Breast Cancer 2020 What’s new?...Stage 3A: No tumor in breast but in 4 – 9 lymph nodes OR Tumor...

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Breast Cancer 2020What’s new?

Dr. Patti Ann Stefanick, D.O., F.A.C.O.S.

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Disclosures

• I have no relevant conflicts to disclose.

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What’s new in Breast Cancer?

Facts and FiguresStagesDetectionDiagnosisInterventionTreatment

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Breast Cancer Statistics - 2019

268,600 new cases invasive cancer diagnosed in women62,930 new cases in situ cancer diagnosed in

women2,670 new cases diagnosed in men42,260 deaths last year37% decrease in death rate over last 20 years

BREASTCANCER.ORG/STATISTICS 2019

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Breast Cancer RiskUp to age Women’s odds 25 1 in 19,608 30 1 in 2,525 35 1 in 622 40 1 in 217 45 1 in 93 50 1 in 50 55 1 in 33 60 1 in 24 65 1 in 17 70 1 in 14 75 1 in 11 80 1 in 10 85 1 in 995 1 in 8 NCI 2018

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Risk Factors for Developing Breast Cancer

Never having children Having your first child after age 30 Drinking more than 1 alcoholic drink/day Overweight Family history of breast cancer Personal history of ovarian cancer First menses before age of 12 Menopause starting after age of 55 Breast biopsy showing atypical cells Having gene mutation (BRCA1, BRCA2)

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Presenting Signs and Symptoms Lump in Breast

– 80%– Usually painless

Change in Nipple– Discharge– Retraction– Enlargement

Breast Redness Axillary Mass Swelling of Arm Bone Pain

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Prognostic FactorsStage of diseaseNumber of involved axillary lymph nodesTumor sizeTumor DifferentiationAneuploidy (abnormal chromosomal number)Cells in S-phase or cell cycleCopies of oncogene HER-2/NEU

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Breast Cancer Survival

Relative survival rates (ACS, 2017 data) 92% at 5 years after diagnosis 83% after 10 years 78% after 15 years

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Factors that influence surviving when diagnosed with breast cancer:

Stage at diagnosisRace/ethnicitySocioeconomicTumor CharacteristicsTime since diagnosisAge at diagnosisACS 2015

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Frequency of Axillary Node Involvement Related to Tumor Size

Tumor size (cm) Frequency of node involvement(%) < 0.5 20.6 0.5-0.9 20.61.0-1.9 33.22.0-2.9 44.93.0-3.9 52.14.0-4.9 60.0>5.0 70.1

(Carter, et al, CANCER, 1989)

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Stages of Breast Cancer

Stage 0: Non-invasive beast cancerStage 1A: invasive cancer up to 2cm, no

lymph node involvementStage 1B: No breast tumor, only lymph node

involvement OR breast tumor <2cm and small groups of cells in the lymph nodes

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Stages of Breast Cancer(continued)

Stage 2A: Tumor up to 2cm and has spread to lymph nodes OR tumor 2 – 5 cm and no lymph nodes Stage 2B: Tumor 2 – 5 cm and spread to lymph

nodes OR Tumor 2 – 5 cm and in 1 – 3 lymph nodes OR Tumor >5 cm and negative nodes

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Stages of Breast Cancer(continued)

Stage 3A: No tumor in breast but in 4 – 9 lymph nodes OR Tumor >5 cm and small groups of tumor cells in lymph nodes OR Tumor > 5 cm and in 1 – 3 lymph nodes

Stage 3B: Any size tumor and spread to up to 9 nodes OR Inflammatory Breast Cancer, involving redness, swelling, possible ulcer of skin

Stage 3C: Tumor of any size and >10 nodes OR spread to nodes near clavicle or collarbone

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Stages of Breast Cancer(continued)

Stage 4: Tumor that has spread beyond the breast and axilla to distant lymph nodes, skin, lung, liver, bone, or brain

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Most common Types of Breast Cancer

Ductal Carcinoma – in – situ (DCIS)Lobular Carcinoma – in – situ (LCIS)Infiltrating Ductal Carcinoma (IFDC)Infiltrating Lobular Carcinoma (IFLC)

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Ductal Carcinoma – in situ (DCIS)

Completely contained within terminal ductulesHistologic types:

- Comedo-Cribriform-Cobweb-Papillary

Comedo is most likely to become invasive

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DCIS

20 – 30% progress to invasive cancerPresents as:

Gross: mass or Paget’s DiseaseMicroscopic

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DCIS – Progression of Disease

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DCIS

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DCIS

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DCIS – Paget’s Disease

Sir James Paget – England, 1814-1899Eczematous changes – areola and nipple1 – 4% of all breast cancers60% with associated breast mass

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Paget’s Disease

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Paget’s Disease

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DCISGross DCIS – treat like IFDCMicroscopic DCIS:

Most common form of DCIS todayFound on screening mammogramsPrecipitation of calcium into lumen of

abnormal ductTreatment: total mastectomy

limited resection and radiationlimited resection and observation

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DCIS in Mammogram

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DCIS - Microscopic

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DCIS - Microscopic

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Lobular Carcinoma – in Situ (LCIS)

