1. Management of Breast Cancer
Dr. Khdair El-Rawaq

2. Frame Breast anatomy Epidemiology Risk factors Staging
Diagnostic Work-up
PROGNOSTIC FACTORS
Management
Management of Early stages
Management of Late stages
Palliative Management

4. Br Lymphatics A :PM muscle B : level I C : level II D : level III E :SCV F: IMN

5. Epidemiology Incidence (In the year of 2008)
Breast cancer is the second most common cause of death for women .
the most common cause of death for women aged 45 to 55..
it is predicted that 215,990 American women will be diagnosed with breast cancer and that 40,110 women will die from this disease

6. Incidence per 100,000 in USA

7. Epidemiology
Breast cancer incidence has long varied in different regions of the world. Incidence is highest in Northern Europe and North America and lowest in Asia and Africa .
Mortality rates declined by 1.4% per year from 1989 to 1995 and thereafter by 3.2% per year. This is thought to be due in part to increased use of mammography, resulting in earlier diagnosis, and the use of effective treatments.

8. Risk factors Age >50 Personal or family Hx Nulliparity
First child > 30 yrs
Jewish- black
Lactation (longer time) (Lancet 2002:360: )
Early menarche- late menopause
Exposure to ionizing radiation
Alcohol increases risk of breast cancer

9. Risk factors
The relationship between high BMI and ↑ BC risk is seen for postmenopausal F
Due to ↑ levels of estrogens, particularly free estradiol
(Trentham-Dietz A; Cancer Causes Control 2000 Jul;11(6): )

10. Risk factors Oral contraceptive agents
More than 10 yrs : risk x2 in >55 yrs (Van Hoften et al. Int J Cancer 2000)
A large meta-analysis → a small but significant increase in relative risk of breast cancer (RR =1.24) in current OCP users
Lancet 1996 Jun 22;347(9017):

11. Staging
changes in the AJCC staging criteria from 1988 to 2002 affect stage-specific outcomes.
It has been demonstrated that reclassification will result in improved outcomes.

12. Staging
A recent study examined overall stage-specific survival using both staging systems for a total of 1350 patients.
It was noted that only 55% of patients who were classified as having stage II disease according to the 1988 system had stage II according to the 2002 system. However, in direct comparison, the number of patients with stage III disease increased by 114%.

13. Diagnostic Work-up for Carcinoma of the Breast
History
Physical examination
Biopsy
Radiologic studies
Laboratory studies

14. History with emphasis on
presenting symptoms (Br. lump, nipple retraction),
menstrual status,
parity,
family history of cancer,
other risk factors.

15. Physical examination
with emphasis on
breast, (Lt>Rt, 5 yrs to reach palpable size)
axilla(10-40% of T1,T2 have pathologic +ve LNs)
supraclavicular area,
abdomen

16. Biopsy
core biopsy directed by physical examination, ultrasound, or mammography as indicated, or needle localization.
Complete agreement between the core biopsy and subsequent histologic sections was reached in 89.7% of lesions and partial agreement in 9.2%

17. Radiologic studies Before biopsy After positive biopsy:
Mammography/ultrasonography
Chest radiographs
MRI of breast (8 clinical trials The sensitivity of MRI ranged from 71% to 100% J Magn Reson Imaging Oct 11)
After positive biopsy:   
Bone scan (when clinically indicated, for stage II or III disease or elevated serum alkaline phosphatase levels).
Computed tomography of chest, abdomen and pelvis for stage II or III disease and/or abnormal liver function tests

18. Laboratory studies Complete blood cell count, blood chemistry
Urinalysis
Other studies    Hormone receptor status (ER, PR)    HER2/neu status,
Tumor marker level (CD 153 preop level , in bone mets)
Consider genetic counseling/BRCA testing in selected cases, mutated P53

19. PROGNOSTIC FACTORS
Intrinsic factors

20. PROGNOSTIC FACTORS
The only accepted prognostic markers that provide critical information necessary for treatment decisions are
TNM stage
axillary LN status
tumor size
grade
lymphatic or blood vessel invasion
hormone receptor status
HER-2 neu oncogene

21. PROGNOSTIC FACTORS Extensive intraductal carcinoma
>25% of the primary tumor
Associated with higher incidence of breast recurrence in some studies
Does not affect DFS or OAS if –ve margins
(Hurd et al. Ann Surg Oncol 1997)

