Western Visayas Medical Center Hospital Cancer Committee

Most common site-specific cancer in women worlwide 2nd most common cause of cancer death in women 5th most common cause of death in women 8-12% lifetime risk of developing breast cancer

 Most common cancer in female being treated in the

wards (20 surgical cases admitted for 2008) Majority of patients in Clinical Stage IIb, III and stage IV Majority of patients in Pathologic stage III Treatment is mostly surgical Poor follow-up

Breast mass 33%

Others
Nipple changes (retractions, discharges) Ulceration/erythema of the skin of breasts

Breast enlargement/asymmetry
Axillary mass

Early Detection

1. Breast self-exam (BSE) every month starting the age of 20. (1-2 weeks after 1st day of menstruation.
2. Clinical breast exam (CBE) starting the age of 20 and every 3-5 years thereafter 3. Clinical breast exam at the age of 40 then yearly thereafter. 4. Mammography starting at the age of 40 then yearly thereafter. 5. Mammography at age 35 for high risk patients.

Hormonal risk factors

Early menarche Nulliparity Late menopause Obesity Hormonal pills/HRT

Nonhormonal risk factors Old age

First degree relatives with breast cancer Radiation therapy Alcohol consumption High fat diet

IIa IIb IIIa IIIb IV -

94% 85% 70% 52% 48% 18%

Mammography* - 30% reduction in mortality rate from breast

cancer
Screening mammography - women with no symptoms
Diagnostic mammography - women with symptoms

Breast Ultrasound adjunct to mammography Ductography* - for women with bloody nipple discharges

MRI* - for high risk patients with dense breast during

mammography

Surgery
Breast conserving surgery (lumpectomy, quadrantectomy)
Mastectomy Modified radical mastectomy

Chemotherapy*
Adjuvant chemotherapy

Neoadjuvant chemotherapy

Radiotherapy Hormonal therapy*

Antiestrogen (Tamoxifen) hormone receptor (+) pre and postmenopausal 25% reduction in breast cancer recurrence 7% reduction in breast cancer mortality Aromatase inhibitors (anastrozole/letrozole)- hormone receptor (+)

postmenopausal

Biologic therapy*- antiHER2/neu antibody therapy

(herceptin/trasruzumab) Ablative endocrine surgery

Breast cancer staging

Stage I Primary tumor is 2 cms or less with no lymphatic spread Stage II IIa no tumor but 1-3 positive axillary nodes; primary tumor is 2 cms or less with (+) 1-3 axillary lymph nodes, (+) SLNB; tumor 2-5 cms with no axillary spread IIb primary tumor is 2-5 cms with spread to 1-3 axillary lymph node; tumor >5 cms with no axillary spread

Breast cancer staging

Stage III IIIa-no tumor but with 4-9 axillary lymph node; <5cms but with 4-9 axillary lymph node; >5 cms but does not grow into chest wall or skin IIIb-tumor has grown into chest wall and skin with no axillary lymph node or with 1-3 lymph node; or 4-9 lymph node IIIc-tumor of any size with spread to 10 or more axillary lymph node or supraclavicular lymph node Stage IV Spread of breast cancer to distant areas of the body

Treatment Pathways

Non- Palpable Breast Mass

History/PE

Doubtful clinical breast exam, high risk, >40 years old

Breast Ultrasound/Mammography (+) lesions (-) lesions

Normal Clinical Breast Exam, <low risk, <40 yo

Mammogram/ Stereotactic needle not available

Image Guided Biopsy (Ultrasound/ mammography)

Observe Malignant Benign

Hx and PE

Palpable Breast Mass

>40 any size, high risk, <40 but mass 2cm or more Biopsy (FNAB/Excision or incision biopsy)

<40, <2 cms in size, low risk

Malignant

Benign

Non-invasive DCIS LCIS

Invasive Infiltrating Ductal CA, others

Observe

Clinical Staging A. Early Stage (I-IIIA) B. Late Stage (IIIB-IV)

Complete excision if incision biopsy was done

Early Breast Cancer (DCIS, Stage I,II,IIIA)

Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2

Mastectomy/Modified Radical Mastectomy Axillary Nodes

Breast Conserving Surgery (with axillary dissection)

High nuclear grade,high histologic grade, HER2 + may proceed with chemotherapy

(+) Chemotherapy

(-) Radiotherapy Hormone Receptor Observe

Oophorectomy for premenopausal

(+) Tamoxifen

(-)

Postmenopausal

HER2/neu (+) tumors may be started with Herceptin

Aromatase inhibitors

Advance Stage Breast Cancer (Stage IIIb-IV) Chemotherapy

Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2, hepatic UTZ, bone scan

Modified Radical Mastectomy/Mastectomy

Breast Conserving Surgery

Adjuvant Chemotherapy

Radiotherapy Hormone Receptor (+) Postmenopausal

Tamoxifen
Aromatase inhibitors HER2/neu (+) tumors may be started with Herceptin

Recurrent Breast Cancer (loc0regional and distant metastasis)

Hx/PE, CBC,CXR, LFT, mammogram, ER/PR,HER-2, hepatic UTZ, bone scan

Biopsy (for local recurrence)

Chemotherapy

Radiotherapy

Hospice Care

Sentinel lymph node biopsy

Use for women with T1 and T2 N0 breast cancer
(+) sentinel node biopsy Axillary dissection and node clearance necesary (-)sentinel node biopsy Axillary dissection not necessary

Predict prognosis and response to therapy Predict more accurately the disease free and overall survival

rate than clinicopathologic staging These tumors tend to grow faster and recur more often EGFr and HER2/neu overexpression signifies high nuclear grade and high proliferation aneuploidy Trastuzumab(Herceptin) 52% decrease in breast cancer recurrence

BRCA-1 and BRCA-2 Tumor suppressor gene BRCA-1

90% lifetime risk of developing breast cancer

BRCA-2 85% lifetime risk of developing breast cancer Cancer prevention for BRCA mutation carriers Prophylactic mastectomy Prophylactic mastectomy and HRT Intensive suveillance Chemoprevention

BCS vs Mastectomy
Factors why women choose mastectomy over BCS Fear of recurrence in remaining breast Fear of dying from breast cancer High cost of radiation with BCS Distance from radiation facility Older women favor mastectomy

Chemotherapy regimen
Node negative women CMF FAC AC Node positive women FAC or CEF AC +/- T A CMF CMF EC

Thank you and good morning.