Tumors confined to breast lobulesFirst described in 1941Incidence unknownMicroscopic, non-palpableFound incidentallyMammography useless

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LCIS

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LCIS

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LCISHaagenson (Columbia, NYC)

“Lobular neoplasia”Gump(Columbia) – “predictive factor”

predicts IFDC, not invasive lobularStrong marker – 37% progress to IFDC (Rosen,

MSKCC)High % bilaterality

25% risk (Columbia)35% risk (MSKCC)

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LCISTreatment – 3 options

Observation (Columbia)includes breast MRI

Ipsilateral mastectomy +/- contralateralbiopsy (MSKCC)Bilateral mastectomies

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LCIS

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LCIS DCIS Premenopausal

No physical findings

No metastasis

Bilateral risk of cancer

• No Microcalcifications on film

•

Pre & postmenopausal

No mass with micro form Mass with gross form

No mets with micro form Possible mets with gross form

Unilateral risk of cancer

Microcalcifications on film

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Infiltrating Ductal Carcinoma (IFDC)

73% of all breast cancers in U.S.Begins in duct and extends through itMay be stellate or circumscribedHistologic grading:

well-differentiatedmoderately differentiatedpoorly differentiated

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DCIS

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IFDC - Microscopic

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Infiltrating Ductal Carcinoma

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IFDC

Treatment options:Total mastectomy with axillary sentinel node

biopsy +/- dissection – with or without reconstructionLimited resection and axillary biopsy(sentinel

node) +/- dissection and radiation treatment (LART)

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Infiltrating Lobular Cancer

10 – 14% of all invasive carcinomasArises from mammary lobules, then infiltrates

in a linear arrangement of tumor cells that wrap around ducts and lobulesUsually accompanied by LCIS tumors

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Infiltrating Lobular Carcinoma

Mammography: no calcifications multifocalno definitive marginsbilateral in 6 – 28% cases

Treatment as per IFDC: Mastectomy + node bxLART

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Infiltrating Lobular Cancer

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Adjuvant Therapy for Breast Cancer

Definition

Systemic therapy given at the time of primary local treatment in the absence of demonstrated metastasis

Chemotherapy : used in adjuvant setting or to treat metastasis

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Chemotherapy Always used in “node +” women Often used in “node –” women Chemotherapy for “node –” women

- Based on 1988 NCI Clinical Alert (Davita)- High nuclear grade, poor differentiation,

high # mitotic figures, vascular or lymphaticinvasion

- oncogene testing essential today- tumor size, high # nodes- Clinical trials are valuable and ongoing

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Adjuvant Therapy

Hormonal manipulation* Estrogen receptor antagonist

- Blocks estrogen receptors to prevent estrogen-fed tumors from feeding on estrogen

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Preoperative Chemotherapy

Used in locally advanced tumorsEffectively shrinks tumors prior to surgery to

assist in breast conservationCan clear a microscopically “+” axilla

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Radiation TherapyUsed in conjunction with breast conserving

surgery for IFDCNSABP B-06 first showed equal survival to

Mastectomy patientsDecreases local recurranceUsed to decrease tumor bulk in locally

advanced cases

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Locally Advanced Breast Cancer

Chemotherapy prior to surgeryMay rely on radiation treatment instead of

surgery to reduce tumor bulk

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Metastatic Breast Cancer

Most common sites: BoneLungLiverBrain

Treatment includes chemotherapy and radiation

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Genetic Testing BRCA-1 and BRCA-2 genes isolated Shows increased susceptibility to breast, ovarian,

pancreatic and melanoma cancer, and prostate cancer in men

Useful in patients with family histories of breast and ovarian cancer

Screenings in larger centers along with genetic counseling, kits in private offices (Myriad)

Carriers choosing prophylactic mastectomies (17%) and oophorectomies (33%)

Increasingly covered by insuranceMAYO CLINIC 2019

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The best way to diagnose breast cancer early for early treatment:

MAMMOGRAPHY

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Mammography: Two typesScreening Age 40, annually thereafter Asymptomatic Negative physical examination Patients with a first-degree relative with breast cancer

should begin screening 10 years earlier than the age the relative was diagnosed

Diagnostic Symptomatic Findings on physical examination Questionable finding on screening mammogram

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Mammography

Film mammography is now obsoleteDigital mammography, images recorded on a

computer, are now the standard of care.3-D mammography, or breast tomosyntheses,

combines multiple breast X-rays to create a 3D picture of the breast. They improve breast cancer detection in dense breast tissue.

The level of radiation in a 3-D mammogram is greater than that of a digital mammogram alone.

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So why is breast density important?

Women with extremely dense breast tissue have a 4 to 6 times greater risk of getting cancer than fatty breasts. JAMA2012

Mammograms detect 98% of cancers in women with fatty breasts but ONLY 48% in women with dense breasts.

Gov. Corbett signed the Breast Density Notification Act, in 2013, making Pennsylvania the 17th state to require notification to patients of their breast density.

