant, prev ious radiotherapy , CT disorders Patient choice Reconstruction can be done during mastectomy or separately Good regional control Total axillary clearance High risk of ly mphoedema, arm pain, shoulder stif f ness and altered sensation Potential that the procedure is not required if nodes are f ound to be negativ e Minimum of 4 ly mph nodes sampled f rom lower axilla Axillary Surgery Axillary sampling If positiv e: axillary clearance or radiotherapy Lower morbidity f or node negativ e Sentinel node biopsy Equiv alent control rates ad surv iv al f or total axillary clearance Injection of radioisotope and dy e at the nipple > should f ollow course of cancer cells > hot cancerous nodes take up isotope and dy e > these are remov ed and tested Tumor Size Number of histological positiv e axillary ly mph nodes Tumor Grade + Hormone receptor status Prognostic Factors Other Factor expression Histological sub ty pe Prognosis - Ly mphov ascular inv asion Prolif erativ e index (rate of cell div ision) 0.2 x tumour size in cm + grade (1 to 3) + axillary node score Axillary npde status: no ly mph nodes = 1, 1 to 3 ly mph nodes = 2, > 3 ly mph nodes = 3 Nottingham Prognostic Index NPI < 2.5 = excellent prognosis NPI < 4 = moderate prognosis NPI 4 - 5 = poor prognosis NPI > 5 = v ery poor prognosis + Well dif f erentiated tumour - HER2 ov er expression Management Reproductiv e f actors: Malignant Breast Disease Moderate Risk (Relatif Risk 1.5 - 2.0) Risk Factor Stratif ications Epidemiology Postmenopausal Reproductiv ef actors:Reproductiv ef actors: Low Risk (Relatif Risk 1.0 - 1.4) Pathological assessment and staging to direct adjuv ant therapy Anti Estrogen Therapy Chemotherapy Should be considered in Almost all women under 35 Post menopausal women with intermediate / poor prognosis 60% of breast cancers are oestrogen receptor positiv e (ER) Surv iv al benef it in these patients Toxicity is less than chemo, although menopausal sy mptoms may distressToxicity is less than chemo, although menopausal sy mptoms may distress Tamoxif en Premenopausal Competitiv e inhibitor, blocks tumour receptors so still circulating oestrogens and theref ore bones are protected 20mg daily f or f iv e y ears Aromatase inhibitors Stops peripheral conv ersion of oestrogens Loss of oestrogen bone protection so patients need calcium supplements 25% of breast cancers express HER2 and respond to herceptin HER2 is protein f ound on surf ace some breast cancers Cancer grow when human epidermal growth f actor binds to HER2 Herceptin stops this process by binding to HER2 protein and blocking the attachment of human epidermal growth f actor and thus prev enting div ision and growth of tumour cells; also attracts immune cells towards cancer S/E: dilated cardiomy opathy (echo bef ore and during), f lu like sy mptoms Expression of HER2, despite Herceptin, is a poor prognositc indicator Indicated f ollowing positiv e ly mph node sampling

Combination chemo reduces recurrence and mortality All but v ery good prognosis premenopausal breast cancer