Breast Cancer,A Common Problem in

Sri Lanka

Dr Dehan GunasekeraConsultant Oncologist

National Cancer Institute of Sri Lanka

Leading Cancer sites-2010

Male Lip ,oral cavity and pharynx 14.1 % Bronchus and Lung 7.7 % Oesophagus 5.8 % Colon rectum 4.4 %

Female Breast 18.4 % Cervix 8.9 % Ovary 5.9 % Thyroid 5.6 %

1985 5012 new Cancer patients

1990 6063 new Cancer patients

1995 7300 new Cancer patients

2000 10925 new Cancer patients

2004 12632 new Cancer patients

2005 13372 new Cancer Patients

Breast Cancer Epidemic! Asian-young,ER-,PR-,High grade Europian->50 years,ER+,PR+Awareness of Breast CA at all agesPresentationMammographic detectionBlood stained nipple dischargeSelf detected lumpClinical breast examination detectedLocally advanced-ulcer,Peud’orangeMetastatic-Pleural effusion,Back ache

6 5

Diagnosis

Triple assesment Clinical Examination-site,size for staging Mammogram/US scan in < 40-45 years FNAC/Core(trucut) biopsy

Metastatic Survey General and systemic examination Xray chest US scan Abdomen and Pelvis LFT FBC,SC Bone Scan,CT scan–depending on the symptom

Histology Preinvasive CA Duct Carcinoma in Situ (DCIS) Lobuler Carcinoma in Situ (LCIS)

Invasive CADuct CA Mucinous Ca Medullary CA Papillary CALobuler CA

Receptor status is mandatory General Concept ER-,PR- Poor prognosis Her2- Good prognosis Change in Concepts due to Complicated cross talk between

Receptors Concept of Triple negative Disease

– ER (-)– PR (-)– Her-2/neu (-)

Treatment Early Stage –Surgery Breast Conserving Surgery+RT to the

breast Wide local Excission Qadrantectomy Lumpectomy Mastectomy+immediate or delayed

reconstructionAxilla- US scan axilla (-) LN –Sentinal Lymph node biopsy US scan axilla (+) LN- Axillary clearance

Place for Radiotherapy Mandatory in Breast conservation Lymph nodes in Axilla+ Large tumours (>5 cm) Poorly Differentiated CA To relieve pain locally-spine

• Place of Chemotherapy Post operative(Adjuvant) Lymph nodes in Axilla+ Poorly Differentiated CA Large tumours (>5 cm) ER-,PR-,Her2 + Metastatic Disease

Preoperative(Neoajuvant) Locally advanced disease(T3,T4) InoperableChemothrapy-Anthracyclin based Paclitaxel based

Place of hormonal TherapyER+,PR+ Premenapausal-TamoxifenER+,PR+ Postmenapausal- Aromatase inhibitors Anastrazole Letrazole Exemestane

The occurrence of relapse and survival (Prognosis) are influenced by

1.Stage at presentation (Size,Pathology,Grade,Metastasis)

2.Lymph node status 3.Hormone receptor status 4.Measures of proliferation of the cancer

cell 5.Genetics of the cancer and the host 6.Age at diagnosis

St Galens Recommendations Low risk

T1 N0 G1 ER+ and /or PR+ Her2 – >35 years No lymphovasculer invasion

Intermediate risk

ER and/or PR + Her2 – N0 No lymphovasculer

invasion pT>1 or G2-3 or <35 years or (1-3) LN

High risk

ER- and PR- LN >3 Her2+

or LN 1-3 with lymphovasculer

invasion

Stage 5 year survival Stage I T1 NO M0 85% Stage II T0-1 N1 M0 T2 N0-1 M0 65% T3 N0 M0 Stage III T0-2 N2 M0 T3 N1-2 M0 T4 any N M0 45% Any T N3 M0 Stage IV Any T any N M1 10%

Prevention All females should do self breast

examination monthly Women over 40 years old should

have Clinical breast examination every 3 years

Bilateral Mammogram at perimenapausal age of 45-50 years

If Clinical Breast examination detects a suspicious lesion under the age of 45 years-US scan breasts and ideally MRI of Breast

Thank you