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Breast Density Scale

1 Almost entirely fatty 10% 2 Scattered fibroglandular tissue 40%3 Heterogeneously dense tissue 40%4 Extremely dense tissue 10%

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www.acr.org 2013

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BIRADS

Stands for “Breast imaging Reporting and Data System”Used by radiologists to standardize

mammography, ultrasound, and MRI reporting

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BIRADS Categories

Category 0

1 2 3

4 5 6

Assessment

Incomplete – needs more imaging

Negative Benign findings Probably benign – “I’m not

sure” – short follow-up Suspicious abnormality Highly suggestive of cancer Biopsy-proven cancer ACR 2013

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Breast Ultrasound

Use of sound waves to penetrate breast tissue and find cystic or solid lesionsUsed to complement mammography, not

instead of itUseful in dense breast tissueUltrasound reveals 28% more cancers in at-

risk women than mammogram alone

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Breast MRI Use of MRI imaging technique to further visualize

dense breast tissue or to evaluate palpable lesions not seen on mammogram or ultrasound

Useful in high risk patients Useful in every new breast cancer patient to identify

multifocal diseaseMay use MRI to biopsy lesions not seen on

mammogram or ultrasound Not used in place of screening mammography Useful in women with implants OFTEN NOT COVERED BY INSURANCE!!!!!! ACS March 2007

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BREAST CANCER DIAGNOSIS

Early detection of breast cancer greatly improves treatment options, chances of successful treatment, and survivalTo make a definitive diagnosis , a biopsy must

be performed80% OF BREAST BIOPSIES ARE BENIGNAJR(1995)165:1373-77

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Diagnosis: The shift in care

Open Surgical biopsy

Performed in the operatingroom

Minimally invasive biopsy Performed in a doctor’s

office As accurate as open surgical

biopsy Stereotactic biopsy Vacuum-assisted core

biopsy FNA

RADIOL CLIN NORTH AM.200;38:791-807

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Stereotactic Breast Biopsy

Minimally invasive breast biopsy technique for non-palpable breast lesions seen on mammogramComputerized system based on geometric

principlesFisher, Lorad

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Locates the abnormality in the breast in three dimensions (horizontal, vertical, depth).

Uses the same visual principles that our brain and our eyes use to see in three dimensions.

Stereotactic (X-Ray) Guided Biopsy

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Stereotactic

Parker S. Lesion Workup and Selection for Biopsy, Breast Imaging and Intervention in the 21st Century. 10/23/02, Key Largo, FLBassett LW, Winchester DP. Stereotactic core-needled biopsy of the breast. ACS and College of Amer. Pathologists CA Cancer J (1997);47:171-190

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• Granular Calcifications• Dense, pleomorphic calcifications, lobular• Dense, pleomorphic calcifications, ductal*• Irregular shape• Spiculated or ill-defined margins• Microlobulations• Associated findings, such as focal skin

thickening and focal solitary dilated duct

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Ultrasound-Guided Breast Biopsy

Minimally invasive breast biopsy technique for masses seen on ultrasoundVacuum-assisted biopsy techniqueFor palpable and nonpalpable lesions

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Ultrasound Guided Biopsy

Locates the abnormality in the breast using high frequency sound waves.

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• Lesions < 1 cm• Indeterminate lesions• Heterogeneous lesions:• Papillary lesions• Complex cysts• Irregular shape• Spiculated or ill-defined margins.• Microlobulations• Associated findings, such as focal skin thickening

and focal solitary dilated duct.

Ultrasound

Fine RE, Staren ED. Updates in Breast Ultrasound. The Surgeons Clinics of NA (2004)

Bassett LW, Winchester DP. Stereotactic core-needled biopsy of the breast. ACS and College of Amer. Pathologists CA Cancer J (1997);47:171-190

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Sentinel Node BiopsyMinimally invasive technique to stage the

axilla in a patient with breast cancerTheory that nodal involvement ascends the

chain, very rarely skips low nodes to involve higher nodesInjection of isosulfan blue and

Radiopharmaceutial (Tc99) will identify the first node of drainage in 92% cases

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Sentinel Node BiopsyNode in axilla will be nucleoactive (“hot”)

bright blue, or bothAverage number of sentinel nodes obtained

per case = 2.2 nodesIf sentinel node + , may proceed with axillary

node dissection; may instead proceed with chemotherapy in some casesIf no sentinel node is identified, must do

axillary node dissection

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Gamma Probe Spectrum for I-125 and Tc-99m

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Why Sentinel Node Biopsy? Accurately stage the axilla in large % women Fewer nodes out means less morbidity:

lymphademaAxillary seromasintercostal brachial nerve syndromepost-op infections

Lower cost Less anesthesia Usually limited to tumors <3 cm and nonpalpable

lymph nodes (clinical stage I and II) Very useful to stage axilla after preop chemo given

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Male Breast Cancer

1% of all breast cancer in USAMale lifetime risk of breast cancer = 1 in 883 In 2019, 500 men died of the diseaseFirm, painless unilateral massUsually presents as more advanced stateTreatment as per female – higher % modified

radical mastectomies and post-op radiation

AMERICAN CANCER SOCIETY STATS 2019

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Breast Cancer…

Early diagnosis is the key to survival!