BREAST CANCER Oncology

John Dewar

Breast Cancer

Commonest cancer in women2nd commonest cause of death from cancer in womenSurvival improving – 5 yr. survival improved from 56% 1970 to 79% in 1999 (year of diagnosis)Increasing incidence – ageing population

Presentation

Screening – age 50-64(70), small, impalpable

Symptomatic – lump in breast

8% with distant metastases

8% locally advanced/inoperable

84% operable

TREATMENT

Surgery

Radiotherapy

Systemic therapy

hormonal therapy

cytotoxic chemotherapy

immunotherapy

RADIOTHERAPY

Postoperatively to breast/chest wall nodal areas: axilla, supraclavicular

fossa, internal mammary nodesPrimary radical for locally advanced Palliatively to painful bony mets, skin deposits, brain mets etc.

POSTOPERATIVE RADIOTHERAPY

Reduces the risk of local recurrence by about two thirds:

60% to 20%

30% to 10%

3% to 1%

POSTOPERATIVE RADIOTHERAPY

All patients being treated conservatively (wide local excision/lumpectomy)

Mastectomy patients selectively – large tumour, extensive nodal involvement, involved margins etc.

Postoperative Radiotherapy – acute side effects

Skin erythema to moist desquamation

Tiredness

Dysphagia if irradiating supraclavicular fossa

No alopecia

Postoperative Radiotherapy – late effects

Local fibrosis and telangectasia

Lung fibrosis (rarely symptomatic)

Cardiac damage (ischaemic heart disease) – rarer now treatment better planned

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

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

SYSTEMIC THERAPY – adjuvant

Hormone therapy: ovarian ablation, tamoxifen, aromatase inhibitors (ER/Pg +ve patients only)Cytotoxic chemotherapy: CMF, doxirubicin/epirubicin, taxanesTrastuzumab [Herceptin]

All decrease odds of death by about 17%, absolute benefit of about 6% at 10 years.

SYSTEMIC THERAPY – adjuvant: side effects

Hormone therapy:

Infertility

Menopausal symptoms

Weight gain

Endometrial cancer

Deep venous thrombosis

Chemotherapy

Nausea & vomiting

Infertility

Alopecia

Neutropenia (sepsis)

Mouth ulcers

Lassitude

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.)

METASTATIC DISEASE

Assess extent of disease

Stage: local recurrence, lung, liver, bone

Hormone receptor status

HER2 receptor status

METASTATIC DISEASELocal problems

Palliative radiotherapy: bony mets, brain mets etc.

Drainage of pleural or peritoneal effusions

Pining of pathological fractures

METASTATIC DISEASE Systemic therapy

Hormone therapy if ER/Pg +ve

Chemotherapy

Bisphosphonates for bony mets

Trastuzumab if HER2 +ve

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

METASTATIC DISEASE

Chemotherapy: CMF, anthracyclines, taxanes, capcitabine etc. etc.

Use in sequence so long as respond and patient fit

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