Western Visayas Medical CenterHospital Cancer Committee

Most common site-specific cancer in women worlwide2nd most common cause of cancer death in women5th most common cause of death in women8-12% 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

breastsBreast enlargement/asymmetryAxillary 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

I - 94%IIa - 85%IIb - 70%IIIa - 52%IIIb - 48%IV - 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 dischargesMRI* - for high risk patients with dense breast during mammography

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

Chemotherapy* Adjuvant chemotherapy Neoadjuvant chemotherapy

RadiotherapyHormonal 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 stagingStage I

Primary tumor is 2 cms or less with no lymphatic spread

Stage IIIIa – 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 stagingStage 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 IVSpread of breast cancer to distant areas of the

body

Treatment Pathways

Non- Palpable Breast Mass

Image Guided Biopsy (Ultrasound/

mammography)

Malignant Benign

Observe

Breast Ultrasound/Mammograp

hyMammogra

m/Stereotactic needle not available

History/PE

Normal Clinical Breast Exam, <low

risk, <40 yo

Doubtful clinical breast exam, high risk,

>40 years old

(+) lesions

(-) lesions

Palpable Breast Mass

Biopsy (FNAB/Excision or incision

biopsy)

Malignant Benign

Non-invasiveDCISLCIS

InvasiveInfiltrating Ductal CA,

others

Observe

Clinical StagingA.Early Stage (I-

IIIA)B.Late Stage (IIIB-

IV)

Hx and PE

>40 any size, high risk, <40 but mass

2cm or more

<40, <2 cms in size, low risk

Complete excision if incision biopsy

was done

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

Mastectomy/Modified Radical Mastectomy

Breast Conserving Surgery (with axillary

dissection)

Hormone Receptor

Hx/PE, CBC,CXR,

LFT, mammogram, ER/PR,HER-2

Axillary Nodes

(+) (-)

Chemotherapy

Tamoxifen

Aromatase inhibitors

Radiotherapy

High nuclear grade,high histologic grade, HER2 +

may proceed with chemotherapy

Observe

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

(+) (-)Oophorectomy

for premenopausal

Postmenopausal

Advance Stage Breast Cancer (Stage IIIb-IV)

Chemotherapy

Modified Radical Mastectomy/Mastecto

my

Breast Conserving Surgery

Adjuvant Chemotherapy

Radiotherapy

Tamoxifen

Aromatase inhibitors

Hormone Receptor (+)

Hx/PE, CBC,CXR, LFT, mammogram,

ER/PR,HER-2, hepatic UTZ, bone

scan

HER2/neu (+) tumors may be started with

Herceptin

Postmenopausal

Recurrent Breast Cancer (loc0regional

and distant metastasis)

Biopsy (for local recurrence)

Chemotherapy

Radiotherapy

Hospice Care

Hx/PE, CBC,CXR, LFT, mammogram,

ER/PR,HER-2, hepatic UTZ, bone

scan

Sentinel lymph node biopsyUse for women with T1 and T2 N0 breast

cancer(+) sentinel node biopsy

Axillary dissection and node clearance necesary

(-)sentinel node biopsyAxillary dissection not necessary

Predict prognosis and response to therapyPredict more accurately the disease free and overall survival rate than clinicopathologic stagingThese tumors tend to grow faster and recur more oftenEGFr and HER2/neu overexpression signifies high nuclear grade and high proliferation aneuploidyTrastuzumab(Herceptin)52% decrease in breast cancer recurrence

BRCA-1 and BRCA-2Tumor suppressor geneBRCA-1

90% lifetime risk of developing breast cancerBRCA-2

85% lifetime risk of developing breast cancerCancer prevention for BRCA mutation carriers

Prophylactic mastectomy Prophylactic mastectomy and HRT Intensive suveillance Chemoprevention

BCS vs MastectomyFactors why women choose mastectomy over

BCSFear of recurrence in remaining breastFear of dying from breast cancerHigh cost of radiation with BCSDistance from radiation facilityOlder women favor mastectomy

Chemotherapy regimen Node negative women

CMFFACAC

Node positive womenFAC or CEFAC +/- TA – CMFCMFEC

Thank you and good morning.