22. PROGNOSTIC FACTORS Involvement of axillary LN
Direct relation bet + axillary LNs and chest wall recurrence and survival
(Haagensen. IJROBP 1977)

23. PROGNOSTIC FACTORS Data are insufficient to recommend use of
p53 measurements
cathepsin D measurements
estimates of DNA content or S phase in breast tissue

24. PROGNOSTIC FACTORS Extrinsic factors Age (<45 V >45)
Race (black V white)

25. CHEMOPREVENTION Breast Cancer Prevention
An ASCO working group published an assessment of tamoxifen use in the setting of breast cancer risk reduction.
All women older than 35 years of age with a Gail model risk of > 1.66% (or the risk equivalent to that of women 60 years of age) should be considered candidates for Breast Cancer Prevention therapy

26. Management of Early stages Breast Cancer
early-stage breast cancer, ie, stages 0 ,I and
II disease.
Stage 0 breast cancer includes noninvasive breast cancer—
lobular carcinoma in situ (LCIS)
ductal carcinoma in situ (DCIS)
Paget’s disease of the nipple
when there is no associated invasive disease.

27. DCIS DEFINITION Confined to the ductal system of the breast
No evidence of invasion:
No disruption of BM
No involvement of surrounding breast stroma
No risk of mets
ALN +(0-5%) ?focus of invasive ca

28. MANAGEMENT BREAST CONSERVATION +/- RT
Metaanalysis Local RR at 5 yrs 22.5% vs 8.9%
Greatest improvement in local control with RT
Necrosis
high grade features
comedo subtype
Boyages and colleagues, Cancer 1999
Other option is mastectomy
Tamoxifen

29. Stage I and II disease
Multiple studies have demonstrated that patients with stage II breast cancer who are treated with either
breast-conservation therapy (lumpectomy and radiation therapy) or
modified radical mastectomy
have similar disease-free and overall survival rates.

31. A)

35. Management of Late stages Breast Cancer
This addresses the management of locally advanced, locally recurrent, and metastatic breast cancer, ie,
stages IIIB,C and IV disease.
Rates of locoregional recurrence may vary from < 10% to > 50%, depending on initial disease stage and treatment.

36. Management of Late stages Breast Cancer
Neoadjuvant systemic therapy
can downstage locally advanced disease and render it operable
may allow breast-conservation surgery to be
Performed.
The majority of patients receiving neoadjuvant chemotherapy, treated with either breast conservation or mastectomy will require radiation therapy following surgery.

39. Metastatic disease
Metastatic disease is found at presentation in 5% to 10% of patients with breast cancer.
The most common sites of distant metastasis are the lungs, liver, and bone.

40. Low-risk patients, (elderly)
Low-risk patients, elderly whose tumor is hormone receptor-positive (ie, estrogen receptor-positive and/or progesterone receptor-positive), may be treated with a trial of Hormone therapy
First-line hormonal therapy consists of an aromatase inhibitor
tamoxifen

41. Hormone-refractory disease can be treated with
Cytotoxic agents systemic cytotoxic therapy.
FAC, paclitaxel, TAC (Taxotere[docetaxel], Adriamycin [doxorubicin], cyclophosphamide), or docetaxel may be used in this situation

42. Intermediate- or high-risk patients
include those with rapidly progressive disease or visceral involvement, as well as those with disease shown to be refractory to hormonal manipulation by a prior therapeutic trial. Those treated by:
Cytotoxic agents systemic cytotoxic therapy
Monoclonal antibody therapy(Trastuzumab ,Lapatinib) and
targeted agents (Avastine)

43. Adjunctive bisphosphonate therapy
High-dose chemotherapy Patients who present with or subsequently develop distant metastasis.
Adjunctive bisphosphonate therapy
Use of these agents results in a significant reduction in skeleton-related events, including pathologic fracture, bone pain, and the need for radiation therapy to bone. Pamidronate and zoledronic acid (Zometa)

44. ROLE OF RADIATION THERAPY IN METASTATIC DISEASE
bone metastases are the most commonly treated metastatic sites in patients with breast cancer,
brain metastases, spinal cord compression, choroidal metastases, endobronchial lung metastases, and metastatic lesions in other visceral sites can be effectively palliated with irradiation

45. THANK YOU