1. Breast Cancer 1

2. Leukemia & Lymphoma New diagnoses each year in the US: 112, 610 Adults 5,720 Children 43,340 died of leukemia or lymphoma in 2010 2

3. Breast Cancer New diagnoses each year in the US: 246,660 Women 2,600 Men 40,450 estimated deaths from breast cancer in 2016 3

4. Leukemia Lifetime Risk: 1/77 Median age of diagnosis = 66 YOA Median age of death = 73 YOA 5 year survival = 54.1% 4

5. Female Breast Cancer Lifetime Risk: 1/8.1 Women (12.3% of women will be diagnosed with breast cancer in their lifetimes) Median age of diagnosis = 61 YOA Median age of death = 68 YOA 5 year survival = 89.4% 5

6. Male Breast Cancer 2,600 New diagnoses in 2015 year 440 Deaths Fewer than 1% of new breast cancer cases are in men Median age at diagnosis and prognosis similar to that of women Median age of death slightly lower due to tendency to be diagnosed at a later stage 6

7. Risk Factors Age Breast Cancer Family History (greater if family member was diagnosed before age 50) Genetic Predisposition Radiation Therapy to the Chest Reproductive History First child when older No children First Menstrual Cycle before age 12 Menopause after age 55 Menopausal hormone replacement therapy Dense Breasts Post-menopausal obesity Physical Inactivity Alcohol Consumption 7

8. Symptoms Change in breast size / shape / appearance Dimpling or puckering skin on the breast Scaly, red or swollen skin on the breast Discharge from the nipple 8

9. Diagnosis-Age Distribution 9

10. Incidence by Race 10

11. Influence of Race on Deaths 11

12. Diagnosis 12 Needle Biopsy, Aspiration Biopsy or Surgical excision Pathologic Determination

13. Additional Tests Hormone Receptor Profile Estrogen Progesterone HER2/neu Expression 13

14. Anatomy The most common (~90%) type of breast cancer is ductal carcinoma. 14

15. Anatomy 15

16. 5 Year Survival by Stage 16

17. Trends in Incidence vs. Survival 17

18. Staging Stage 0: Dysplasia; non-invasive. Eg.,DCIS Diagnosed by mammography— non-palpable 18

19. DCIS Ductal carcinoma in situ [A.K.A., ductal intraepithelial neoplasia] Noninvasive condition that can evolve to invasive cancer, with variable frequency and time course Most often diagnosed by mammography  4,900 women were diagnosed with DCIS in 1983  Approximately 64,000 diagnosed in 2013 Natural history of DCIS is poorly understood because nearly all DCIS cases are treated. 19

20. DCIS 28 confirmed (biopsy) DCIS Untreated & followed for 30 years 9 (~30%) developed invasive breast cancer 4 (44%) died of the disease 20 98.1% 10-year disease-free survival for women treated for DCIS (lumpectomy & radiation therapy) Most cases of DCIS will not evolve to invasive cancer; treatment of non-palpable DCIS represents over-diagnosis & over-treatment

21. Staging Stage 1: Neoplasia; invasive. Only breast tissue involvement. Tumor < 2cm in diameter. 21

22. Tumor Size 22

23. Staging Stage 2: Fits one of the following criteria: a.) Tumor is 2-5 cm in diameter; b.) Tumor has disseminated to the axillary, ipsilateral lymph node + tumor is 5 cm. 23

24. Staging Stage 3: Locally-advanced cancer. Divided into the following categories: IIIA.) Tumor has disseminated to the axillary, ipsilateral, adjacent lymph nodes or to sternal lymph nodes + tumor is 5 cm in diameter IIIB.) Tumor is any size and has grown into the chest wall or the skin. Lymph nodes may or may not be involved OR Tumor is confined to breast tissue + tumor is > 5 cm. IIIC.) Tumor is any size and has disseminated to the axillary lymph nodes and the sternal lymph nodes OR the tumor is any size and has disseminated to the supraclavicular lymph nodes. IIICIIIA 24

25. Inflammatory Breast Cancer Rare (~ 1%) Breast is red and swollen Staged = at least IIIB. 25

26. Staging Stage 4: Metastatic cancer. Tumor is any size but has spread to distant organs. 26

27. Surgical Treatment Stage 0 Stages I and II 27

28. Other Treatments Radiation Therapy Chemotherapy Biological Therapy Targeted Therapy 28

29. http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/allpages#3 29 http://seer.cancer.gov/statfacts/html/breast.html

30. 30 Screening

31. Clinical Breast Exam Self Breast Exam Mammography MRI, Sonography Biopsy (with other Clinical Finding) 31

32. Screening Mammography vs. Physical Exam PE: 27.6% Sensitive 99.4% Specific Mammography:77.6% Sensitive* 98.8% Specific* * effectiveness declined significantly with increasing breast density. Conclusion: 11, 130 patients; Mammography significantly increases detection of small cancers and lower-stage cancers than does PE. Kolb, et al., 2002. Radiology 225:165-175. 32

33. Screening 33

34. Screening: New Directives (2016) Preventive Services Task Force (USPSTF) Guidelines*: Screening for women aged 40-49 is not supported Biennial (versus annual) screening supported for women aged 50-74. *Against the advice of the national cancer advisory board—1 st time in history. Kopans, 2010. Radiol Clin N Am. 48: 843-57. 34

35. Screening Kopans, 2010. Radiol Clin N Am. 48: 843-57. 35 http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=103278 http://screeningforbreastcancer.org/read-the-materials http://www.cancer.org/healthy/informationforhealthcareprofessionals/acsguid elines/breastcancerscreeningguidelines/index